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Presents updates on upcoming international congresses in the systems research and behavioral science sector happening in 2003. 47th Annual Conference of the International Society for the Systems Sciences in Crete, Greece; Informing Science+IT Education Conference in Pori, Finland.

The article highlights the 12th International Symposium on Toxicity Assessment that was held in Skiathos Island, Greece from June 12 to 17, 2005. It was organized by the Department of Planning and Regional Development of the University of Thessaly. As had previous symposia with the same context, the symposium was designed to encourage the exchange of ideas and to strengthen communication and cooperation between environmental researchers and the scientific community such as managers, regulators, policy-makers and academia.

Information about the topics discussed at the 13th International Conference on Experimental Mechanics (ICEM 13) which was held in Alexandroupolis, Greece from July 1-6, 2007 is presented. The event emphasizes the novel application of various techniques of experimental mechanics. The nine papers of the present issue, were peer reviewed according to the standard review policy of the journal. A paper by P.-F. Lou and C.-H. Wang presents a stereo vision method to measure the crack tip parameters.

Provides information on the 2005 Conference on World Mission and Evangelism of the World Council of Churches which took place near Athens, Greece from May 9 to 16, 2005. Topics discussed at the conference; Document adopted by the Commission on World Mission and Evangelism on behalf of the event; Research papers presented at the conference.

This article presents information on the 1995 issue of the journal "Applied Stochastic Models and Data Analysis." This special issue is devoted to the sixth international symposium on applied stochastic models and data analysis, which was held in Greece on 3-6 May, 1993. The majority of the papers included were presented as invited papers at the above symposium. The papers included cover some, but not all topics in the applied stochastic models and data analysis field. Emphasis was given to the formulation of the most representative collection of papers. The selection of these papers was based on the aims and scopes of this journal. The improvement of existing theory and the development of appropriate estimation techniques followed by a real-life application were the main criteria for final approval.

The article discusses the highlights of the 2008 Eurographics Symposium on Parallel Graphics and Visualization (EGPGV 2008) held on April 14-15, 2008 in Crete, Greece. The first paper session was dedicated to volume rendering techniques, presenting multi-graphics processing units (GPU) methods, the second session focused on scientific visualization while the third session included parallel techniques for graph layout, mesh simplification and global illumination. The keynote address of Hans-Christian Hege focused on high performance computing.

This article presents information about the proceedings of the conference of International Society for the Investigation of Stress (ISIS). Following the inaugural conference in Munich in 1988, the second international conference of ISIS took place on 10th October to 11th October 1989 in Athens. The conference preceded the VIII World Congress of Psychiatry which was also held in the Greek capital. Selected papers from the ISIS conference are being published in this issue and the subsequent issue in January 1991. The second conference consisted of three symposia, which are: stress, psychology, and disaster that also includes free communications on those topics.

ANTIARRHYTHMICS P001 THE ANTI‐ARRHYTHMIC EFFECTS OF STATINS IN PATIENTS WITH CORONARY ARTERY DISEASE AND IMPLANTABLE CARDIOVERTER DEFIBRILLATORS Panattoni G; Papavasileiou LP; Della Rocca DG; Cioè R; Magliano G; Topa A; Sergi D; Santini L; Forleo GB; Romeo F Cardiology Department, University of Tor Vergata, Rome, Italy Introduction: A few studies have suggested that statins may have anti‐arrhythmic effects in patients with coronary artery disease. One proposed mechanism for the antiarrhythmic effect of statins is their antioxidant properties. The aim of our study was to determine whether statin therapy could reduce mortality, the occurrence of ventricular arrhythmias and appropriate or inappropriate intervention of the device in patients with implantable cardioverter defibrillators (ICDs). Methods: We investigated 244 consecutive patients with coronary artery disease who received ICDs at our institution between April 2003 and November 2010. Patients were subdivided into "statin" (n = 177, 153 males, age 67.4 ± 10.2 years) and "no‐statin" (n = 67, 56 males, age 71.4 ± 8.2 years) groups based on the use of statins. Results: Mean follow‐up was 20,6 ± 17,2 months and the two groups were homogeneous regarding antiarrhythmic therapy and ejection fraction. The overall incidence of non‐sustained (NSVTs) was lower among the statin group when compared with the no‐statin group (44 vs 31 patients, p = 0.02). No significant differences were found in the overall mortality (25 vs 12 patients, p = ns). The use of statin did not reduced significantly the occurrence of appropriate or inappropriate intervention of the device (31 vs 20 patients, p = 0.09 and 9 vs 3 patients, p = ns respectively) and of therapy. Conclusions: In our study statin therapy is associated with a lower incidence of non‐sustained ventricular tachycardias in patients with coronary artery disease and ICDs but does not influence overall mortality and appropriate or inappropriate intervention of the device. P002 QUINIDINE: AN "ENDANGERED SPECIES" DRUG APPROPRIATE FOR MANAGEMENT OF ELECTRICAL STORM IN BRUGADA SYNDROME Theofilogiannakos EK; Paraskevaidis S; Kamperidis V; Chatzizisis Y; Tsilonis K; Dakos G; Vassilikos V; Styliadis IH 1st Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessalon The clinical manifestation of Brugada Syndrome (BS) varies from asymptomatic form to electrical storm and sudden cardiac death. We report two cases of BS that were presented with electrical storm. A 38‐year‐old man, who was treated with ICD implantation two years ago presented to our emergency department with electrical storm (i.e. three episodes of ventricular tachycardia in the same day) provoking shocks from the ICD. On admission, the patient was on a febrile status due to pneumonia that may was the predisposing factor that lead to the electrical instability. The second patient was a 75‐year‐old man, who was treated with ICD implantation nine years ago, was admitted for seven episodes of ventricular fibrillation within 24 hours that was successfully treated with ICD shocks. There was no predisposing factor that could lead to the electrical instability. Since the ICD implantation both patients did not receive any medication. Both patients were started on oral hydroquinidine (600 mg twice daily), remaining electrical stable for the rest of their hospitalization. After six months of hydroquinidine treatment the patients were also asymptomatic without any recorded ICD therapy. Recently, a discussion was initiated among electrophysiologists concerning quinidine shortage in the drug market. Quinidine is effective medical treatment for patients with short QT syndrome, BS and a subgroup of idiopathic ventricular fibrillation. Electrical storms in patients with the above syndromes should be treated with ICD. However, since ICD does not prevent the occurrence of arrhythmias, oral quinidine could be a reasonable choice for long‐term prevention of life‐threatening tachyarrhythmias. P003 SMALL NUMBER OF CANDIDATES FOR ANTIARRHYTHMIC DRUGS IDENTIFIED BY DATA FROM IMPLANTED PACEMAKERS Fisher JD; Yedlapati N; Rosal‐Greif V Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA Background: Modern pacemakers (pacers) quantify atrial fibrillation (AF) episodes and overall burden (% of time in AF). Many AF episodes are asymptomatic but still can be stroke risks. Records of 742 consecutive pacer checks were reviewed by a single investigator (JDF). Objective: To determine see how many patients (pts) had AF and might be candidates for antiarrhythmic drug (AAD) therapy. Methods: Charts were reviewed on or near the day of the in‐office pacer check. Pts were considered potential candidates for AAD therapy if they had dual chamber pacers (DDD), and electrograms showing AF or flutter burden between 1% and 99%, confirmed after 1 more month. 80% of patients had dual chamber pacers. Patients with single chamber pacers were excluded because in our practice these are used in AF patients when there is no intention of restoring sinus rhythm. Other exclusions were: Severe Co‐Morbidities – 9; Demented, aged – 10;Already on AAD – 8; MDs refused – 4;Patient refused – 17; AF disappeared – 8Chronic AF – 2; Language barrier – 13;Died – 1; SVT not AF – 2; Lost – 4; Moved – 2; Too Recent implant – 1 There were 11.3% non‐excluded DDD Patients with 1–99% AF. The Average% AF (Burden)was 24%. Conclusion: AF can be detected and quantified in DDD pacemaker patients, but only a low percentage go on to have appropriate antiarrhythmic drugs administered. P004 CHRONIC USE OF AMIODARONE IN ICD RECIPIENTS Santini L; Cioè R; Magliano G; Viele A; Minni V; Forleo GB; Mahfouz K; Sergi D; Topa A; Romeo F Department of Cardiology, University of Rome "Tor Vergata," Rome, Italy Purpose: Amiodarone is one of the most studied and used drug to treat life‐threatening ventricular arrhythmias. The aim of our study was to evaluate the influence of use of amiodarone on the outcomes of patients receiving implantable cardioverter defibrillator (ICD). Methods: We enrolled 428 consecutive patients (358 males, mean age 66,8 ± 11.3 years) who underwent ICD implantation at our Institute between September 2003 and January 2011. We subdivided patients in two groups regarding the used of amiodarone in chronic treatment. The Amiodarone + group (n = 161 patients, 139 males, 68.2 ± 10.6 years) and the Amiodarone‐ (n = 267, 219 males, 66.0 ± 11.6 years). Results: Groups resulted to be homogenous regarding age, sex, ejection fraction and underlying heart disease. After a mean follow‐up of 22,1 ± 18.0 months, 38 patients (23.6%) in Amiodarone + group experienced appropriate discharges versus 46 patients (17.2) in the Amiodarone − group (p = ns); while the incidence of inappropriate discharges was 5% (8 pts) and 6.7% (18 pts) respectively (p = ns). The incidence of TVNS was 26% (42 pts) vs 34% (91 pts) respectively (p = ns). No significant difference was found about mortality due to cardiovascular diseases (10/161 pts vs 18/267, p = ns). Conclusions: As reported by major clinical trials only the use of ICD influence mortality when compared to antiarrhythmic treatment. The chronic use of amiodarone in ICD recipients does not influence occurrence of major arrhythmic events, nevertheless reduces total number of events per patient. P005 ATRIAL TACHYARRHYTHMIA DECREASES VENTRICULAR MICROPERFUSION DURING AMIODARONE BUT NOT DURING DRONED‐
ARONE TREATMENT Hammwohner M; Bukowska A; Sixdorf A; Roehl FW; Lendeckel U; Goette A St.Vincenz Hospital Paderborn, Germany Atrial fibrillation (AF) is associated with an increased risk for acute coronary syndromes. AF‐induced ischemia seems to be related to disturbance of ventricular microcirculation. This study was conducted to evaluate the effects of dronedarone (DRO) and amiodarone (AMIO) infusion on ventricular macro‐ and microperfusion during rapid atrial pacing (RAP). Coronary flow reserve (CFR, microvascular perfusion marker) and fractional flow reserve (FFR, epicardial coronary artery flow marker) were determined in the left anterior descending artery in 30 pigs using a sensortipped thermodilution and pressure guidewire. Measurements were conducted at baseline, and after 6h of RAP with 600 bpm and/or DRO/AMIO infusion. RAP alone was performed in 6 pigs, 6 animals underwent RAP with DRO i.v. (10mg/kg) and 5 with AMIO i.v. (5mg/kg). 6 pigs were instrumented without intervention (Sham), 7 animals received DRO alone. FFR measurement (baseline = 100%) revealed a decreased FFR only in RAP and AMIO animals after 6h compared to all other groups (RAP:93 ± 6%; RAP + AMIO:82 ± 20%; p < 0.05). However, FFR did not drop below <0.8 in any animal. DRO infusion increased FFR compared to RAP after 6h (DRO:105 ± 5% vs RAP:93 ± 6%; p < 0.05). RAP and AMIO significantly decreased CFR (baseline = 100%) when compared with any other group (RAP:57 ± 11%; RAP + AMIO:54 ± 18% vs Sham:103 ± 14% vs RAP + DRO:96 ± 13% vs DRO:110 ± 17%; p < 0.05). DRO infusion abolished RAP induced decrease in CFR with a tendency towards an increased CFR compared to baseline (+10%). DRO infusion did not alter QTc compared to Sham. QTc increased in the DRO group (baseline Qtc 372 ± 10ms vs 6h DRO 408 ± 36ms). There were no significant differences in cardiac or systemic hemodynamic parameters between all groups. RAP impaires left ventricular microcirculation. DRO but not AMIO exerted vasodilatory effects in coronary arteries and improved microcirculation, thus abolishing RAP‐induced microvascular flow disturbances. P006 CONVERSION EFFICACY OF PROPAPHENONE IBOUTILIDE AND AMIODARONE IN MEN AND WOMEN WITH PAROXYSMAL ATRIAL FIBRILLATION OF RECENT ONSET Panageas V; Zika A General Hospital of Pyrgos Introduction: We aimed to determine whether the efficacy of antiarrhythmic agents is associated with sex, in patients with Paroxysmal Atrial Fibrillation of 3–48h. duration (PAFib). Methods used: We have observed 94 patients (64 men and 30 women). with PAFib. Patients were treated with Propaphenone (PR.), Ibutilide (IB) or Amiodarone (AMIO). If sinus rhythm was not restored with the first drug we used another one. Successful cardioversion was defined as arrhythmia termination within 48 hours. The results were analysed using Fisher's exact test. Summary of Results: Of 94 patients 89 were restored (95%). 60 men (93,75%) and 29 women (96,77%) were restored (p‐value = 1). As regards Propaphenone we used it as a 1st choice in 32 men (efficacy: 81,25%) and in 15 women (efficacy: 93,34%)(p = 0,6599). Propaphenone was never used as a 2nd choice). Amiodarone was used in 21 men as a 1st choice, with 90,5% efficacy and in 4 men as a 2nd choice, with 75% efficacy. In women it was used only as a 1st choice in 5 cases with 80% efficacy. (Amiodarone: p = 0,5153 as a first choice and 1,0000 as a 2nd choice). Finally, Iboutilide was used in 11 men and 10 women as a first choice and in 4 men and 1 women as a 2nd choice with efficacy 100% (in all of theme) (so p = 1,0000). Conclusions: In Southern‐West Greece the association between the gender and the conversion rate of antiarrhythmic drugs is not statistically significant. P007 ATRIAL EXCITATION PATTERNS OF REFRACTORY AND NON REFRACTORY TO PROPAPHENONE RECURRENT PAROXYSMAL ATRIAL FIBRILLATION Dakos G; Vassilikos V; Chouvarda I; Chatzizisis I; Mantziari L; Kamberidis V; Paraskevaidis S; Tsilonis K; Maglaveras N; Styliadis I 1st Cardiology Dept., Aristotle University of Thessaloniki, Greece The aim of this study was to associate the effects of propaphenone on the atrial excitation patterns of the recurrent paroxysmal atrial fibrillation (PAF), with P wave wavelet analysis. Methods: Thirty‐three PAF patients (20 males, mean age 60 ± 11 years) who received propaphenone, were divided into 2 Groups, after were followed for 2.3 ± 0.4 years. Nine patients (5 males, mean age 61 ± 7years) with multiple AF recurrences (>5 /year) were consisted Group A, while twenty‐four patients (15 males, mean age 60 ± 12 years) with less than 2 recurrences/year were consisted Group B. Two consecutive recordings were obtained, before and 37 ± 6 days after propaphenone administration with a 3 – channel digital recorder for 10 minutes and digitized with a 16–bit accuracy at a sampling rate of 1000 Hz. The P wave was analyzed using the Morlet wavelet and wavelet parameters expressing the mean and max energy of P wave were calculated in the three orthogonal leads (X, Y, Z) and in the vector magnitude (VM), in three frequency bands (1st: 200–160 Hz, 2nd: 150–100 Hz and 3rd: 90–50 Hz). The P wave duration was also measured in these axes and in the VM. Paired‐samples T‐test was used for comparing continuous variables. Results: After propaphenone administration, Group A patients showed higher mean and max energy values in the 2nd and 3rd frequency bands at Z axis, while Group B patients had shorter P wave duration at Z axis along with higher max energy values in the 1st and 3rd frequency bands at X axis and mean and max energy values in all frequency bands at Y axis. Conclusion: The refractory and non refractory to propaphenone recurrent PAF are associated with specific effects of propaphenone on the atrial excitation patterns, that can be revealed with P wave wavelet analysis. ATRIAL FIBRILLATION ABLATION P008 LONG‐TERM RESULTS OF BALOON CRYOISOLATION OF PULMONARY VEINS IN PATIENTS WITH PAROXYSMAL OR PERSISTENT ATRIAL FIBRILLATION Misikova S; Stancak B; Spurny P; Komanova E; Olexa P; Machacova Z; Sedlak J; Sudzinova A East Slovakia Institute of Cardiovascular Diseases, Kosice, Slovakia Introduction: Balloon cryoisolation of pulmonary veins is a novel method for treatment of atrial fibrillation. The aim of this study is to evaluate it's mid‐ and long term effectiveness in reducing the occurrence of atrial fibrillation. Patients and methods: We evaluated 95 patients with paroxysmal or persistent atrial fibrillation (mean age 58,6 ± 5,1 years, 62 men, 33 women) who underwent cryoisolation of pulmonary veins with 28 mm and 23 mm balloon size. The ablation protocol consisted of application of cryoenergy with duration of 900–1200 s into the ostium of each vein and check for the isolation with normal lasso or special microcircular catheter. The ambulatory evaluation via 24 Holter monitoring was repeated in 6 and 12 months. Results: We successfully isolated 361 (95%) pulmonary veins, veins without reach of balloon catheter were 19 (5%). Fluoroscopy time was 25 ± 10 min., procedural time 174 ± 79 min, average ACT during the ablation was 281 ± 38 s. The freedom of atrial fibrillation based on Holter data and patient's reports in 6 and 12 months was 68% and 65% respectively with more success in paroxysmal atrial fibrillation group. The phrenic nerve palsy was found in 5 patients, in 4 of them resolved within 6 months. Small pericardial effusion without the need of intervention was found in 1 patient, and femoral pseudoaneurysm managed by vascular surgeon in 1 patient. Conclusion: Balloon cryoisolation of pulmonary veins is fast, effective and safe ablation method. Long‐term success rate is comparable with conventional radiofrequency ablation especially in paroxysmal forms of atrial fibrillation. P009 PREVENTION OF POST OP ATRIAL FIBRILLATION WITH SURGICAL PULMONARY VEIN ISOLATION Ayala‐Paredes FA; Lavallee L; Lessard N; Teijeira J CHUS Universite de Sherbrooke Background: Post operative atrial fibrillation (Afib) is highly prevalent after CABG surgery; surgical pulmonary vein isolation, would reduce the risk of post operative AFib in patients (pts) with high risk. Methods & Results: Pts at least 65 years old with either hypertension or diabetes, but not previous Afib were randomized (1:1) to a CABG only (controls) or CABG + Cardioblate BP2 (Medtronic) to isolate four pulmonary veins (PV isolation) during the bypass surgery, plus left atrial appendage exclusion. A Reveal XT was implanted for long term monitoring. End point was any Afib lasting 2 min or longer before discharge. 42 pts were studied to date (from 50 expected), 88% men; with no complications and non significant changes in surgical times due to the addition of PV isolation. There were no differences in basal characteristics, diabetes or hypertension rates; beta –blockers or ACE/Ang II inhibitors use, but a marked reduction of new atrial fibrillation in patients with pulmonary vein isolation. In hospital Afib was present in 68.4% of controls versus 26.09% of PV isolation pts (p = 0.06). At 30 days Afib rate was 21.1% in controls versus 8.6% in PVI pts (p = 0.2). Most of patients (64.8%) with post op AFib received amiodarone for at least 30 days (47.4% group control vs 17.4%; (p = 0.049). Total surgical times were similar in both groups 206 (± 57 min) for controls versus 198.7 (± 30.3 min) in PVI pts (p = 0.8) as total hospital stay 8.21 (± 4.3 days) in controls versus 8.7 (± 3.9 days) in PVI pts (p = 0.7). Conclusion: A simple and time efficient surgical technique could significantly decrease the incidence of post operative atrial fibrillation, in pts with no history of atrial fibrillation, but high risk profile. This could decrease time to discharge and need of anti‐arrhythmic or anticoagulant therapy. This approach merits a wide scale validation as it could change the way CABG pts are managed. P010 PREVALENCE OF RIGHT ATRIAL THROMBUS ON THE TRANSEPTAL SHEATHS DETECTED BY INTRACARDIAC ECHOCARDIOGRAPHY DURING CATHETER ABLATION FOR ATRIAL FIBRILLATION WHILE ON THERAPEUTIC COUMADIN Di Biase L; Santangeli P; Bai R; Sanchez J; Mohanty P; Horton R; Lakkireddy DJ; Raviele A; Burkhardt JD; Natale A Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA Introduction: The reported prevalence of left atrial thrombus formation on the transseptal sheath detected by ICE ranged from 5 to 10.3% in patients undergoing pulmonary vein isolation (PVI) for atrial fibrillation (AF). Aim of our study was to report the prevalence of thrombus on the transeptal sheath placed in the right atrium (RA) before the transeptal access in patients undergoing PVI. Methods: Data from 4 centers performing catheter ablation of AF under ICE guidance and utilizing an open irrigated catheter have been collected. Before transeptal, a bolus of i.v. Heparin (10000 UI) was administered. Sheaths were continuously irrigated with heparinized saline and ACT was kept above 300 sec with additional bolus of i.v. heparin when required. Before administration of i.v. heparin, we assessed the prevalence of thrombus attached to the transeptal sheath placed in the RA. Results: Data from 2773 patients were analyzed. 1749 patients underwent PVI without Coumadin discontinuation with a mean INR of 2.46 + 0.32 while 1024 patients underwent PVI after Coumadin discontinuation 3 days preceding the PVI. In all patients the right thrombus was detected by ICE during transeptal access or immediately after the first transeptal puncture. The prevalence of right thrombus on the transeptal sheath was found in 9% (158 pts) of patients on 'therapeutic" Coumadin before PVI and in 8.6% (88 pts) of patients off Coumadin before PVI (p > 0,001). In all cases the right thrombus have not been aspirated but only monitored during the whole procedure by ICE. No parameter included in the baseline characteristics of the patients was found to be a predictor of this finding. Conclusions: Our study shows that thrombus on the transeptal sheaths is detected by ICE in about 9% of the patients undergoing PVI despite a therapeutic "INR". These results suggest that administration of i.v. heparin before transeptal access is required even in patients with "therapeutic" INR. P011 LEFT ATRIAL SPONTANEOUS ECHO CONTRAST IS CLINICAL PREDICTOR FOR THE RECURRENCE OF ATRIAL FIBRILLATION AFTER CATHETER ABLATION? Kim M‐N; Park S‐M; Shim W‐J; Choi J‐I; Park S‐W; Kim Y‐H Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine Background: Left atrial spontaneous echo contrast (LASEC) is known as one of markers of thrombogenic milieu in patients with atrial fibrillation(AF). But it was not examined that SEC has a influence on the recurrence of AF after catheter ablation. Method: 229 patients with non‐valvular AF who underwent catheter ablation for AF were enrolled and performed trans‐thoracic echocardiography (TTE) and trans‐esophageal echocardiography (TEE) before procedure. SEC was diagnosed by TEE as the presence of smoke‐like echogenic materials which swirled in the cavities. And other 2D‐echocardiography parameters were measured. Result: Left ventricular ejection fraction (LVEF) of patients with (+) SEC was mildly decreased than in patients without SEC (55.5 ± 5.8% vs. 56.4 ± 3.7%, P = 0.003). E/e' ratio, the marker of diastolic function of the LV was larger in patients with (+) SEC than in patients without SEC (10.8 ± 5.9 vs. 8.7 ± 2.9, P = 0.004). Ablation time was longer in patients with (+) SEC than in patients without SEC (91 ± 59 min vs. 88 ± 34 min, p < 0.001). Patients with (+) SEC had a non‐significant, but higher incidence of AF recurrence after ablation (25.9 vs. 20.1%, P = 0.45). Conclusion: LASEC was closely associated with LV systolic and diastolic function as well, however, was not significantly related to clinical outcome after catheter ablation of AF. Further study including large number of the patients is warranted. P012 LONG TERM RESULTS OF ABLATION FOR LONE ATRIAL FIBRILLATION VIA RIGHT MINITHORACOTOMY: TOWARDS A RATIONAL REVISION OF TREATMENT PROTOCOLS Nasso G; Bonifazi R; Romano V; Visicchio G; Fiore F; Speziale G GVM Care & Research, Bari, Italy Objective: Despite continued technical improvements, the results of transcatheter radiofrequency ablation of atrial fibrillation may be suboptimal in some patients subgroups. The short‐term follow‐up results of the minimally invasive epicardial ablation of lone atrial fibrillation were encouraging. Methods: One‐hundred‐four patients with drug‐refractory lone atrial fibrillation underwent minimally invasive surgical ablation with a right 3–4 cm minithoracotomy by isolation of the pulmonary veins, and were followed‐up for average 17 months. Previous failed transcatheter ablation was not an enrolment criterion for this procedure in the last phase of our experience. Results: The procedure is confirmed to be safe (one case of procedure‐related morbidity, no operative deaths) and effective (89% overall freedom from recurrent arrhythmia at follow‐up with 96 freedom from arrhythmia for paroxysmal AF Type and 80% free for persisting AF).The results tend to improve with the expansion of the surgical experience. Cox hazards regression and Kaplan‐Meier analysis identified persisting type of atrial fibrillation and enlarged left atrium as the major predictors of recurrent atrial fibrillation at follow‐up. Health‐related quality‐of‐life is confirmed improved at the end of the follow‐up vs. baseline in the majority of the SF‐36 domains. Conclusions: The minimally invasive epicardial ablation of lone atrial fibrillation yields stable and gradually improving results. Earlier referral of patients to surgery is justifiable after a careful cardiologic work‐up. In order to define the relative roles of the minimally invasive ablation and the transcatheter ablation, which may be considered in the future as alternative therapies, a randomized trial of these two procedures is advisable. P013 A RANDOMISED CONTROLLED TRIAL OF CATHETER ABLATION VERSUS MEDICAL TREATMENT OF ATRIAL FIBRILLATION IN HEART FAILURE (THE CAMTAF TRIAL) Hunter RJ; Berriman TJ; Diab I; Baker V; Richmond L; Abrams D; Dhinoja M; Earley MJ; Sporton S; Schilling RJ Cardiology Research Department, St Bartholomew's Hospital Introduction: We sought to compare the impact of a catheter ablation strategy (CA) to a medical rate control strategy (MED) in patients with persistent atrial fibrillation (AF) and heart failure (HF). Methods: Patients with persistent AF, symptomatic HF, and a left ventricular (LV) ejection fraction (EF) < 50%, were randomised to CA or MED. HF medication and anticoagulation were optimised prior to baseline observations. For those with recurrent AF in the CA group, a repeat procedure was performed at the end of the 3 month blanking period and follow up re‐started. The primary end‐point was the difference in LV EF between groups on echocardiography at 6 months. Echocardiographic data were anonymized and core reported by a blinded collaborating centre. Results: 54 patients were randomised, but 5 were excluded (LV normalised during optimisation of medications prior to baseline tests in 2, and 3 withdrew un‐happy with their treatment allocation). Patients were 58 ± 11 yrs and 96% were male. Baseline EF was 31 ± 10% in the CA group and 33 ± 9% in the MED group. NYHA class was 2.5 ± 0.5 in both groups. Patients underwent 1.6 ± 0.7 procedures. There were 2 complications: 1 stroke and 1 tamponade. In the CA group 1 patient withdrew after a procedural stroke, and in the MED group 1 patient died. All 21 remaining in the MED group, and the 24 of 26 in the CA group that had reached 6 months follow‐up were included in the analysis of the primary end‐point. Freedom from AF was achieved in 21/24 (88%) off antiarrhythmic drugs. LV EF in the CA group at 6 months was 39 ± 10% compared to 32 ± 13% in the MED group (p < 0.05). NYHA class was also significantly lower in the CA group (1.7 ± 0.8 compared to 2.3 ± 0.6 in the MED group; p < 0.05). Conclusions: CA is effective in restoring sinus rhythm in patients with persistent AF and HF, and improves LV function and heart failure symptoms compared to medical treatment alone. P014 A NOVEL APPROACH TO MINIMALLY‐INVASIVE ABLATIVE MAZE SURGERY FOR REFRACTORY LONE ATRIAL FIBRILLATION Benussi S; Pozzoli A; Taramasso M; Dorigo E; Calabrese M; Nascimbene S; Anzil F; Alfieri O San Raffaele University Hospital, Cardiothoracic Surgery Department Purpose: One of the main limitations of the Maze is the requirement of median sternotomy. This, has limited the popularity for the surgical treatment of lone atrial fibrillation (AF) despite its recognized superior efficacy. We evaluated the outcomes of an original technique, devised to perform a complete MazeIII procedure with bipolar radiofrequency (RF), through a minimally‐invasive approach. Methods: The procedure was carried out through right minithoracotomy. Cardiopulmonary by‐pass was instituted through peripheral venous and arterial cannulation. After cross‐clamping, all Maze III ablations were performed using a new glidepath‐guided, articulated bipolar RF clamp, including a complete box around the 4 pulmonary veins. If needed, mitral and tricuspid connecting ablations, were completed using cryoenergy. Results: 14 patients were included (13 male; mean age 53 ± 9.6 years). All patients had highly symptomatic persistent (5/14 patients, 35%) or long‐standing persistent (9/14 patients, 65%) lone AF, refractory to a median number of 3 percutaneous ablations (min 1, max 5). The mean duration of AF before surgery was 117 ± 68.4 months, and mean hospital stay was 12 ± 6.7 days. Procedural success rate was 93% (13/14). There was no operative mortality or major complications. No patient required a permanent pacemaker. Follow‐up was complete for all patients, with a mean period of 13 ± 7.7 months and 13/14 patients were in stable sinus rhythm at latest follow‐up. Three months after surgery, left ventricular ejection fraction improved significantly (from 55.2%± 5.9% to 63%± 3.8%, p = 0.007). Furthermore, after surgery, EHRA score decreased by ≤ 2 in 9 patients (64%) and NYHA functional class also improved by ≥ 1 in 11 cases (78%). Conclusions: A MazeIII procedure can be reproducibly performed through right minithoracotomy using an articulated bipolar RF clamp and cryoenergy, with excellent mid‐term results. Maze surgery with bipolar RF can thus be performed through minithoracotomy safely, without compromising efficacy. P015 EVALUATION OF ECHOCARDIOGRAPHIC TECHNIQUES SENSITIVITY FOR GUIDING TRANSEPTAL PUNCTURE Ardashev AV; Zhelyakov EG; Rybachenko MS; Konev AV; Kuzovlev OP; * Belenkov YuN 83 Clinical Hospital of FMBA, * Lomonosov State University, Moscow, Russia Objective: to compare the sensitivity of transthoracic (TTE), transesophageal (TEE) and intracardiac (ICE) echocardiography for guiding transeptal puncture. Methods: The study concluded of 208 pts (48 female, mean age was 56.4 ± 11.3 years) who underwent RFA of left atrium because of atrial fibrillation. Transeptal puncture was performed after interatrial septum (IAS) visualization using TTE in 32 (15.4%), TEE – in 26 (12.5%), ICE – in 150 (72.1%) pts. ICE was preformed using the electronic phased‐array intracardiac ultrasound catheter sector imaging system (AcuNav, Siemens). Optimal contact of transeptal needle with IAS was defined as a tension of septum using echocardiographic techniques. Verification of tenting and following transeptal puncture with LA catheterization defined as a true positive result. Lack of visualization of tenting with successful transeptal puncture under fluoroscopy was defined as a false negative result. Results: Clear visualization of the IAS using TTE technique was demonstrated in 2 (6%) cases, and the sensitivity amounted for 6.7%. Obvious verification of IAS by TEE was revealed in 20 (77%) pts, and sensitivity of this technique was 86.9%. ICE control of septum puncture was performed in 127 pts. ICE allowed visualizing septum and tenting in 125 pts and the tension of septum was unable to be determined in 2 cases despite of the efforts of specialists. ICE sensitivity for IAS verification was 98.4%. Conclusion: In our study we estimated that ICE is the most sensitive ultrasound technique for obvious verification of optimal location of the transeptal needle in the region of IAS comparing with TTE and TEE. P016 ABLATION OF LONG‐LASTING PERSISTENT ATRIAL FIBRILLATION BY INTRAPROCEDURAL USING OF IBUTILIDE TO IDENTIFY PERSISTENT CFAES: RESULTS FROM A RANDOMIZED STUDY COMPARING TWO DIFFERENT STRATEGIES Rebecchi M; de Ruvo E; Sciarra L; De Luca L; Pitrone P; Guarracini F; Zuccaro LM; Dottori S; Verlato R; Calò L Policlinico Casilino, Rome, Italy. Introduction: Ablation of long‐lasting (LL)‐persistent atrial fibrillation (AF) is highly variable, with different strategies and outcome. We sought to compare RF ablation of CFAEs in right (RA) and left atrium (LA) identified by using endovenous low‐dose of ibutilide plus pulmonary veins isolation (PVI) with linear lesions in LA plus PVI. Methods: Fifty‐four symptomatic patients with LL‐persistent AF, refractory to AADs, were randomized to two different ablation approach. Twenty‐seven patients (group A; mean age 58.7 ± 7.4 years, 14 males) underwent PVI plus bi‐atrial ablation of CFAEs areas identified prior and post endovenous low‐dose of ibutilide (0.5 mg) administration. The remaining 27 patients (group B; mean age 58.6 ± 9.4 years, 14 males) underwent PVI and linear lesions (roof and mitral isthmus) in the LA. Results: All patients completed ablation procedure without complications. In the group A, the prevalence of CFAEs before ibutilide administration was higher in the LA than in the RA (35.4% vs 21.2% P = 0.016). After ibutilide administration, AF cycle lenght significantly decreased if compared with baseline (264.2 ± 51.9 vs 153.4 ± 33.9, P = 0.0001) and CFAEs prevalence was globally reduced of 69.4% (P = 0.001) in LA and of 81.7% (P = 0.001) in RA. Complete PVI was performed in all patients of both groups. Complete mitral isthmus and roof conduction block was observed in 15 (55%) and in 24 (88%) patients of group B, respectively. After a mean follow up of 13 ± 8 months, 22 (81.4%) patients of group A and 9 (33.3%) patients of Group B were free from AF recurrences (P = 0.001). Conclusion: In patients with LL‐persistent AF, PVI plus bi‐atrial ablation of CFAEs after ibutilide administration is safe and more effective in term of success rate if compared with PVI plus linear lesions approach. This study suggests the utility of intraprocedural use of ibutilide to perform ablation of persistent CFAEs that could be critical for the maintenance of AF. P017 CRYOBALLOON‐ABLATION TO TREAT PARO‐
XYSMAL ATRIAL FIBRILLATION USING ELECTROANATOMICAL VOLTAGE MAPPING:
WHAT IS THE LEVEL OF PULMONARY VENOUS ISOLATION? Catanzariti D; Maines M; Angheben C; Cirrincione C; Vaccarini C; Vergara G Division of Cardiology, S. Maria del Carmine Hospital, Rovereto (TN) – Italy Background: Balloon‐based technology and cryoenergy were recently introduced to increase the safety of procedure and to reduce discontinuity of circular lesions around pulmonary veins (PVs), by avoiding a major role in the outcome of the operatory dexterity. However relatively unknown remains the exact level of PVs isolation induced by cryoballoon‐ablation (CBA). Methods: In 22 consecutive patients undergoing CBA for paroxysmal or short standing persistent atrial fibrillation after prior MRI data acquisition, 3D reconstruction of the LA could be generated using the EnSite Verismo Software incorporating the 3D reconstruction of the LA created by MRI. This software was also used for measuring distances and the diameter of various anatomical structures and for reconstructing the complete "true" 65533 anatomy of PVs antra. Using preselected amplitude voltage limits of 0.05–0.5 mV and differential pacing techniques, the topographic extension of PVs isolation was assessed after CBA. Results: All 80 PVs of patients study were isolated by CBA (including 9 left common trunk and 1 right middle accessory veins). An antral level of isolation was observed in the vast majority of PVs with severe reduction of voltage outside the tubular portion of PV and at various extent proximal to the PV ostium. Indirect approaches to CBA were preferred in 42% of cryofreezes to enlarge the perivenous atrial lesions, while the coaxial approach was reserved in the remaining cases. Conclusion: CBA exerts its effects on electrical isolation at the antral level of PV ostia largely resorting to indirect approaches for achieving mechanical occlusion during cryoenergy delivery. P018 PVI IN 2011: IS IT NECESSARY TO PERFORM A DETAILED TIME CONSUMING ELECTROPHYSICAL MAPPING OR SHOULD WE FOCUS ON A RAPID AND SAFE THERAPY? A COMPARISON OF DIFFERENT ABLATION TOOLS Maagh P; Butz T; van Bracht M; Trappe HJ; Meissner A Department of Cardiology and Angiology, Cologne gGmbH, Hospital Merheim/Germany Background: PVI is an established treatment option in the field of drug refractory atrial fibrillation (AF). Different ablation tools are available, comparisons between procedure duration (PD) and fluoroscopy time (FT) are lacking. Objective: We compared PD and FT using I) the High Density Mesh Mapper (HDMM) with irrigated‐tip radiofrequency (RF) for antral ablation, and II) the single device RF technique of the High Density Mesh Ablator (HDMA), and III) the "single shot" device of the Arctic Front Cryoballoon with cryothermal energy. Methods: In our single center between August 2007 and March 2010, a series of 111 PVI procedures were performed in paroxysmal AF (PAF) and persistent AF (persAF) patients (mean age 59.7 ± 9.9 years with a 6.4 ± 4.4 years history of PAF (67 patients, 60.4%) and persAF (44 patients, 39.6%)). PD and FT were entered into a retrospective database. Results: The procedures included 42 PVIs with the HDMM (37.8%), 47 with the HDMA (42.3%) and 22 with the cryoballoon (19.8%). Comparing the 30 first procedures in groups of 10 in the HDMM and HDMA group, PD and FT fell in the HDMM group (257.5 to 220.9 min and FT from 80.5 to 67.3 min (both p < 0.005) as well as in the HDMA group (182.9 to 147.2 min and FT from 41.02 to 29.1 min). In the cryoballoon group, there was a steep learning curve with a steady state after the first 10 procedures (PD and FT decreased from 189.5 to 151.0 min and 36.9 to 33.0 min, p values 0.005 and 0.05 respectively). Severe complications did not occur. Conclusion: The cryoballoon technology had the shortest PD and FT. The strongest indicators of quality of ablation should include PD and FT as well as the efficacy to prevent AF recurrence. Further studies will show if we should adopt a "wait‐and‐see" attitude referring the AF recurrence or if the time for correct mapping of the PV potentials is a price we should be willing to pay. P019 INITIAL RESULTS OF PURSE‐STRING PV BOX ISOLATION PROCEDURE FOR NON‐MITRAL ATRIAL FIBRILLATION Imai K; Sueda T; Bagus H; Katayama K; Takahashi S; Takasaki T; Kurosaki T; Uchida N Department of Cardiovascular Surgery, Hiroshima University Hospital Introduction: Although less invasive procedure for atrial fibrillation (AF) such as catheter ablation or minimally invasive surgery diminished AF with high success rate, several problems still remain unsolved, including repeat sessions or uncertainly of ablation tools. We have performed surgical PV Box isolation (PVBI) for AF combined with mitral valve disease (MVD) with good success rate, however, PVBI for non‐MVD is invasive because of its incision line. We have developed less invasive surgical procedure, purse‐string PBVI with certain ablation line for non‐MVD AF. Method: Seven non‐MVD paroxysmal AF (pAF) cases (3 ASD, 2 AVR 1 TVR and 1 OPCAB) that have indication for surgical intervention, were received PVBI. Box ablation line was created by using bipolar radiofrequency surgical device which can create a long (about 7 cm) continuous transmural lesion. At first, bilateral epicardial PV isolation line was made and second, upper and lower connecting line was added without incision of left atrial wall using purse‐string technique: one‐half of ablation jaw was inserted into the left atrium through a purse‐string suture on the right PVs toward the left PVs. All patients were received continuous monitor ECG (in hospital) and Holter ECG of every 6 month (after discharge), AF recurrence was estimated by more than 5 minutes duration. Result: No complications or death were procedure related. At discharge, freedom from AF was 86%. In the patients of AF free at discharge, 100% of patients were free from pAF at averaged 13 months follow‐up. Conclusion: Purse‐string PVBI can be a less invasive and effective procedure for non‐MVD pAF. P020 PULMONARY VEIN ISOLATION WITH THE PULMONARY VEIN ABLATION CATHETER VERSUS CONVENTIONAL POINT‐BY‐POINT ABLATION USING THE CARTO SYSTEM: A LARGE, COMPARATIVE, SINGLE CENTRE STUDY De Greef Y; Segers V; Schwagten B; De Keulenaer G; Stockman D Department of Cardiology, Antwerp Cardiovascular Institute Middelheim, Belgium Aim: To compare pulmonary vein isolation (PVI) using the pulmonary vein ablation catheter (PVAC) with conventional PVI guided by CARTO. Methods: Two‐hundred consecutive patients with paroxysmal atrial fibrillation (AF) and left atrial (LA) diameter of <50 mm underwent either CARTO‐ (N = 100) or PVAC‐guided (N = 100) PVI. Follow‐up (symptoms and Holter) was performed at 1 month and every 3 months thereafter. Repeat ablation was guided by a circular catheter and CARTO to describe PV reconnection characteristics. Results: Clinical characteristics were similar. Successful PVI was obtained in 378 out of 390 (97%) veins in the PVAC vs. 393 out of 393 (100%) in the CARTO group. At 1 year follow up, 73 patients in the PVAC group were free of AF compared to 67 of CARTO patients (P NS). Procedure time was significantly shorter in the PVAC group (126 ± 44min vs. 201 ± 44, p < 0.0001). At repeat, the N (total (%)/per patient) of reconnected PV's was similar after PVAC (19 patients; 50 (66%)/2.7 ± 1.1) and CARTO (20 patients; 50 (63%)/2.4 ± 1.4) (P NS). Neither the N (total/per patient (PVAC N 44; 2.3 ± 0.9 vs CARTO N 59; 3.0 ± 1.6, P NS) nor spatial distribution of conduction gaps differed between both groups. PV stenosis occurred more significantly after PVAC (4 vs. 0, p < 0.05) while pericardial injury (8 vs. 0, p < 0.05) and LA tachycardia (9 vs. 3, p < 0.05) were more frequent after CARTO. Conclusions: Pulmonary vein isolation using the PVAC catheter is as efficient but significantly faster than the conventional approach. Whereas findings at repeat were similar, their safety profile differs significantly. P021 CATHETER ABLATION OF ATRIAL FIBRILLATION IN PATIENT WITH MECHANICAL MITRAL VALVE: PVAI VS. TRIGGER ABLATION Bai R; Di Biase L; Mohanty P; Santangeli P; Mohanty S; Pump A; Sanchez J; Burkhardt JD; Horton R; Natale A Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA Background: It has not been reported whether trigger ablation prevents more arrhythmia recurrences than standard pulmonary vein antra isolation (PVAI) in patients with mechanical mitral valve (MMV) undergoing ablation of atrial fibrillation (AF). Methods: 109 patients with MMV who underwent ablation for either persistent (N = 70) or paroxysmal (N = 39) AF were divided into 2 groups: standard PVAI was performed in Group 1 (N = 45); in Group 2 (N = 64), in addition to PVAI, an isoproterenol challenge up to 30μg/min was performed and ectopic atrial beats or tachycardias (trigger activities) arising from extra‐PV foci were abolished. RF was delivered with a 3.5mm open irrigated‐tip catheter guided by CARTO map. The endpoint of procedure was complete PVAI (for both Groups 1 and 2) as well as elimination of all potential trigger sites (for Group 2). Patients were followed‐up by ECGs, transtelephonic monitoring, 7‐day Holters and office visit. Results: All patients (51 males; age 62 ± 10yrs) underwent the procedure successfully. INR on the day of ablation was 2.6 ± 0.3. There were 2 groin hematomas and 1 pericardial effusions in Group 2; while 1 diaphragmatic paralysis, 1 tamponade and 2 AV fistulae in Group 1. All except one patient in Group 2 had extra‐PV triggers. At 1‐year follow up, 39 (61%) patients in Group 2 and 7 (15%) patients in Group 1 were in sinus rhythm off AAD with single procedure (p < 0.0001). 85% of patients in Group 1 underwent redo ablation due to early recurrence of AF. Very late recurrence (32 ± 4 months) was observed in 12 (19%) patients in Group 2 and consisted of focal atrial tachycardia in 9 and atypical atrial flutter in 3 patients, which were treated with repeat ablation. Conclusion: Catheter ablation of AF in patients with MMV is feasible and safe. Trigger ablation in addition to standard PVAI was associated with less arrhythmia recurrence at follow‐up. Focal atrial tachycardia appeared to be the predominant cause of very late recurrences. P022 A FAST EVALUATION OF THE LEFT ATRIUM BEFORE ABLATION: ICETEE (INTRACARDIAC ECHOCARDIOGRAPHY PROBE USED FOR TRANSOESOPHAGEAL ECHOCARDIOGRAPHY) Schuster P; de Bortoli A; Chen J; Hoff PI Haukeland University Hospital, Department of Heart Disease, Bergen, Norway Aim: In high risk patients before atrial fibrillation (AF) radiofrequency ablation (RFA) we used nasogastrically an expired resterilized intracardiac echocardiography (ICE) probe (AcuNav, Siemens; 10 F) as a a simplified transesophageal echocardiography (TEE) procedure and registered the time consumption. Method: 25 patient (mean age 59 ± 9 years, 4 female) were examined without any form of sedation or anaesthesia using the ICEETEE method to exclude atrial thrombi and to determine left atrial (LA) appendage flow. 17 patients because of high CHADS2 score (>2), four paroxysmal AF patients not using preprocedural Warfarin, three patients admitted to RFA with AF unknown duration, one with unknown duration of a fast AFL and the purpose of DC conversion. Results: Due to previous painful and difficult gastroscopi one patient refused a conventional TEE before the RFA procedure. Despite good sedation, local anesthesia and an experienced operator including help of a gastroenterologist conventional TEE had failed in another patient. No difficulties during the nasogastric insertion of the probe were experienced in any patient. In all patients a good overview of the LA excluding thrombi and an acceptable LA appendage Doppler flow were demonstrated. The duration of the ICEETEE examination was 8 ± 2 min and a mean of 11 ± 5 loops were recorded. In the 24 RFA patients the ICEETEE procedure lasted 8 ± 3 min of the 208 ± 73 min of total procedure duration. No thrombembolic complications occurred during the RFA procedures. Conclusion: A simplified and fast risk stratification using an ICE probe nasogastrically as TEE is feasible and only 8 min (4%) of the total RF procedure time are needed to perform an ICEETEE examination. P023 EFFECT OF GENDER AND AGE ON RESULTS OF ABLATION OF PAROXYSMAL ATRIAL FIBRILLATION Rafla S; Kamal A; Kautzner J* Alexandria Univ. Cardiology Dept, Egypt and IKEM institute, Prague, Czech Republic* This analysis assesses the effect of gender and age on the results of ablation of paroxysmal AF. Methods: We studied 150 patients (pts) (86 males and 64 females) having a mean age of 51.3 yrs, who suffered from symptomatic drug refractory paroxysmal AF. Cardiac MSCT image integration to the 3D electroanatomic LA map was used in 106 pts (70.6%, however all of them underwent intracardiac echo guided imaging during the ablation procedure. 40 pts underwent manual RF ablation using CARTO, 40 pts underwent ablation using NavX system, 70 pts underwent robotic ablation using Sensui system. Pulmonary vein isolation was done to all pts using either pulmonary vein (PV) antral isolation in 116 (77.3%) or circumferential pulmonary vein ablation in 34 pts (22.7%). Circumferential PV ablation was usually associated with posterior wall ablation. Additional roof line was done in 28 pts (18.6%). All pts were followed at 3, 6, 9, and 12 months. Results: 34 patients (22.6%) developed early recurrence of AF after an initial blanking period of 3 months. We had 16 patients(10.6%) with treatment failure at short term follow up, this number increased to 18 patients (12%) at midterm follow up and further small increase to 20 patients(13.3%) at long term follow up, recurrences were any episode of AF and /or AFL/AT > 30 seconds after the blanking period. ECG during follow up: Normal SR 32 (80%), Atrial Tachycardia 4, PAF 2, A flutter 2. Complications rate: None in 92,5%, air embolism zero, cardiac tamponade zero, trivial pericardial effusion 1, groin hematoma 5%. There was no difference between males and females in success of ablation or complications. Those below age 50 and above 50 were not different in incidence of maintenance of SR or complications. Conclusions: Neither gender nor age had influence on success of ablation of AF or on incidence of complications. P024 A MIDTERM FOLLOW‐UP RESULT OF SIMPLIFIED MAZE PROCEDURE BASED ON RADIOFREQUENCY PV BOX ISOLATION Imai K; Sueda T; Bagus H; Katayama K; Takahashi S; Takasaki T; Kurosaki T; Uchida N Department of Cardiovascular Surgery Introduction: It has been reported that some less invasive modified Cox‐maze procedures were effective for limited patients. We report a midterm follow‐up result of our simplified procedure based on PV Box isolation for permanent/chronic atrial fibrillation (AF) combined with several type of organic heart disease. Methods: Among a total of 194 cases, we extracted 93 cases that received modified maze procedures; pulmonary vein box isolation (PVBI) or hybrid procedure (HBP). The HBP consisted of 1) circumferential isolation of four pulmonary veins (this is "PVBI") with monopolar or bipolar device, 2) radiofrequency ablation (RF) between PVBI‐line and mitral annulus (with monopolar or bipolar), 3) RF for RA isthmus (bottom line of Koch's triangle and between RA incision and coronary sinus orifice with monopolar or pen type bipolar) and 4) RF from IVC to RA incision line. We divided the patients based on their etiological background and analyzed the operative results in overall, every groups and between groups retrospectively. Results: Overall freedom from recurrent AF was 80% at latest follow up. The significant (p < 0.01) predicting factor of AF recurrence were AF duration, amplitude of V1‐f wave and LAD. In the patients of bi‐atrial strain (mitral regurgitation + tricuspid regurgitation), the AF free rate in the HBP group was significantly higher than that in PVBI (91% vs. 68%, p = 0.0307) without any differences of their backgrounds. Conclusions: For further improvement of operative outcomes with lesser invasion, it may be necessary to choose the tailored procedure based on the etiology. P025 USE OF PARTIALLY WITHDRAWN CORONARY SINUS CATHETER TO EVALUATE CAVOTRICUSPID ISTHMUS BLOCK DURING RADIOFREQUENCY CATHETER ABLATION Marinskis G; Aidietis A; Kaireviciute D; Jurkuvenas P; Bagdonas K Clinic of Cardiac and Vascular Diseases, Vilnius University Purpose: to assess feasibility of verification of cavotricuspid isthmus (CTI) block by evaluation of low right atrial activation sequence using coronary sinus (CS) electrode withdrawn to the inferior vena cava (IVC) orifice. Methods: in 167 patients (pts) who underwent CTI ablation for typical atrial flutter, presence of cavotricuspid block has been verified by halo catheter or evaluation of low lateral right atrial activation sequence by ablation catheter, and comparison of His bundle electrogram (HBE) and proximal coronary sinus (PCS) atrial activation timing. In all pts, decapolar CS catheters with 5 mm inter‐electrode space and 10 mm space between electrode pairs have been introduced using femoral approach. After prolongation of CTI conduction times, CS electrode was withdrawn to the IVC orifice and timing of atrial activation on the proximal (5th) pair and the 4th pair of electrodes has been compared. Results: when complete CTI block has been achieved, pacing lateral to ablation line has been accompanied by "bracketing" of low right atrial activation – activation on the proximal pair (closer to ablation line) was later than activation on the 4th pair. That was seen in 127 of patients with CTI block (sensitivity 76%, specificity 100%). In 40 pts with complete CTI block after extensive ablation close to CS ostium, either the signals on the proximal pair could not be appreciated, or atrial activation on this pair was the earliest. Conclusion: evaluation of low right atrial activation sequence by coronary sinus catheter partially withdrawn to the inferior vena cava helps to confirm cavotricuspid isthmus block after ablation. P026 SERUM n‐3/n‐6 POLYUNSATURATED FATTY ACID RATIO IS A STRONG PREDICTOR OF SINUS RHYTHM MAINTENANCE AFTER CATHETER ABLATION OF PAROXYSMAL ATRIAL FIBRILLATION Nakanishi H; Hirata A; Okada M; Kashiwase K; Nishio M; Asai M; Nemoto T; Matsuo K; Konishi S; Ueda Y Cardiovascular Division, Osaka Police Hospital, Osaka, Japan Purpose: Atrial fibrillation (AF) is the most common cardiac arrhythmia. Despite advances in rhythm control including catheter ablation (CA), the effect on secondary prevention of AF is not completely established. There have been some evidences that the n‐3 polyunsaturated fatty acids (PUFAs) have anti‐arrhythmic effects, however, these effects are controversial. The present study was designed to evaluate the effect of the serum n‐3/n‐6 PUFA ratio on the rate of SR maintenance after CA of paroxysmal AF (pAF). Methods: We assessed 38 patients with pAF. The serum n‐3/n‐6 PUFA ratio was defined as an eicosapentaenoic acid (EPA) / arachidonic acid (AA) ratio. All the serum samples were obtained before admission. In the procedure, all patients underwent bilateral extensive encircling pulmonary vein (PV) isolation. Additional procedures (left atrial (LA) linear [1 patient], complex fractionated atrial electrograms [3 patients], non‐PV foci [2 patients], or cavo‐tricuspid isthmus [15 patients]) were performed as necessary. The definition of AF recurrence was one more than 3 months after the procedure. In this study, no patients were taking purified EPA ethyl ester agent. Results: 27 patients maintained SR, while 11 patients had recurrence of AF. SR maintenance group had significant higher serum EPA/AA ratio (0.50 ± 0.20 vs. 0.29 ± 0.11, p = 0.002) than AF recurrence group. There were no significant differences between two groups in age (64.0 ± 10.6 vs. 59.3 ± 14.0 yrs, p = NS), gender (15 (56%) vs. 7 (64%) males %, p = NS), LA diameter (39.5 ± 4.4 vs. 42.5 ± 6.4 mm, p = NS), left ventricular (LV) ejection fraction (67.7 ± 5.9 vs. 68.3 ± 6.6%, p = NS), LV end‐diastolic dimension (49.1 ± 5.2 vs. 51.3 ± 4.2 mm, p = NS), CHADS2 score (0.7 ± 0.7 vs. 1.3 ± 1.1, p = NS), follow up period (11.7 ± 6.0 vs. 15.6 ± 7.8 mths, p = NS), and antiarrhythmic drugs after procedure (8 (30%) vs. 4 (36%), p = NS). Conclusions: Serum n‐3/n‐6 PUFA ratio is important for secondary prevention after CA of pAF. P027 RATIONALE AND DESIGN OF VATCAT: VIDEO‐ASSISTED THORACOSCOPIC PULMONARY VEIN ISOLATION VERSUS PERCUTANOUS CATHETER ABLATION IN ATRIAL FIBRILLATION TRIAL Velthuis BO; Stevenhagen J; Storm van Leeuwen RPH; Speekenbrink RGH; van der Palen J; Scholten MF; VATCAT Medisch Spectrum Twente Background: Recent studies have demonstrated that radiofrequency isolation of the pulmonary veins (PVI) and surgically video‐assisted thorascopic pulmonary vein isolation (VATS‐PVI) are acceptable or even superior alternatives to anti‐arrhythmic drug therapy in patients with symptomatically paroxysmal atrial fibrillation (AF). However, data comparing effectiveness in both interventions are limited. Objective: The primary objective is to compare the effectiveness of PVI and VATS‐PVI. The secondary objective is the comparison of duration and costs of hospitalization, discomfort during admission, experienced AF burden during follow‐up and time to recurrence. Methods: The Video‐Assisted Thoracoscopic pulmonary vein isolation versus percutaneous Catheter Ablation in atrial fibrillation Trial (VATCAT) is a prospective single center study. 160 patients with paroxysmal or persistent AF will be randomized to percutaneous PVI or VATS‐PVI. After a stabilization period of 90 days, which allows for a second procedure, 7‐day Holter‐ECG will be done at 3, 6 and 12 months. Treatment failure will be defined as reoccurrence of AF exceeding 30 seconds. Results: Inclusion started in August 2010, currently 40 patients are included. 22 patients were treated of which 9 received VATS therapy. Conclusion: This study should provide data on the effectiveness of either PVI strategy based on intensive rhythm observation. It is unique because, to the best of our knowledge, no previous randomized trial comparing both strategies has been published. P028 USEFULNESS OF CONTRAST INTRACARDIAC ECHOCARDIOGRAPHY IN PERFORMING PV BALLOON OCCLUSION DURING CRYO‐ABLATION FOR ATRIAL FIBRILLATION Maines M; Catanzariti D; Angheben C; Cemin C; Giovanelli C; Vergara G Division of Cardiology, S. Maria del Carmine Hospital, Rovereto (TN) Introduction: Cryoballoon ablation (CBA) has proven very effective for pulmonary vein (PV) isolation (PVI) if complete mechanical occlusion is achieved and conventionally assessed by angiographic injection of contrast within PV lumen. The aim of our study was to assess the usefulness of saline contrast intracardiac echocardiography (CE) in guiding CBA. Methods: Twenty consecutive patients with paroxysmal atrial fibrillation were assigned to fluoroscopy plus CFD (n = 10; group 1: iodinated medium as both an angiographic and an echographic contrast) versus CE plus CFD (n = 10; group 2: saline contrast) for guidance of CBA. CFD‐guidance was used only in pull‐down approaches (16% in the study) in both groups. Results: We evaluated 227 occlusion of 71 PVs. CE‐guided assessment of occlusion, defined as the loss of echocontrastographic back‐flow to the left atrium after saline injection regardless of the visualization of PV antrum, showed a high level of agreement with the angiographic diagnosis of occlusion. PVI rate was similar in both groups and effectively guided by CE (PVI using ≤ 2 double cryofreezes: 89% of PVs in gr. 1 vs 91% in gr. 2; P = n.s.). Group 2 patients (CE guidance) had significantly shorter procedure (128 ± 17 minutes vs 153 ± 18; P < 0.05) and fluoroscopy times (30 ± 11 minutes vs 42 ± 9, P < 0.05) and used lower iodinated contrast (90 ± 25 mL vs 191 ± 45, P < 0.05). Conclusion: PV occlusion and PVI during cryoablation can be effectively predicted by CE. This technique reduces radiological exposure and iodinated contrast use. P029 NO DIFFERENCE IN TRIGGER INDUCIBILITY DURING ATRIAL FIBRILLATION ABLATION PERFORMED WITH GENERAL ANESTHESIA Mountantonakis SE; Kondapalli L; Marchlinski F; Hutchinson M Electrophysiology Section, Division of Cardiology, University of Pennsylvania, Philadelphia, USA Background: General anesthesia (GA) has been increasingly utilized during catheter ablation of AF. When AF ablation is performed under GA, many operators do not intentionally elicit AF triggers with catecholamine infusion due to concern for either excessive medication‐induced hypotension or autonomic‐dependence of trigger induction. We sought to determine whether patients undergoing AF ablation with GA had fewer provocable triggers than patients whose procedures were performed under conscious sedation alone. Methods: 23 patients who underwent AF ablation under GA (Group 1) were matched for age, gender, ejection fraction, left atrial size and type of atrial fibrillation with 23 patients who underwent catheter ablation under conscious sedation (Group II). Patients in Group 1 were maintained under general anesthesia with intravenous propofol; those in Group 2 were anesthetized with boluses of midazolam and fentanyl without airway support. Both groups received escalating doses of isoproterenol (ISO) until either: 1) a maximal dose of 20 mcg/min was achieved or 2) AF was induced. We included only pulmonary vein or non‐pulmonary vein triggers which initiated AF in the analysis. If necessary, intravenous phenylephrine was administered via bolus (25 mcg) and/or continuous infusion (up to 200 mcg/min) to maintain a mean arterial pressure >60 mmHg. The incidence of AF triggers between the two groups was compared. Results: AF triggers were identified in 19/23 patients from Group I and 18/23 patients from Group II (83% vs. 78%; p = 0.9). There was no difference in trigger site or the total ISO required between the 2 groups (15.8 vs 14.8mcg/min, p 0.624). The use of phenylephrine was more frequent in Group I (83% vs. 52%, p = 0.028). Conclusion: The use of GA does not appear to inhibit the provocation of AF triggers. Although ISO‐induced hypotension is more often required in patients under GA, effective doses of ISO can be reliably achieved with phenylephrine infusion. P030 RADIOFREQUENCY CATHETER ABLATION OF ATRIAL FIBRILLATION IN RETIREED PATIENTS Ardashev AV; Konev AV; Zhelyakov EG; Rybachenko MS; *Belenkov YuN 83 Clinical Hospital of FMBA, * Lomonosov State University, Moscow, Russia Aim: To assess effectiveness and safety of radiofrequency catheter ablation (RFA) of atrial fibrillation (AF) in elderly pts with paroxysmal, persistent and permanent AF. Methods: Study was conducted on 214 pts who underwent primary RFA of AF. 76 of them were older than 60 years of age and underwent 93 procedures. The mean age was 68 ± 3.5 years (22 females). The mean duration for AF was 8.7 ± 6.5 years. 36 had paroxysmal, 19 had persistent AF and 21 had permanent AF despite use of 1.7 ± 0.4 antiarrhythmic drugs (AAD). All pts were divided into two groups. First group consisted of 60 pts ranged from 60 to 70 years old (mean age – 65.7 ± 3.5 years), second group concluded of 16 pts ranged from 71 to 83 years old (mean age – 73.7 ± 2.4 years). The ablation strategy consisted of wide‐area circumferential lines around pulmonary veins, roof lines and extensive RFA of the left atrial substrate modification using a three‐dimensional mapping system. Follow up consisted of 1, 3, 6 and 12 months out‐patient clinical visiting after de‐novo RF‐procedure and included of repetitive 24 hour Holter monitoring. Results: There were no complications associated with RFA. 24 (40%) pts of the first group vs 5 (31%) pts of the second subgroup had arrhythmia of the blanking period (p = 0.84) 10 (17%) pts of the first group vs 5 (31%) pts of the second group underwent redo procedures because of atypical atrial flutter, focal atrial tachycardia and atrial fibrillation in period from 6 to 12 months after primary RFA (p = 0.009) because of failure to sinus rhythm control using combined RFA and AAD approach. The incidence of stable sinus rhythm in the first/second groups were 60%/69%, 72%/69%, 83%/81% and 92%/75% at 1, 3, 6 and 12 months, respectively. Conclusion: RFA is a safe and effective treatment for elderly patients with AF. One year arrhythmia free survival rate was higher in patients ranged from 60 to 70 years old. P031 EVALUATION OF ESOPHAGEAL DISPLACEMENTS DURING PULMONARY VEIN ISOLATION IN PAROXYSMAL ATRIAL FIBRILLATION ABLATION Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A; Kamlofsky M; Banega R Instituto Cardiovascular de Buenos Aires (ICBA) Purpose: Catheter ablation represents a substantial achievement in AF treatment but this technique is not free from complications. Atrio esophagic fistula has been described as an infrequent but lethal complication. The aim of this study is describe esophagus position shifts using the shadow function. Methods: Single‐center prospective analysis of consecutive patients who underwent ablation of atrial fibrillation and received a MSCT‐64 prior to ablation between May 2009 and May 2011. A multislice 64 computed tomography was optimized for imaging of pulmonary veins. We performed the tridimensional reconstruction of the esophagus. We designed the left atrium shell and the esophagus position with a quadripolar EP catheter inside the esophagus lumen. We obtain the fiducially points from the pulmonary vein ostium and transport passively the esophagus acquired points obtained during shell construction. If esophagus tract fit with 3D Esophagus reconstruction its position was assessed by using the Nav X Shadow tool during the entire procedure. Significant displacements were defined as those presenting a more than 3 mm shift between the esophagus passive fusion and the 'in vivo' position determined by the shadow function. Results: 153 patients were included with a mean age 61 ± 9.7 yrs, 90% male and a mean BMI of 26.5 ± 6.4 kg/m2. 142 (93%) patients were in sinus rhythm at time of MSCT‐64. We determine the esophagus tract in 146 patients (95%). In 17 patients it was impossible to perform the reconstruction because of technique problems in acquisition image. Significant displacements were observed in 21 patients (15%) and 125 (85%) showed no significant position shifts (p value <0.05). Conclusions: The present study suggests that the Esophagus does not present significant position shifts during PVI. Shadows tool confirm that initial assessment of esophagus position after 3D reconstruction is safe and precisely to guide PVI procedure. P032 CONTINUATION OF VITAMIN K ANTAGONISTS AS ACCEPTABLE ANTICOAGULATION REGIMEN IN PATIENTS UNDERGOING PULMONARY VEIN ISOLATION Oude Velthuis B; Stevenhagen YJ; van Opstal JM; Scholten MF Medisch Spectrum Twente Background: Recent studies have demonstrated that radiofrequency isolation of the pulmonary veins (PVI) is an effective treatment for symptomatic atrial fibrillation. Based on these positive results, non‐ pharmacological therapy has been incorporated in the guidelines for drug refractory atrial fibrillation, resulting in an increased popularity. The prevention of thromboembolic complications remains an important issue. Methods: In January 2010, we adopted an anticoagulation strategy based on continuation of vitamin K antagonists (VKAs) and selective use of transesophageal echocardiogram (TEE). We retrospectively analyzed the results of this strategy in all patients referred for PVI treatment. VKAs were started for all patients 2 months prior to treatment. Discontinuation of oral anticoagulation was considered 3 months after treatment based on thromboembolic and bleeding risk profile. Bleeding and thromboembolic complications were registered during outpatient clinic follow‐up up until 3 months. Results: We performed 151 PVI procedures from January 2010 to March 2011. All patients were seen 6 weeks after discharge. No transient ischemic accident or ischemic cerebrovascular incident occurred pre‐, peri‐ or postprocedure. Four (2.7%) procedures were complicated by tamponade requiring pericardiocentesis. Conclusions: Our data support the increasing evidence for continuation of periprocedural administration of VKAs complemented by a selective TEE approach as a safe therapy for thromboembolic complications. P033 EFFECTIVNESS OF AF ABLATION STRATEGIES IN "YOUNG" AF‐ABLATION CENTER Chasnoits A; Goncharik D; Halianishcha V; Kovalenko O; Persidskikh Y; Plaschinskaya L Republican Scientific and Practical Center "Cardiology", Minsk, Belarus Purpose of the study: to estimate effectiveness and time consumption of 3 different strategies of ablation in patients with paroxysmal and persistent atrial fibrillation (AF) in condition of first starting AF‐ablation center. Methods: 35 consecutive patients underwent Carto XP Merge endocardial ablation procedure. Follow up period was 3 – 18 month. Data presented as Median (Q25; Q75). Summary: Patient divided into 3 groups: 1) ganglionary plexi (GP)‐ablation (n = 11 (4 females), age 55.0 (50.0, 58.0). AF duration 6,50 (4,0; 8,0) years; left atrium (LA) size 41,50 (36,50; 47,00) mm). 2) pulmonary vein (PV)‐isolation (n = 18 (5 females), age 52,50 (48,0; 62,0) years, AF duration 2,00 (1,00; 2,00) years, LA size 41,00 (40,0; 42,0) mm). 3) PV + GP ablation group. (n = 6 (1 female), age 54 (44,0; 59,0), AF duration 4,0 (3,0; 8,0) years, LA size 42,0 (37,0; 42,0) mm). Time of procedure does not significantly differ between groups 4,0 (5,0; 6,0) hour, 3,5 (4,88; 5,5) hour, and 4,0 (4,0; 6,0) hour respectively. After at least 3 month post procedure in GP‐group 5 patient out of 11 were in sinus rhythm (45,45%); in PV‐group 12 out of 18 were in sinus rhythm (66,66%); and in PV + GP‐group – all 6 patients (100%) were in sinus rhythm. Average effectiveness resulted as follows: 23 patients out of 35 (65,71%) were in sinus rhythm. Statistical analysis by Kruskal‐Wallis, Mann‐Whitney and Fisher exact p, two‐tailed tests showed significantly better effectiveness (p < 0,05) only in PV + GP‐group than in GP‐group. GP‐ablation and PV‐isolation groups do not differ in effectiveness by this number of patients. Conclusion: Effectiveness of GP‐ablation and PV isolation does not significantly differ in firs starting AF‐ablation center, but results in group PV + GP are significantly better than in just GP‐group, what is connected to size of myocardial critical mass, involved by PV + GP ablation. It does not take additional time to perform GP‐ablation, doing PV‐isolation. We suggest performing a GP + PV ablation technique. P034 SEQUENTIAL APPROACH FOR TREATMENT OF LONGSTANDING PERSISTENT ATRIAL FIBRILLATION Revishvili A; Matsonashvili G; Labartkava E; Serguladze S; Shmul A; Kvasha B Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia Nowadays surgical ablation of persistent atrial fibrillation (PAF) is thought to be the most effective approach. But still postablative atrial tachycardias (PAT) can be observed in a short period after intervention because of incomplete lesions. Subsequent percutaneous ablation can improve success rate by precise elimination of critical gap‐zones. From May 2007 to June 2011 55 consecutive patients (40 patients with concomitant valvular pathology and 15 patients with failed prior to surgery percutaneous ablations) with symptomatic PAF (mean arrhythmia duration 6 ± 2 years, mean age 56 ± 4 years, mean left atrial volume 180 ± 22 ml., mean EF 58 ± 5%), refractory to antiarrhythmic therapy, underwent bipolar modification of MAZE procedure (MAZE IV) using the Atricure system. Within 14 days after surgery PAT was observed in 7 cases (14%). These patients underwent electrophysiological (EP) study and radiofrequency ablation (RFA). During mean follow up of 14 ± 2 months 49 patients (98%) had stable sinus rhythm, 1 patient (2%) required dual chamber pacemaker implantation because of symptomatic sinus bradycardia. No peri‐operative complications were observed. In 7 patients with PAT during EP study next observations were registered: 1 patient with left atrial ectopic tachycardia because of restoration of conduction from left superior pulmonary vein (LSPV), 1 patient with typical atrial flutter with cycle length (CL) 235 ms and 5 patients with left atrial flutter (mean CL 240 ± 15 ms). During mapping critical sites of left atrial (LA) flutters were found at LA ridge (3 patients) and at LSPV‐LA roof junction(2 patients). All arrhythmias were successfully ablated and during mean follow‐up of 2 ± 1,2 years no evidence of any tachycardia was registered on repetitive Holter monitoring. Two‐step approach can improve long term success for maintaining sinus rhythm and can increase effectiveness of invasive methods of treatment of PAF. P035 DETECTION OF ATRIAL EXCITATION CHAN‐
GES FOLLOWING CIRCUMFERENTIAL PULMONARY VEINS ISOLATION USING WAVELET ANALYSIS Vassilikos V; Dakos G; Chouvarda I; Paraskevaidis S; Mantziari L; Hatzizisis I; Tsilonis K; Maglaveras N; Styliadis I 1st Cardiology Dept, Aristotle University of Thessaloniki, Greece The aim of this study was to investigate differences in P wave duration and excitation characteristics following circumferential pulmonary veins (CPV) isolation using P wave wavelet analysis. Methods: We studied 33 patients (20 males, mean age 52.5 ± 7 years) which underwent CPV isolation because of non‐responsive to drugs atrial fibrillation. The recordings were obtained during sinus rhythm before and after PV isolation with a 3 – channel digital recorder for 10 minutes and digitized with a 16–bit accuracy at a sampling rate of 1000 Hz. The PVs were isolated in pairs using the Nav‐X mapping system. The P wave was analyzed using the Morlet wavelet and wavelet parameters expressing the mean and max energy of P wave were calculated in the three orthogonal leads (X, Y, Z) in three frequency bands (1st: 200–160 Hz, 2nd: 150–100 Hz and 3nd: 90–50 Hz). Nonparametric Wilcoxon matched‐pairs signed‐rank test was used for comparing continuous variables, while p < 0.05 was considered significant. Results: Following CPV isolation, P wave duration at X, Y and Z axes was significantly shorter (96.8 ± 18 vs 86.7 ± 12msec, p < 0.001, 99.3 ± 14.7 vs 89.9 ± 13.8msec, p = 0.001 and 99.5 ± 17 vs 91.3 ± 15msec, p = 0.001, respectively), while mean and man energy in all frequency bands at X and Y axes along with mean energy in all frequency bands at Z axis were significantly lower. Conclusions: P wave wavelet analysis demonstrates significant differences in atrial conduction patterns following CPV isolation, as suggested by the shortening of P wave duration and the lower wavelet energies. P036 TNT DEMONSTRATES COMPARABLE IMPACT OF CIRCULAR MULTIELECTRODE AND IRRIGATED COOL TIP CATHETERS IN ATRIAL FIBRILLATION ABLATION Herstad J; Hoff PI; de Bortoli A; Solheim E; Lizhi S; Chen J; Schuster P Haukeland University Hospital, Department of Heart Disease, Bergen, Norway Aim: Comparing the level of myocardial injury by measuring TnT using non‐irrigated circular multielectrode or irrigated cool tip catheters. Method: 40 patients (mean age 53 ± 12 years, 10 females) underwent pulmonary vein isolation (PVI) for paroxysmal (n = 36) or persistent (n = 4) atrial fibrillation. A multielectrode low energy phased radiofrequency catheter (PVAC, Medtronic Ablation Frontiers Inc, USA; n = 20, group 1) or 3‐D mapping system, irrigated cool tip catheter and circular mapping catheter for demonstrating PVI (n = 20, group 2) were used. TnT (ng/L) was measured 15–22 hours post procedural. Results: No significant differences in age or sex were demonstrated between the groups and no complications were observed. In group 1 procedure time was significantly lower (150 versus 193 min, p < 0,05) and X‐ray duration shorter (26 versus 36 min, p < 0,05). The applied RF energy (43 min (group 1) versus 55 min (group 2), p = ns) resulted in a not significant different release of TnT between the groups (720 ± 352 versus 1397 ± 1134, p = 0,06). The time corrected TnT release per minute ablation (21 ± 12 versus 26 ± 17, p = ns) was similar. Conclusion: Signal controlled PVI using multielectrode radiofrequency catheters compared to irrigated cool tip catheters results in a similar myocardial injury suggesting comparable impact in shorter procedure time and shorter X‐ray duration. P037 THE LONG‐TERM SAFETY OF ANTICOAGULATION STRATEGY AFTER RADIOFREQUENCY CATHETER ABLATION OF ATRIAL FIBRILLATION Park JH; Ko KJ; Han PK; Lim RS; Jang JK; Park HC; Kim YH Korea University Arrhythmia Center Background: The purpose of this study was to investigate the safety and efficacy of standard anticoagulation (SA) over 3 months after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) in comparison with the early‐stopped warfarinization (EW) within 3 months. Methods and Results: We compared safety between SA (n = 50) and EW (n = 59) group in 109 patients who underwent RFCA of AF (78 males, 55.9 ± 11 years old, paroxysmal AF 59.6%, CHADS2 score 1.5 ± 0.9, duration of follow up 693.1 ± 234.6 days, duration of AF 46.7 ± 42.5 months). Results: There was no significant difference in CHADS2 score (1.5 ± 0.9 vs 1.4 ± 0.8, P = NS) between SA and EW group. Compared to EW group, uninterrupted preprocedural warfarinization (70.6% vs 39.4%, P = 0.014) was greater in SA group, therefore, INR value (1.47 ± 0.51 vs 1.14 ± 0.28, P = 0.002) at the procedure was higher. However, the incidence of hemorrhagic complications (11.9% vs 6.0%, P = NS) or the thromboembolic events (1.7% vs 0.0%, P = NS) was not different between two groups. Conclusion: In patients with low to intermediate risk of thromboembolism (mean CHADS2 1.5) early stopped warfarinization within 3 months after catheter ablation of AF had comparable safety with warfarinization over 3 months. Further prospective study in large scale is warranted to determine long‐term safety of each anticoagulation strategy. P038 INCIDENCE OF SUPERIOR VENA CAVA ELECTRICAL ACTIVITY DURING ATRIAL FIBRILLATION RADIOFREQUENCY TREATMENT Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A Instituto Cardiovascular de Buenos Aires (ICBA) Introduction: It is widely known that almost 94% of atrial fibrillation triggers are located in pulmonary veins and only few are located in extrapulmonary vessels. Nevertheless, new ablation techniques including superior vena cava (SVC) isolation have demonstrated higher success rates. Objective: To determine the incidence of SVC electrical activity in patients elegible for pulmonary vein isolation (PVI) as a methodological approach to understand atrial fibrillation (AF) pathophisiology in a huge cohort of patients. Method: Single‐center analysis of consecutive patients who underwent pulmonary vein isolation ablation between may 2009 and january 2011. Electrical activity in SVC was assessed by placing a circular multipolar catheter (Optima, St. Jude medical) inside the vessel. The SVC electrical activity was defined as the registry of potentials inside this structure (impulse conduction between right atrium and SVC) as far as 5 cm by the Optima catheter during sinus rhythm or AF. Results: A total of 107 patients were included. Electrical activity in SVC was assessed in only 42 patients; 90.47% male; Mean age 48 ± 8,4 years; 73.80% presented as paroxysmal AF. A total of 16 patients (38.09%) showed SVC electrical activity. Conclusion: This study confirms a high prevalence, almost 40%, of SVC electrical activity in patients referred for PVI. If this finding become in a new goal in AF treatment has to be determine in future trials. P039 PREVALENCE, CHARACTERISTICS AND PREDICTORS OF PULMONARY VEIN NARROWING AFTER PVAC ABLATION De Greef Y; Tavernier R; Raeymaeckers S; Schwagten B; Desurgeloose D; De Keulenaer G; Stockman D; Duytschaever M Department of Cardiology, Antwerp Cardiovascular Institute Middelheim, Belgium Background: The risk and determinants of pulmonary vein narrowing (PVN) after pulmonary vein isolation (PVI) using a novel multi‐electrode ablation catheter (PVAC) are unknown. Methods and Results: PV diameters (PVD) and left atrial (LA) volume were compared by computed tomography before and 3 months after PVI using duty‐cycled phased RF energy (2:1 or 4:1 bipolar/unipolar ratio) in 50 patients. PVD was measured in a coronal and axial view at three levels (A = ostium, B = 1cm more distal, C = 2cm more distal). Moderate PVN was defined as a PVD reduction of 25–50%, severe PVN as > 50%. Axial PVD shortened by 17 ± 16%, 14 ± 16% and 8 ± 22% at level A, B and C respectively (p < 0,001 for all); coronal PVD decreased by 16 ± 14%, 13 ± 17% and 7 ± 19% (p < 0,001 for all). Moderate PVN occurred in 55/200 PVs (28%) in 36 patients (72%); severe PVN occurred in 8/200PVs (4%) in 7 patients (14%). The left superior PV and the number of 2:1 applications were predictors for PVN. LA volume decreased by 10 ± 18% (p < 0,001). Conclusions: PVAC ablation results in a consistent moderate reduction of the PVD predominantly at the ostium. PV narrowing occurred more frequently in the LSPV and was related to the number of 2:1 applications. Severe PVN in 14% of patients, raises concerns about the risk for clinical PV stenosis. P040 ATRIAL FIBRILLATION TREATED WITH PULMONARY VEINS ABLATION:PATIENTS PROFILE AND LIFE QUALITY Fernandez‐Oliver AL(1); Mgueraman‐Jilali R; (1) ELECTROPHISIOLOGY AND ARRHYTHM UNIT Universitary Hospital Virgen de la Victoria. Malaga. Spain Purpose. Atrial fibrillation (AF) is a highly prevalent arrhythmia with significant impact on patients' life quality. Pulmonary veins ablation (PVA) offer new treatment expectations. Purposes: 1. To assess daily living activities changes, the patient quality of life as a result of arrhythmia, and changes after PVA. 2. To get the profile of patients with AF those who perform PVA. Method. Quantitative, retrospective, descriptive study. Sample of 44 patients (56 procedures) underwent PVA (March 2008–August 2009). We custom‐assessment interview prior to the procedure and post‐ablation to 3,6 and 9 months for assessing the impact it was on issues as respiratory distress, palpitations, difficulty performing daily activities. Were also given to patients health questionnaire EQ‐5D to responses objectively. Also we discussed Holter records evaluation to verify presence of sinus rhythm or AF recurrence. Results. Mean age 51 years (19‐72), 66% men; 65% of patients improved significantly their quality of life, refer unwell without pain /discomfort, assessing their current health status markedly improved (39% according rating scale). 50% following a 15% to more than one and 19% waiting for a new procedure; 12% were asymptomatic before PVA. We obtained a profile highlighting: Overweight ‐ Obesity (86.3%) and Hypertension (43.2%). Emphasize that 22.7% have no CVRF, 29.5% have one, 31.8% two, 13.6% three, and 2.2% four CVRF. Detected greater success 72.4% males vs. 40% women (p = 0.03). Conclusions. Despite the information given on CVRF remains high prevalence assessing the need for modification, corrective strategies and approach to heart‐healthy living habits. We need to plan a continuity care program, information and control of CVRF. Care plans implementation and data transmission between hospital and primary health care centers increases the efficacy and safety of the PVA treatment, while increasing the patient perception of safety, quality and continuity of care. ATRIAL FIBRILLATION: EPIDEMIOLOGY, AETIOLOGY AND MANAGEMENT P041 MANAGEMENT OF ATRIAL FIBRILLATION IN EMERGENCY ROOMS OF 23 MIDDLE EASTERN HOSPITALS: FINDINGS FROM GULF RACE Zubaid M; Rashed W; Alsheikh‐Ali AA; AlMahmeed W; Shehab A; Sulaiman K; Al‐Zakwani I; Al Qudaimi A; Asaad N; Amin H; Gulf SAFE Registry Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait Purpose: To study emergency room (ER) management strategies of patients presenting with atrial fibrillation (AF) in the Middle East. Methods: We used data from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE), a prospective multinational registry of consecutive AF patients presenting to ERs of 23 hospitals in the Gulf region of the Middle East between October 2009 and June 2010. Results: Of 2043 patients enrolled, we analyzed data from 923 patients whose primary reason for ER visit was AF (age 52 ± 16, age ≥ 75 (9%), 56% male, 26% with diabetes, 48% with hypertension, 12% with history of heart failure, 6% with prior stroke/transient ischemic attack, 17% with history of significant valvular disease). Types of AF were: first attack 46%, paroxysmal 26%, persistent 11%, permanent 16% and not known 1%. Majority of patients (75%) presented to ER within 48 hours of symptom onset. While in ER, 98 patients (11%) had spontaneous cardioversion. Out of the remaining 825 patients the ER management strategy was rate control in 482 patients (59%) and rhythm control in 341 patients (41%). Cardioversion was attempted during ER stay in 226 patients (27%). Electrical cardioversion was used in 24 patients (11%) and pharmacological cardioversion in 202 patients (89%). The remaining 115 patients were admitted to hospital for cardioversion. Among those cardioverted pharmacologically in ER amiodarone was the drug used in the majority of patients (64%), propafenone was used in about one third of patients and all other antiarrhythmic drugs were used in only 5% of the patients. Majority of patients (76%) were admitted to hospital independent of the management strategy used and even after successful cardioversion in ER. Conclusions: Despite being relatively young with a short history of AF duration, most patients Admitted to ER Primarily for AF were not cardioverted and a majority got admitted to hospital. P042 HOW BENIGN IS ATRIAL FIBRILLATION? A LOOK AT THE ONSET (THE FIRST EPISODE) Fraile A; Goicolea L; Perea JA; Villanueva A; Kallmeyer C; Galán L; González‐Panizo J; González A; Zorita B; García‐Cosío F Hospital Universitario de Getafe, Madrid. Spain Chronic atrial fibrillation (AF) is often considered a benign arrhythmia in which attempts to recover and maintain of sinus rhythm might be deleterious, however some studies suggest a poor prognosis at the outset of the arrhythmia. Objective: To study the prognosis of patients after a first episode of AF in an industrial city in the center of Spain, 250000 in population, served by one public hospital. Methods: We registered all patients seen in the emergency room (ER) during the year 2010, with a previously undetected AF. Clinical evolution of admitted patients was obtained from clinical records. Discharged patients were followed in a dedicated clinic 15 ± days post discharge. Results: We registered 75 patients with a first episode of AF, 21 (28%) needed hospitalization: in 6 (28.6%) due to congestive heart failure, 4 chest pain (19′1%), respiratory insufficiency in 2 (9.5%), cerebrovascular accident in 2 (9.5%), poor ventricular rate control in 2 (9'5%), and in 5 (23.8%) other causes nonrelated to cardiovascular disease. The reason for ER visit among those discharged was: palpitations in 23 (42.6%), dyspnea in 7 (13%), chest pain in 6 (11.1%) and neurological symptoms in 6 (11.1%). In 10 patients (18.5%) AF was an incidental finding, and 2 (3.7%) patients consulted for other reasons. As compared to those discharged from the ER, hospitalized patients were older (71.2 vs. 63.9 y, p 0.043) with more associated disorders: hypertension (76.2% vs. 50%, p 0.011); valvular heart disease (23.1% vs. 16%, p 0.005); cerebrovascular accidents (19% vs. 9.2%, p 0.019). Two patients died during hospitalization: one from respiratory distress syndrome and another of aspiration pneumonia. Conclusions: The initial episode of AF prompts hospitalization in 28% of the cases. Advanced age, hypertension, structural heart disease and neurological complications are the factors associated with the more severe clinical pictures. Death is not rare during this first episode of AF (1.5%). P043 EFFECTS OF ATRIOVENTRICULAR NODE ABLATION IN PATIENTS WITH CHRONIC ATRIAL FIBRILLATION CANDIDATE FOR CARDIAC RESYNCHRONIZATION THERAPY Moghaddam M; Bagher Zadeh A; Moshkani Farahani M Jam Hospital, Tehran, Iran Objectives: Cardiac resynchronization therapy (CRT) is an important advance for the treatment of end stage heart failure (HF). The aims of this study were (i) to assess the clinical benefit of CRT in patients with Atrial Fibrillation (AF) and (ii) to evaluate the impact of Atrioventricular junctional (AVJ) ablation on the outcome of AF patients undergoing CRT. Method: A total of 68 permanent AF patients were included in this prospective study and CRT implantation. The patients randomized in 2 groups, 34 Patients received optimal medication to control ventricular rate and other 34 patients underwent an AVJ ablation and were followed up for 21 ± 11 months. Clinical parameters and echocardiographic parameters were compared at baseline and after a follow‐up of 1 and 6 months after and every 6 months thereafter. Patients were evaluated for the occurrence of cardiac death, hospitalization for HF, and responsiveness to CRT (improvement of 1 (NYHA) class at 6 months). Results: Although EF and NYHA class was improved with marginal significance, QRS duration and severity of Mitral Regurgitation was not significantly changed in Medical Therapy group but all of these parameters were significantly improved in AVJ ablation group. Although the clinical characteristics was somewhat improved in both groups after CRT implantation, the improvement was much higher in AVJ ablation group. Conclusion: Beneficial effects of CRT could be noticed in a significant number of AF patients, therefore these patients should not be excluded from CRT implantations. AF without AVJ ablation was an independent predictor of hospital admissions and non‐responsiveness to CRT. Performing AVJ ablation in AF patients undergoing CRT seems crucial to attain maximal clinical benefit. P044 SLEEP QUALITY IN PATIENTS WITH ATRIAL FIBRILLATION Kayrak M; Gul EE; Alibaşiç H; Abdulhalikov T; Gunduz M; Aribas A; Yazici M; Ozdemir K; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Although, AF was related with impaired quality of life (QoL), decreased functional physical activity, and elevated levels of anxiety and depression in clinical investigation, little is known about the level of sleep quality (SQ) in patients with AF. We aimed to examine self reported SQ of patients with AF. Methods‐Materials: Ninety‐one patients with a history of asymptomatic non‐valvular AF (mean age 62 ± 10 years) and 110 age and gender‐matched patients with sinus rhythm were recruited. Patients with heart failure, coronary heart disease, chronic kidney disease, severe valvular heart disease, and cerebrovascular accident were excluded from the study. Echocardiography was performed in all study population. SQ was measured using the Pittsburgh Sleep Quality Index (PSQI). The PSQI scoring yielded seven components: subjective SQ (C1), sleep latency (C2), sleep duration (C3), sleep efficiency (C4), sleep disturbances (C5), use of sleep medications (C6), and daytime dysfunction (C7). A global PSQI score > 5 indicated ''poor sleepers". Main Results: Demographic features were comparable between groups. Also, echocardiographic measurements were similar in two groups. The prevalence of '' poor sleepers" was significantly higher in patients with AF compared to patients with sinus rhythm (76% vs. 45%, p < 0.001). In addition, patients' global PSQI score was also increased in AF group compared with control group (9.4 ± 4.6 vs. 5.8 ± 4.1, p < 0.001, respectively). In a multivariate regression model, predictors of poor SQ was found as HT (odds: 1.9 (1.2–3.6 with 95% CI)) and AF (odds: 3.7 (1.9–6.8 with 95% CI)). However, age, gender, and BMI did not predict a poor SQ in this model. Nevertheless the effect of diabetes on SQ was in a trend of significance (p = 0.06). Conclusion: Poor SQ is a potentially important problem in patients with AF and may be determined with PSQI score, a simple screening tool. P045 CORRELATION BETWEEN WARFARIN PRESCRIPTION AND STROKE RISK AMONG MIDDLE EASTERN PATIENTS WITH ATRIAL FIBRILLATION: DATA FROM THE GULF SURVEY OF ATRIAL FIBRILLATION EVENTS (GULF SAFE) Zubaid M; Rashed W; Alsheikh‐Ali AA; AlMahmeed W; Shehab A; Sulaiman K; Al‐Zakwani I; Al Qudaimi A; Asaad N; Amin H; Gulf SAFE Registry Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait Purpose: To describe anticoagulation use among patients with non‐valvular atrial fibrillation (AF) in the Middle East and its relation to stroke risk. Methods: We used data from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE), a prospective multinational registry of consecutive AF patients presenting to emergency rooms of 23 hospitals in the Gulf region of the Middle East between October 2009 and June 2010. Results: Of 2043 patients enrolled, we analyzed data from 846 patients with previous history of non‐valvular AF (age 62 ± 15, 50% female, 37% with diabetes, 68% with hypertension, 35% with history of heart failure, 16% with prior stroke/transient ischemic attack, 3% with history of major bleed and 8% with renal impairment). Among these patients, 17% had CHADS2 score of 0, 24% had CHADS2 score of 1 and 59% had a CHADS2 score of 2 or more. Warfarin prescription increased with higher stroke risk categories: 27% in patients with CHADS2 score of 0, 38% in patients with CHADS2 score of 1 and 52% in patients with CHADS2 score of 2 or more (P‐trend < 0.01). However, warfarin was inappropriately used and underused in a large number of patients. About one in four patients considered at low risk for stroke (CHADS2 score 0) were prescribed warfarin (27%) while a substantial proportion of high risk patients (CHADS2 score of 2 or higher) were not prescribed warfarin (48%). Conclusions: There is significant misuse and underuse of warfarin among Middle Eastern patients with AF. Future studies should aim to understand determinants of anticoagulation patterns for stroke prevention among Middle Eastern patients with AF and strategies to improve them. P046 REVERSE BIATRIAL REMODELING IN PERSISTENT ATRIAL FIBRILLATION AFTER CARDIOVERSION van Bracht M; Christ M; Plehn G; Prull M; Meissner A; Butz T; Trappe HJ Department of Cardiology and Angiology, Marienhospital Herne, Ruhr University Bochum, Herne, Germany Background: Atrial fibrillation is the most common cardiac arrhythmia. Approximately 25% of those over forty will experience atrial fibrillation at least once in their life. It is well known that "atrial fibrillation begets atrial fibrillation" due to morphological and electrophysiological remodeling. In cardiac magnetic resonance imaging biatrial volumes and function can be measured with great accuracy. Our aim was to evaluate changing of atrial volumes and ejection fraction in patients with persistent atrial fibrillation after cardioversion. Methods: We examined 15 patients (8m,7f) with persistent atrial fibrillation directly after cardioversion and in a 4 weeks follow up. All scans were done in sinus rhythm. The images were performed with a 1,5 T Siemens Sonata scanner. SSFP sequences with a slice thickness of 5 mm and no gap were used. Image analysis was performed offline using CMR Tools (Imperial College London, UK). Results: Enddiastolic volumes (EDV) after cardioversion in the right atrium: 69,4 ml ± 15,1 (m), 67,9 ml ± 32 (f). At the four week follow up volumes decreased to 61,8 ml ± 31,7 (m), 60,5 ± 17,4 (f). Ejection fraction of the right atrium measured after cardioversion 19,4%± 11,1 (m), 20,7%± 8,6 (f), four weeks later 30,7%± 13,2 (m) and 27%± 16,9 (f). In the left atrium EDV decreased from 99,3 ml ± 32,5 (m) 96 ml ± 25,1 (f), to 99,2 ml ± 29,6 (m), 90,3 ml ± 27,4 (f) and ejection fraction increased from 22,4%± 12,6 (m), 17,6%± 6,4 (f) to 36,2%± 10,8 (m), 27%± 16,9 (f). Conclusion: Already 4 weeks after cardioversion the biatrial dilatation in persistent atrial fibrillation decreases and the atrial ejection fraction increases. Structural remodeling in persistent atrial fibrillation seems to be to some extent reversible. P047 ANATOMICAL CHARACTERISTICS OF LEFT ATRIUM AND LEFT ATRIAL APPENDAGE IN PATIENTS WITH STROKE/TRANSIENT ISCHEMIC ATTACK Park HC; Park YM; Ban JE; Park JH; Choi JI; Park SW; Kim YH Arrhythmia center, Korea University, Seoul, Korea Background: The left atrial appendage (LAA) has been identified as a frequent source of cardiac thrombus associated with systemic embolism in atrial fibrillation (AF). The aim of this study was to identify morphological characteristics of the LA and LAA that may confer higher stroke/TIA risk. Methods: We enrolled 119 patients with AF who underwent 3D‐CT examination. We assessed LA and LAA anatomy and categorized LAA morphology and LAA position, and counted the number of LAA lobes. Thirty one patients had a history of stroke/TIA (S group) and the others (88 patients) were free (NS group). There were no significant differences in age between two groups (63.0 ± 6.3 years in S, 63.5 ± 6.1 years in NS group, NS). Results: The LA size (41.9 ± 6.1 mm) and LA volume (108.2 ± 40.5 mm3) in S group were similar to those of NS group (42.3 ± 6.6 mm and 98.0 ± 35.8 mm3, p = 0.7 and p = 0.2, respectively). There were no significant differences in LAA volume (p = 0.8) and LAA neck diameter (p = 0.2) between two groups (22.3 ± 4.2 mm3 and 10.1 ± 3.4 mm in S, 22.6 ± 5.1 mm3 and 11.1 ± 5.0 mm in NS group). There were no significant differences in LAA morphology, LAA position and the number of LAA lobes between two groups. Conclusions: Morphological and dimensional characteristics of the LA and LAA did not determine the risk of stroke/TIA in patients with AF. Keywords: stroke/transient ischemic attack (TIA), 3D contrast‐computed tomography P048 INCIDENCE OF ATRIAL FIBRILLATION AFTER ATRIAL FLUTTER RADIOFREQUENCY ABLATION Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A Instituto Cardiovascular de Buenos Aires (ICBA) Introduction: Atrial fibrillation (AF) and atrial flutter (F) are frequently associated arrhythmias. Cavotricuspid isthmus (CTI) ablation for typical F is a proven effective treatment; nevertheless, AF can still be developed after this procedure. Objective: To determine the incidence of AF after CTI ablation in a cohort patients eligible for Atrial Flutter ablation, whether they presented or not prior AF. Method: Patients eligible for CTI ablation were included. Prior history AF was assessed. Telephonic follow up and Holter monitoring was performed to determine AF incidence after ICT ablation. Results: A total of 179 patients (77.09% male; Age 66 ± 8 years) were analyzed. Prior AF was observed in 80 patients (44.61%) of which 76 (95%) developed AF during the follow up. There was no history of prior AF in 99 patients (55.30%) of which 37 (37, 37%) presented AF after CTI ablation. Both groups' variables were analyzed. Atrial fibrillation predictors after CTI ablation were: Prior history of AF (p = 0.001); Male sex (p = 0.03); Valvular Heart disease (p = 0.04); Coronary heart disease (p = 0.01) and hypertensive heart disease (p = 0.003). Antiarrhythmic drug therapy with Class IC / III drugs was higher in the group with prior AF (90.01% vs. 24.6%). Conclusion: Atrial Flutter is a major risk factor to predict Atrial Fibrillation recurrence after CTI ablation. It occurs predominantly in males, with higher prevalence of cardiomyopathy. Radiofrequency treatment of atrial flutter may not be a suitable technique to reduce AF incidence in patients with these characteristics. Difference between real lone Atrial Flutter vs Atrial Fibrillation under Class I drugs treatment must be posed as differential entities. We emphasize the global treatment of this kind of patients. P049 PSYCHOLOGICAL DISTRESS AND IS ASSOCIATED INFECTION IS AN INDEPENDENT RISK OF ATRIAL FIBRILLATION RECURRENCES RATE IN LONE ATRIAL FIBRILLATION PATIENTS Hatzinikolaou‐Kotsakou E; Latsios P; Kotsakou M; Reppas E; Beleveslis T; Moschos G; Tsakiridis K Electrophysiology Department, Saint Luke's Hospital‐Thessaloniki, Greece Background: Depression is common after the first recurrence in lone atrial fibrillation (AF) patients (pts). While there is evidence that major depression (MD) is related to reduced natural killer cell cytotoxicity (NKCC) and enhanced cytokine production in healthy individuals. Its effect on recurrences rate in Lone AF pts is unknown. We examined the role of hostility, depression, somatic symptom, anxiety, overall psychological distress and associated infectious illness on long‐term recurrences in pts with lone AF. Methods: The study included 355 pts with lone AF, mean age 57 ± 14 years, after the cardioversion for the first recurrence episode of AF, followed prospectively with annual Kellner Symptom psychometric questionnaire at 8 weeks interviews. NKCC was measured by 3‐hour chromium release assay. We calculated the incidence rate of AF by quartiles of psychometric scores. We estimated the odds ratio (ORs) and 95% confidence intervals (CI), to represent the association between depression, anxiety, somatic symptom, and hostility scores and risk of AF. Results: After adjusting for non psychological risk factors, of AF, higher anxiety, depression hostility somatic symptom and total psychological distress were significantly associated with risk recurrences of AF. A higher quartile group was associated with a significant increase in risk. For each higher quartile group, adjusted odds ratio for total psychological distress was 2. 4 (CI, 1.4–4.3). Compared to those without psychological distress, depressed pts had diminished NKCC (22.1 ± 12 vs 13.4 ± 9.8%, p = 0.02). Conclusions: Among patients with lone AF, psychological distress in general is associated with reduced NKCC, increased infectious illness and with a dose‐response increase in the long‐term risk of AF recurrence rate. Cognitive behavioral therapy may hold promise for improving depression and for reducing AF recurrences in this population. P050 ATRIAL FIBRILLATION AFTER ISOLATED CORONARY SURGERY: COMPARISON BETWEEN OP‐ CABG AND CPB‐ CABG. INCIDENCE, TREATMENT AND LONG TERM EFFECTS Rostagno C; Blanzola C; Sclafani G; Codecasa R; Carone E; Giunti G; Rapisarda F; Stefano PL; Cardiologia Generale 1, Cardiochirurgia AOU – Careggi – Firenze Background: The effects of operative technique (off‐pump versus conventional cardiopulmonary assisted revascularization) on post‐operative AF is still unclear. Aim of present investigation was to compare the incidence of POAF and its prognostic role in patients undergoing respectively OP‐CABG and CPB –CABG. Methods and Results: We conducted a prospective study on 229 patients undergoing isolated CABG between January 1 2007 and December 31 2007. Patients with PO AF were followed up for an average period of 522 days (end of the study June 31 2008). The two groups did not show significant baseline difference with the exception that OP‐CABG were significantly older than CPB‐CABG patients (70.5 vs 64.9 years). 52/229 (22.7%) developed AF after coronary surgery. Incidence of POAF was not significantly different in patients undergoing CPB‐CABG (20/90‐ 22.2%) in comparison to those undergoing OP –CABG (32/139 – 23%). Hospital mortality was 0.4%(one death for cardiogenic shock after CPB‐CABG). Only in patients with POAF after CPB‐CABG length of hospitalization was significantly higher (7.55 days versus 5.9 in patients with PO‐AF after OP‐CABG P <.001). During follow up AF recurred in 6 patients, 3 for both groups, within 2 months after surgery. Hospitalization was required in 3. Three patients recovered SR after amiodarone, 1 required electrical cardioversion, 1 had spontaneous recovery of SR while in the last one AF persisted. Only one patient died during follow up. No strokes were recorded. Conclusions: Although we did not find any difference in the incidence of postoperative AF between OP‐ and CPB‐CABG however OP‐CABG patients were significantly older than CPB‐patients. Early and late mortality did not show relation with POAF probably due to immediate treatment with recovery of sinus rhythm before hospital discharge. Recurrence of AF occurred in 6/52 patients (11.5%) however only in one AF persisted. P051 THE USE OF ANTICOAGULATION THERAPY IN PATIENTS WITH PACEMAKER DETECTED ATRIAL FIBRILLATION Music L; Boskovic A Clinical Center of Montenegro Euro Heart survey have already demonstrated the suboptimal use of anticoagulation in patients with atrial fibrillation (AF). Recent generations pacemakers demonstrated the ability to detected episodes of AF by recording electrogram (egm). The aim of the study is to reveal appropriate use of anticoagulations in patients with AF episodes diagnosed by pacemaker EGM during routine pacemaker interrogation. These AF episodes are quantified on the basis of their duration. The medication regime was noted and control at the next scheduled pacemaker interrogation. Two hundred patients with dual chamber pacemaker were included in the study. Atrial fibrillation was diagnosed in 79 (40%). Anticoagulation by vitamin K antagonist was prescribed 51 (63%) with new detected AF on the risk factor – based point scoring system CHA2DS2VASc and antiplatelet agent prescribed in 30 (27%) Among patients with prescribed anticoagulation therapy, 35 (43%) had optimal value of international normalized ratio (INR) during regular control of 3 months and 6 months, 4 (5%) gave up because of discomfort of checking value of INR, 41 (52%). Patients had suboptimal value of INR. The majority of patients in this study received anticoagulation therapy according the current guidelines. But the values of INR were not satisfactory. Pacemakers provide the important information on cardiac rhythm and represent a useful tool of detecting subclinical AF. The rate of appropriate anticoagulation prescription and control of optimal INR may be improved through specific treatment recommendations and better compliance with patients and anticoagulation drugs. P052 THE EFFECT OF SINUS RHYTHM RESTORATION WITH ELECTRICAL CARDIOVERSION ON SELF REPORTED SLEEP QUALITY IN PATIENTS WITH ATRIAL FIBRILLATION Kayrak M; Gul EE; Alibaşiç H; Abdulhalikov T; Yildirim O; Aribas A; Yazici M; Ozdemir K; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance encountered in clinical practice and associated with impaired quality of life. In patients with AF, sinus rhythm maintenance after electrical cardioversion or direct current cardioversion (DCC) provides improvement in functional capacity and decrease in symptoms. However, the effect of DCC on the sleep quality (SQ) is still unknown. Therefore, we aimed to examine the effect of sinus rhythm restoration after successful DCC on the SQ in patients with AF. Methods‐Materials: DCC was performed in eligible 53 patients with persistent AF. Electrical cardioversion was performed successfully (i.e., sinus rhythm restoration) in 48 patients. To eliminate the placebo effect of DCC, patients were divided into two groups; patients with sinus rhythm maintenance (n = 34) and recurrent AF patients (n = 14) according to sixth months follow up. SQ was assessed using the Pittsburgh Sleep Quality Index (PSQI) before DCC and sixth month later. The PSQI scoring yielded seven components: subjective sleep quality, sleep latency, sleep duration, sleeps efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction. Patients with global PSQI score > 5 was defined as "poor sleepers." Thus increase in global PSQI score was considered as a marker of worsened SQ. Main Results: Demographic features and baseline PSQI scores were comparable in two groups. In sinus rhythm maintenance group, baseline global PSQI score was significantly improved compared to sixth month follow‐up (8.7 ± 4.1 vs. 7.2 ± 3.8, p < 0.001, respectively). However, global PSQI score did not change in AF recurrence group compared to baseline value (Table). The difference of intergroup change reached to statistical significance in repeated ANOVA analysis (p < 0.05). Conclusion: Maintenance of sinus rhythm after DCC may have favorable effect on SQ in patients with AF. P053 MINIMAL EXTRACORPOREAL CIRCULATION SIGNIFICANTLY REDUCES THE OCCURRENCE OF POSTOPERATIVE ATRIAL FIBRILLATION Jakubova M; Sabol F; Stancak B; Luczy J; Kolesar A; Hermely A; Torok P East Slovakia Institute of Cardiovascular Diseases, Kosice, Slovakia Introduction: Atrial fibrillation (AF) is the most common arrhythmia after cardiac surgery. The pathogenesis of postoperative atrial fibrillation is multifactorial. It has been hypothesized that atrial fibrillation might be related to extracorporeal circulation. Objectives: The aim of the study was to monitor preoperative, intraoperative, and postoperative factors and their relationship to the occurrence and duration of AF. Methods: 196 patients with coronary heart disease (152 men, age 62,7 ± 10,1 years) underwent surgical revascularization. Extracorporeal circulation was used in 64 patients and minimal extracorporeal circulation was used in 75 patients. 57 patients underwent surgery without using ECC. During the first 3 postoperative days, patients were monitored for the incidence and duration of AF. Laboratory markers of inflammation (CRP, leukocytes), and serum potassium were routinely measured. Results: Patients' preoperative characteristics did not differ between groups. The incidence of AF was 56% (110 patients). The highest incidence was in the ECC subgroup. The incidence of AF in patients operated using minimised circuit or operated off pump was significantly lower (75% vs. 47% vs. 46%, p < 0,001). The longest duration of AF was in patients operated with ECC, patients in group with minimal extracorporeal circulation and without extracorporeal circulation fibrillated significantly shorter (9,7 ± 11,6 vs. 4,9 ± 8,3 vs. 3,1 ± 5,2, p ≤ 0,001). The incidence of postoperative AF significantly correlated with elevation of inflammatory markers (Leukocytes and CRP) compared to patients free of AF (p ≤ 0,001, p ≤ 0,05). Conclusion: The use of minimal extracorporeal circulation lowers the incidence of postoperative AF in comparison to classical ECC. P054 THE ANTIARRHYTHMIC IMPACT OF RANOLAZINE IN PATIENTS WITH SICK SINUS SYNDROME AND PAROXYSMAL ATRIAL FIBRILLATION Leftheriotis D; Flevari P; Rigopoulos A; Rizos I; Anastasiou‐Nana M "Attikon" University Hospital, Department of Cardiology, Athens, Greece Background: It has been reported that Ranolazine (Ran) suppresses atrial fibrillation (AF), but its efficacy in patients with sick sinus syndrome (SSS) and paroxysmal AF is not clear. Besides, pacemakers that detect and store AF episodes can be useful tools for revealing asymptomatic AF recurrence. Therefore, we studied the antiarrhythmic impact of Ran on patients with paroxysmal AF, who had such pacemakers due to SSS. Methods: We studied 22 patients with SSS, paroxysmal AF under no antiarrhythmic medication, and stable coronary artery disease who had a dual chamber pacemaker with the capability to detect and store AF episodes (Altrua DR, Boston Scientific, MA, USA, and Sensia DR, Medtronic, MN, USA). The number and total duration of AF episodes within the last 6 months and QTc duration were assessed at baseline. Subsequently, Ran was administered (375 mgr, twice daily) for six months and AF episodes, total time in AF, and QTc were reassessed. Side‐effects related to Ran were reported. Results: Two patients missed their six‐month reevaluation. Among the remaining 20 patients, 7 (35%) discontinued Ran within the first three months due to side effects: constipation (3), abdominal pain (2), dyspnea and dizziness (1), and decreased urination (1). Compared to baseline, treatment with Ran was associated with a non significant trend towards a decrease in the number of AF episodes (16.5 ± 2.6 vs 15.9 ± 2.8, p = 0.3) and a significant decrease in the total AF duration (4.8 ± 2.9 vs 3.7 ± 2.5 hours, p = 0.01) without QTc prolongation (457 ± 2 vs 459 ± 3 ms, p = 0.2). Conclusions: In clinically stable patients with a pacemaker due to SSS, paroxysmal AF and coronary artery disease, Ran did not significantly reduced AF episodes, but it shortened the total time in AF. Although QTc was not significantly prolonged, a high rate of Ran discontinuation was observed, due to its side effects. P055 PRACTICAL ASPECTS OF CARDIOEMBOLIC STROKE PREVENTION IN PATIENTS ELIGIBLE AND UNELIGIBLE FOR WARFARIN THERAPY Timcenko M; Volceka D; Skorodumovs A; Sipacovs P; Kenina V; Miglane E; Millers A Paul Stradin's Clinical University Hospital Objectives: The aim of the study is to evaluate efficacy of warfarin (Wn) therapy in CS prevention and eligibility of Wn substitution with antiplatelet therapy (a/p) for CS secondary prevention if one is contraindicated. Methods: The trial is ongoing unicenter prospective. 94 cases of acute stroke classified as CS had been analysed. First, clinical record analysis was done. Then patient's telephone inquiry was used to recognize incidence of primary outcome (PO) (death, stroke, systemic embolism, hospitalization) or haemorrhage within 90 days from the stroke onset. 76 patients had completed trial. Results: None of patients used Wn prior stroke. Main source of embolism was atrial fibrillation (AF) in 86,2% of cases. In 77.8% of cases CHADS2 score prior stroke was >1. At discharge Wn was recomended in 55 (58,5%) cases, a/p was recommended in 35 (37,2%). Wn was avoided by these reasons: patient's incompliance in 30,8% (12), INR control inaccessibility in 15,4% (6), hemorrhagic risk in 28,2% (11), severe stroke in 25,6% (10). 90 days after discharge: Wn was continued in 35 cases (46,1%), but 41 patients (53,9%) were on a/p therapy. There was PO in a/p group in 18 (43,9%; confidence interval (CI) 29,9–59,0%), in Wn group in 2 (5,7%; CI 1,6–18,6%) (p = 0,0002); major haemorrhage in a/p group in 0 (0%; CI 0–8,6%), in Wn group 2 (5,7%; CI 1,6–18,6%) (p = 0,209); minor haemorrhage in a/p group in 1 (2,4%; CI 0,4–12,6%), in Wn group 5 (14,3%; CI 6,3–29,4%) (p = 0,0889); death in a/p group in 14 (34,2%; CI 21,6–49,5%), in Wn group in 0 (0%; CI 0–9,9%) (p = 0,0001) cases. Conclusion: Wn is used insufficiently for primary CS prevention. The incidence of PO and death within 90 days after CS is significantly higher in group of patients unable to use Wn for secondary CS prophylaxis. Wn is contraindicated after CS in almost half of cases, but risk of haemorrhage isn't the main contraindication. Wn is more effective in PO and death prevention in CS patients compared to a/p. P056 CLINICAL FLOW OF ATRIAL FIBRILLATION DEPENDING ON CONCOMITANT THYROID FUNCTION Lyzohub SV; Sychov OS; Romanova OM; Frolov OI; Mogilnitskiy YV NSC «Institute of Cardiology named after N.D.Strazhesko» of AMS of Ukraine Objective: To estimate amount of patients with atrial fibrillation (AF) with concomitant thyroid pathology (TP); to study frequency of new cases of TP in the patients receiving amiodarone; to study morphological and functional indices of cardio‐vascular system in the groups of patients with hyper‐ and hypothyroid function. Methods: We included 763 patients. All patients underwent clinical examination, including thyroid function evaluation, EchoCG, ECG HM, 24‐hours BP monitoring. Results: In thre patients with AF 90% had normal thyroid function, 10% (77 patinets) had thyroid disorders, including hypothyroid status in 29 patients (4%), and hyperthyroid status in 48 patients (6%). In hyperthyroidism and hypothyroidism groups patients did not significantly differ in age, concomitant CAD ot myocardiofibrosis, but significantly differed by concomitant CHF status – 4% in hyperthyroidism group compared to 41% in hypothyroidism group. We observed difference in appreciation of paroxysms severity by patients according to EHRA scale depending on thyroid function. Thus, in normal thyroid function group 50% had class II, while only 8% had class IV. In the groups with thyroid function impairment we observed increase of patients with class III to IV according to EHRA scale, which is probably connected to cardiovascular system function alterations and deepened by CNS dysfunction. Conclusion: • TP was found in 10% of patients. Hyperthyroidism was present in 6%, hypothyroidism – in 4% of patients.• Patients with concomitant hypothyroidism significantly differed from those with hyperthyroidism by lower LV EF, lower mean, maximal and minimal HR during 24 hrs, lower quantity of AF paroxysms, as well as higher amount of ventricular extrasystoles according to ECG HM data.• Significant difference in patients perception of AF paroxysms severity according to EHRA scale depending on thyroid function was observed, which is due both to hemodynamics and CNS alterations. P057 THE ROLE OF ATRIAL FIBRILLATION IN PATIENTS WITH IMPLANTABLE CARDIO‐
VERTER‐DEFIBRILLATOR Panattoni G; Papavasileiou LP; Della Rocca DG; Forleo GB; Topa A; Cioè R; Magliano G; Sergi D; Santini L; Romeo F Cardiology Department, University of Tor Vergata, Rome, Italy Purpose: Atrial fibrillation (AF) is common in patients with implantable cardioverter‐defibrillators (ICDs) and could lead to inappropriate shocks due to AF misclassification. The aim of our study was to evaluate the effects of AF on ICDs outcomes. Materials and Methods: We enrolled 428 consecutive patients (358 males, mean age 66.8 ± 11.3 years) who underwent ICD implantation at our institution. We excluded 322 patients without history of AF. Patients were divided in two groups: 45 patients (38 males, mean age 73.0 ± 8.8 years) with permanent AF (group A); 61 patients (48 males, mean age 69.4 ± 11.0 years) with history of paroxistical (83.3%) and persistent (16.7%) AF (group B). During follow‐up the occurrence of appropriate or inappropriate device therapy as well as mortality was noted. Results: During a mean follow–up of 24.8 ± 20.1 months, no significant differences were found in the overall mortality (12 vs 7 pts, p = ns). The presence of AF did not increase significantly the risk of appropriate therapy (13 vs 12 pts, p = ns) or of inappropriate therapy (5 vs 4 pts, p = ns). Type of treatment, with ATP or shock did not result to be statistically significant between groups (ATP: 7/13 vs 10/12 p = ns, shock: 6/13 vs 2/12, p = ns). Conclusion: In our study type of AF does not influence significantly the occurrence of appropriate or inappropriate device therapy and mortality. P058 PREVALENCE OF RISK FACTORS IN PATIENTS WITH A FIRST EPISODE OF ATRIAL FIBRILLATION Gonzalez A; Hinojar R; Perea JA; Zorita B; Goicolea L; Fraile A; Palma J; Romero R; Ruiz‐Polaina M; García‐Cosio F Hospital Universitario de Getafe, Madrid, Spain Background: Therapeutic failures in atrial fibrillation (AF) has turned the attention of clinical researchers toward chronic subclinical remodeling related to risk factors causing chronic atrial overload, in the hope that "upstream" therapy might improve prognosis. Objective: To study AF risk factors present in patients with a first episode of AF, who do not have significant structural heart disease, attending a public Spanish hospital that provides care to a population of 250000 people. Methods: From January 2008 to December 2010, patients attending the emergency room for a first episode of AF were registered. We excluded patients admitted to the hospital for coexistent structural heart disease. Follow‐up was done 10–20 days after discharge. Results: 170 patients were diagnosed and discharged, of which 50,6% were men. The mean age was 63.9 ± 13.9 years. 79 patients (46.5%) had hypertension, 11 (6.5%), were obese, 29 (17.1%), were diabetic, 10 (5.9%) had coronary artery disease, 11 (6.5%) chronic obstructive pulmonary disease, and 5 (2.9%) obstructive sleep apnea. Two patients (1.2%) practiced high level sports, 2 (1.2%) consumed alcohol in excessive quantities and 8 (4.7%), had history of hyperthyroidism. In 53 patients (31.2%), no risk factors were present. One risk factor was present in 47 patients (27.6%), 2 in 40 (23.5%), and 3 or more in 30 (17.7%). Conclusions: Most patients presenting with a first episode of atrial fibrillation have risk factors that could be corrected with the purpose of maintaining sinus rhythm once it has been achieved. A high percentage of patients have no risk factors and follow‐up should reveal if they have a better prognosis for AF control. In patients with no risk factors and recurrence of AF, it seems important to rule out triggering arrhythmias which could be treated with an ablation such as atrio‐ventricular tachycardias and arrhythmogenic foci in pulmonary veins. P059 INTERLEUKIN‐18 AMONG ATRIAL FIBRILLATION PATIENTS IN THE ABSENCE OF STRUCTURAL HEART DISEASE Guo Y; Luan Y; Li S; Yu B; Li S; Li N; Tian Z; Cheng J; Tian Y Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086 Background: Inflammation plays a role in the genesis and perpetuation of atrial fibrillation (AF). Interleukin (IL)‐18 is a pleiotropic proinflammatory cytokine with a central role in the inflammatory cascade. We hypothesize that the circulating IL‐18 concentration is elevated in AF patients. Methods: In a case‐control study design, 56 cases with AF and 26 controls were enrolled. All AF cases were categorized into paroxysmal and persistent AF, or lone AF and AF with hypertension. Circulating levels of IL‐18, tumor necrosis factor‐α, high‐sensitivity C‐reactive protein (hs‐CRP), matrix metalloproteinase (MMP)‐9 and tissue inhibitor of matrix metalloproteinase‐1 were measured. Results: In adjusted analyses, only age, MMP‐9 and IL‐18 were independently associated with AF, in which IL‐18 had the most significant association [p = 0.0011, STB = 1.76, OR = 1.02; 95% CI (1.01–1.03)]. IL‐18 levels in persistent AF patients were higher than those in paroxysmal ones(p = 0.0011). Patients who developed AF within 24 hours prior to sampling displayed a higher level of IL‐18 than those with sinus rhythm (p = 0.0027). IL‐18 was positively correlated with left atrial diameter (LAD) (r = 0.33, p = 0.0117). Conclusions: This study is the first to document elevated IL‐18 in AF patients. IL‐18 may be superior to other inflammatory markers which are known to be elevated in AF. Keywords: Atrial fibrillation, inflammation, interleukin‐18, MMP‐9, hs‐CRP. P060 THE RELATIONSHIP BETWEEN VITAMIN D DEFICIENCY AND NONVALVULAR AF Demir M; Uyan U; Günay T; Özmen G; Keçeoğlu S; Doğanay K; Melek M Bursa Yüksek İhtisas Education and Research Hospital Cardiology Clinic Bursa/Turkey Aims: The role of vitamin D (vitD) deficiency suggests cardiovascular disease such as coronary artery disease, heart failure and hypertension.VitD deficiency actives renin‐angiotensin‐aldosterone system which affects cardiovascular system.For this reason, could be suggested relationship between vitD deficiency and atrial fibrillation (AF). In our study we compared 25‐ OH vitD levels, between nonvalvular‐valvular AF and control groups in sinus rhythm. Method: Patients with replacement therapy of vitD and who has a disease affect vitD levels were excluded. 102 patients with nonvalvular chronic AF without any other cardiovascular disease (42 male; average age 62,51 ± 5.88; Group I) and 96 patients with AF which is associated with mitral valve disease (38 male; mean age 61,51 ± 5; Group II) were included in our study. 100 age‐matched healthy people with sinus rhythm were accepted as control groups (40 male; mean age 61,35 ± 5,44). All groups underwent transthoracicechocardiography. Routine biochemical parameters, 25‐OH vitD and parathormon (PTH) levels were performed. Results: Baseline characteristics of the study groups were comparable. Group I patients had a lower vitamin D level than Group II and control group (6,51 ± 4,89; 9,24 ± 7,39 and 11,18 ± 6,98 ng/ml, p < 0.001, respectively). In Group I and Group II patients left atrium (LA) diameter and systolic pulmonary artery pressure (SPAP) is higher than the control groups. In nonvalvular AF patients, LA diameter (OR: 2.29; 95% CI: 1,850–2,984, p < 0.001)and 25 OH VitD level (0.86, 95% CI: OR: 0,786–0.940, p = 0.001) were found independent predictors for AF. In patients with valvular AF, LA diameter, SPAP and right atrium diameter were predictors for AF. Conclusion: As a result of our study revealed relationship between vitD deficiency with nonvalvular AF. But the vitD level were found similar in valvular AF patients with mitral valve disease and control group. This situation suggests that vitD deficiency may cause nonvalvular AF. P061 AGE RELATED PREDICTION OF RECURRENCE OF ATRIAL FIBRILLATION IN METABOLIC SYNDROME PATIENTS Borrello F; Nardi S; Cassadonte F; Pirrotta S; Ciconte VA; Maglia GP Cardiology and ICU Pugliese Hospital Catanzaro, Italy Background: Metabolic Syndrome (MS), already known as a concurring condition in atrial fibrillation (AF), is a worldwide cluster of multiple cardiovascular risk factors. To establish the recurrence of AF is important for selecting patients who will be undergoing catheter ablation, several studies respectively evaluated the risk factor of the recurrence of AF post‐ablation. Objective: To investigate the factors predicting the recurrence of AF after catheter ablation in MS population. To assess the specific weight of each risk factor contributing MS in each decades. Methods: Out of 500 patients undergone AF catheter ablation in 2 years in Catanzaro and Terni, 100 (53 ± 26 years, 56 male) fulfilled the criteria for MS, including 59 paroxysmal AF and 41 persistent AF who were studied. Clinical data before, during, at 6, and 12 month follow‐up were recorded. Statistical analysis was performed to determine the factor weight predicting late recurrence of AF (LRAF). Results: There were 38 patients who experienced LRAF at 12 month follow‐up. Metabolic syndrome was statistically associated with recurrence of LRAF in all the subpopulation examined (< 45 yrs, 45–65, 65–75 yrs). From 75 years of age on, recurrence of AF was independent from the presence of MS. In addition, in patients younger than 65 yrs of age, the more risk factors of MS, the more the recurrence of AF. Conclusion: Our data suggest that MS is associated with LRAF in paroxysmal and non‐paroxysmal AF in patients younger than 75 yrs of age. Below such age, the more risk factors determining MS, the higher the risk of AF recurrence. P062 AUTONOMIC OUTFLOW DURING PROVOCATIVE MANEUVERS IN PAROXYSMAL LONE ATRIAL FIBRILLATION Oliveira M; Laranjo S; Tavares C; Xavier R; Geraldes V; da Silva N; Santos S; Ferreira R; Rocha I Autonomic Nervous System Unit, Institute of Molecular Medicine; Cardiology, Sta Marta Hospital Autonomic dysfunction appears to play a role in paroxysmal atrial fibrillation (PAF), but the mechanisms linking autonomic nervous system activity with PAF are incompletely understood. Aim: to assess the RR‐intervals (RRI) and systolic blood pressure (BP) variability in lone PAF patients (P) during standard autonomic tests. Methods: 16P with PAF (8 men; 55 ± 17 years) and 16 healthy individuals (HI) (8 men; 54 ± 10 years) while on sinus rhythm. RRI and BP were continuously assessed and LF (low‐frequency), HF (highfrequency) and LF/HF calculated in response to head‐up tilt (HUT), handgrip (HG), cold pressure (CPT) and deep breathing (DB), by using the wavelets transform analysis. Results: In baseline RRI and BP were similar for both groups. HI showed larger mean RRI and maximum RRI during DB. During HUT, two BP profiles were observed: an increase in PAF P and a decrease followed by an increase and further recovery in HI. HG and CPT provoked an increase of BP with a delayed pattern in PAF P. DB elicited a modulation of systolic and diastolic BP in both groups, but a significant decrease occurred only in HI. PAF P showed lower LF in HUT, and decreased HF in basal and during tilting movement in RRI variability analysis, without differences regarding systolic BP variability. LF of BP variability increased earlier in PAF P, with higher values during the second minute of HG. During the CPT, LF for BP variability analysis increased significantly only in HI. There were no differences between groups for RRI variability during DB. Conclusions: P with PAF present modified cardiovascular responses during maneuvers evoking autonomic outflow. These data underscore the presence of autonomic disturbances in PAF. P063 ASSOCIATION BETWEEN NEUTROPHIL/LYMPHOCYTE RATIO AND RECURRENCE OF ATRIAL FIBRILLATION AFTER SUCCESSFUL ELECTRICAL CARDIOVERSION Kayrak M; Gul EE; Demir K; Duman C; Alibaşiç H; Akıllı H; Aribas A; Ozdemir K; Gok H; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Current evidence links Atrial Fibrillation (AF) to the inflammatory state. Inflammatory indexes such as C‐reactive protein, interleukin‐6, and high‐sensitivity C‐reactive protein (hs‐CRP) have been related to the development and persistence of AF. More recently, the neutrophil/lymphocyte (N/L) ratio, which can be easily derived from the WBC count and determines the state of inflammation (reflecting neutrophil) and poor general health (lymphopenia), has emerged as a potentially useful prognostic parameter and was related with postoperative AF. We hypothesized that an elevated N/L ratio would be associated with an increased incidence of AF recurrence after successful electrical cardioversion. Methods‐Materials: One hundred and forty nine patients with a history of symptomatic AF (mean age 62 ± 10 years) underwent cardioversion. Echocardiography, complete blood count, and hs‐CRP assay were performed prior to cardioversion.During a follow‐up period of sixth months, AF recurred in 46 patients (31%). Main Results: Baseline hs‐CRP levels were greater in patients with AF recurrence compared to those with sinus rhythm (8.0 ± 5.1 mg/dl vs. 5.1 ± 3.7 mg/dl, p = 0.007, respectively). Overall, baseline N/L ratio was comparable between groups (AF recurrence 2.9 ± 2.0 and SR 2.8 ± 1.5, p = 0.96). Duration of AF was significantly longer in AF recurrence group than SR group (19 ± 12 months vs. 12 ± 9 months, p = 0.012, respectively). In addition, left atrial diameter was enlarged in AF recurrence group compared to SR group (p = 0.002). There was no correlation between N/L ratio and echocardiographic parameters. There was a weak positive correlation between hs‐CRP levels and N/L ratio (r = 0.22, p = 0.05). Conclusion: Our data suggest N/L ratio was failed to predict of AF recurrence. It needs to future investigation to determine the role of N/L ratio in AF development and recurrence. P064 ANTI‐COAGULATION USE FOR STROKE PROPHYLAXIS IN ATRIAL FIBRILLATION IN A MULTI – ETHNIC POPULATION Neo S; Francis PJ; Li A; Chia P‐L; Foo D Department of Cardiology, Tan Tock Seng Hospital Aims: We evaluate the patterns and prevalence of anti‐coagulation amongst patients of different ethnic backgrounds presenting with atrial fibrillation (AF) to a tertiary hospital. Methods: We identified 588 patients with AF admitted to our institution between years 2006 to 2010 and performed a retrospective review of their medical records. Baseline demographics, stroke and bleeding risk stratification scores and anti‐coagulation use were evaluated. Results: The mean age was 63 ± 14 years and 33% were aged ≥75. 77.6% were Chinese, 4.8% Indians, 11.7% Malays. Hypertension (67.7%) was the commonest associated co‐morbid condition, with no statistically significant difference amongst the ethnic groups. The mean composite CHA2DS2‐VASc score was 3.1 ± 2.0. The mean composite HAS‐BLED score was 1.8 ± 1.3. 62.9% had no contraindications to anti‐coagulation. Although 45.1% had composite CHA2DS2‐VASc scores ≥2 and HAS‐BLED scores ≤2, only 26.7% received warfarin. The commonest reasons for physicians not starting warfarin were patients' refusal due to fear of adverse effects of bleeding and increased fall risks in the elderly. There was no statistical difference regarding lack of anti‐coagulation across the different ethnic groups. Patients with permanent AF have higher odds of receiving anti‐coagulation compared to those with paroxysmal AF (OR 2.3; 95% CI, 1.51‐ 3.36; p < 0.001). Conclusions: The prevalence of anti‐coagulation in elderly is low in our multi‐ethnic population. Both physician and public education is of importance to prevent increased health care costs and AF related stroke mortality and morbidity. P065 THE FEATURES OF AUTONOMIC HEART RATE CONTROL IN PATIENTS WITH PERMANENT ATRIAL FIBRILLATION IN RESPONSE TO ACTIVATION OF SYMPATHETIC NERVOUS SYSTEM Mamontov OV; Berngardt ER; Parmon EV; Treshkur TV; Shlyakhto EV Almazov Federal Heart, Blood and Endocrinology Centre, Saint‐Petersburg, Russia Background: Assessment of autonomic heart rate (HR) regulation in patients suffering from permanent atrial fibrillation (AF) remains an unresolved problem. Most methods are based on evaluation of dynamics of sinus rhythm (SR). At the same time, alteration of autonomic cardiac nerve tone in patients with AF can be realized by modification of atrioventricular (AV) conduction. Objectives: The aim of the study was to evaluate features of autonomic HR modulation in patients suffering from permanent AF in response to activation of sympathetic nervous system. Methods: The study enrolled 43 patients suffered from heart failure II‐IV functional class (NYHA), mean age 53,8 ± 7,2 yrs. 20 pts had ischemic, 16–nonischemic and 7–mixed cardiomyopathy. 30 pts had SR and 13 ones had permanent AF. All patients underwent a handgrip test (HGT) during which blood pressure (BP) was measured by continuous noninvasive method (Finometer, FMS) and high resolution ECG was recorded simultaneously. BP and HR were estimated initially and in 3 min from starting of the HGT. Results: During the HGT comparable augmentation of BP was registered in both groups: dBP systolic in AF and SR patients was 20.5 ± 11.4 and 19.5 ± 10.7 mmHg, respectively, p > 0.05; dBP diastolic (dBPD) 14.3 ± 5.2 and 11.2 ± 6.4 mmHg, p > 0.05 resp. HR increase significantly greater in AF group than in SR one: dHR 11.7 ± 7.0 and 5.7 ± 4.0 bpm, resp., p < 0.005. In AF group dHR was strongly correlated with dBPD (r = 0.62, p < 0.005) but in SR group this correlation was less significant (r = 0.36, p > 0.05). The difference in HR increase and its relation with dBPD between SR and AF groups explains the difference in intensity of modulating impact of arterial baroreflex on sinus node and AV conjunction that opposes sympathetic activation. Conclusions: Parallel with BP augmentation strongly marked HR is observed in patients with AF during a simpathotonic HGT. That may indicate weak limitative influence of vagal feedback on AV conduction. BASIC SCIENCE: FROM BENCH TO BEDSIDE P066 CHANGES IN THE AGING‐ASSOCIATED OF L‐TYPE CALCIUM CHANNEL OF THE LEFT ATRIA OF THE CANINES Tianyi G; GuoJun X; Xianhui Z; Baopeng T; Xia G; Yaodong L Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi, China Introduction: Action potential (AP) contours vary considerably between normal adult and aged left atrial fibers. The ionic and molecular bases for these differences remain unknown. So we investigate whether the L‐type calcium current (ICa.L) an L‐type calcium channel of left atria may be altered with age. Methods: We used whole‐cell patch‐clamp to record action potential (AP) and ICa.L in left atrial (LA) cells dispersed from normal adult (2–2.5 years) and older canines (>8 years).The a1c (Cav1.2) subunit of L‐type calcium channel mRNA and protein expression were assessed by real‐time quantitative RT‐PCR and Western blotting respectively. Results: Whereas resting potential, AP amplitude and Vmax did not differ with age, the plateau was more negative and AP duration was max longer in old tissue. Aged LA cells have lower peak ICa.L current densities than Adult LA cells (P < 0.05). In addition, Compared to the adult group,the Cav1.2 mRNA and protein expression of LA were decreased in aged group. Conclusions: The lower plateau potential of AP and the decreased ICaL of LA in aged canines may contribute to the slow conduction and discontinuous conduction of LA. While the decreased expression of Cav1.2 with age may be the basis of the decrease of ICaL with age. Atria; Calcium channel; Cellar electrophysiology; Aging P067 SINUS RHYTHM RESTORATION AFFECTS COLLAGEN TURNOVER IN PATIENTS WITH PERSISTENT ATRIAL FIBRILLATION Kallergis EM; Kanoupakis EM; Mavrakis HE; Goudis CA; Saloustros IG; Vardas PE Department of Cardiology, University Hospital of Heraklion, Crete, Greece Objectives: To evaluate the importance of serum markers of collagen turnover in predicting the outcome of electrical cardioversion (CV) of persistent atrial fibrillation (AF) and to clarify the relationship between AF and fibrosis. Background: Collagen turnover and atrial fibrosis have been implicated in the generation and perpetuation of AF. Methods: Serum C‐terminal propeptide of collagen type I (CICP) and C‐terminal telopeptide of collagen type I (CITP) were measured in 98 patients with AF before and two months after CV. Results: All patients were successfully cardioverted to sinus rhythm (SR) although in 27 of them AF recurred. Baseline CICP levels were comparable in patients in sinus rhythm 60 days after CV and in those who experienced a relapse of AF (82.464 ± 16.65 ng/ml vs. 86.45 ± 10.95 ng/ml, respectively, p = 0.18). Baseline CITP levels were significantly higher in patients with AF recurrence compared to those who remained in SR (0.47 ± 0.15 ng/ml vs. 0.33 ± 0.19 ng/ml, respectively, p = 0.001). The restoration and maintenance of SR resulted in a decrease of CICP but not of CITP levels. In the 75 patients who maintained SR, CICP levels were significantly lower at the end of the study as compared to baseline, (61.89 ± 14.18 ng/ml vs. 82.464 ± 16.65 ng/ml p < 0.001), while there was no difference in plasma CITP levels, (0.35 ± 0.20 ng/ml vs. 0.33 ± 0.19 ng/ml, respectively, p = 0.477). Conclusions: AF can result in alterations in atrial structure and architecture that make the atrial myocardium more susceptible to the maintenance of the arrhythmia. Sinus rhythm restoration could affect the fibrotic process occurring or exacerbating during AF course. P068 ASSESSMENT OF VENTRICULAR ELECTROPHYSIOLOGICAL CHARACTERISTICS AT PERI‐INFARCT ZONE OF POST MYOCARDIAL INFARCTION IN THE RABBITS FOLLOWING STELLATE GANGLION BLOCK Gu Y; Wang X; Wang L; Tang Y Cardiovascular Research Institute of Wuhan University Background: To investigate the characteristics of ventricular electrophysiology following stellate ganglion block at peri‐infarct zone in the rabbits with MI. Method and Results: Sixty‐four rabbits were randomly assigned into two groups: MI group (n = 32), ligation of the anterior descending coronary; SO, sham operation group (n = 32), without coronary ligation. Both MI group and SO group were divided into four subgroups according to the right or left SGB and the corresponding control (n = 8, each). After eight weeks, 90% of monophasic action potential duration (MAPD90) of epicardium, midmyocardium and endocardium, transmural dispersion of repolarization (TDR), effective refractory period (ERP), ventricular fibrillation threshold (VFT) were measured at the infarct border zone (MI group) and corresponding zone (SO group) following SGB. For SGB, 0.5ml of 0.25% bupivacaine was used.As compared with the corresponding control group, in both of the MI group and SO group, LSGB prolonged the MAPD90 of three layers, reduced the TDR, increased the ERP and the VFT (P < 0.05). However, RSGB shortened the MAPD90, increased the TDR, reduced the ERP and the VFT(P < 0.05). Conclusion: The results demonstrated that LSGB can increase the electrophysiological stability of ventricular myocardium. Keywords: Stellate ganglion block; transmural dispersion of repolarization; effective refractory period; ventricular fibrillation threshold; Myocardial infarction. P069 ELECTROPHYSIOLOGICAL EFFECTS OF WENXIN GRANULE IN RABBITS WITH CON‐
GESTIVE HEART FAILURE IN VIVO Tang YH; Liu MX; Lian ZM; Wang Xi; Wang T; Hu P Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, china To observe the effect of Wenxin Granule on electrophysiology in rabbits with congestive heart failure(HF). 32 rabbits were randomly divided into four groups, they are sham‐operated no‐drug group (sham group), sham‐operated Wenxin Granule group (SHAM‐Wenxin group), HF no‐drug group (HF group) and HF Wenxin Granule group (HF‐Wenxi Group). HF model was successfully produced by volume overload combined with pressure overload. The rabbits were feed by Wenxin Granule 8 weeks. Sinusatrial node function, atrial and ventricular myocardium monophasic action potential duration (MAPD), effective refractory period (ERP), transmural dispersion of repolarization (TDR) and ventricular fibrillation threshold (VFT) were record by monophasic action potential (MAP) technique. Results: 1. sinusatrial node conduction time (SACT), sinusatrial node recovery time (SNRT), cSNRT were all prolonged in HF group (P < 0.05). SACT was shorter in HF‐Wenxin group (P < 0.05). 2. Compared with sham group, MAPD50 and MAPD90, ERP were prolong in sham‐Wenxin group and HF‐Wenxin group (P < 0.05). But there were no significant difference between HF group and HF‐Wenxin group (P>0.05).3. Compared with sham group and HF‐Wenxin group, the MAPD90 of the middle layer myocardium of left ventricular was prolonged and TDR was larger in HF group (P < 0.05 respectively). 4. Compared with HF group, VFT were remarkably increased in HF‐Wenxin Granule group (P < 0.05). Conclusions: Wenxin Granule had no more negative effects on sinus node dysfunction in heart failure rabitts. APD became conformity in three layers myocardium of heart failure by using Wenxin Granule, to decrease TDR in left ventricular, Wenxin Granule can increase VFT of heart failure rabitts, there was protective function in heart failure accompaning with arrhythmia. P070 SINUS NODE DYSFUNCTION AND HYPER‐
POLARIZATION‐ACTIVATED (HCN) CHANNEL SUBUNIT REMODELING ASSOCIATED WITH ATRIAL FIBRILLATION Tianyi G; GuoJun X; Xianhui Z; Baopeng T; Xia G Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China Background: Atrial fibrillation (AF) is frequently associated with Sinoatrial node (SAN) dysfunction. But underlying mechanisms remain poorly understood.The hyperpolarization‐activated cation current contributes significantly to sinoatrial node pacemaker function and possibly to ectopic arrhythmogenesis. This study examined the hypothesis that AF impair SAN function by altering hyperpolarization‐activated (HCN) channel expression and AF may lead to HCN channel of atria remodeling. Methods: We assessed expression of HCN1, 2, 4 and beta‐subunit minK in sinus rhythm (SR) beagle canines and canines subjected to 8‐week atrial tachypacing‐induced atrial fibrillation (AF). Realtime RT‐PCR and Western blot were used to quantify HCN subunit and beta‐subunit minK mRNA and protein expression in the right atrium (RA) and sinoatrial node. Results: AF canines have longer sinus node recovery time than SR canines, which reflects impaired SAN function.HCN2 and HCN4 expression was greater at both protein and mRNA levels in sinoatrial node than RA. AF significantly decreased sinus node HCN2,4 and beta‐subunit minK expression at both mRNA and protein levels,while increased HCN2,4 and beta‐subunit minK expression of RA. Conclusions: The decreased expression of HCN2,4 and beta‐subunit mink of sinoatrial node contribute to AF‐induced sinus node dysfunction; while upregulation of atrial HCN2,4 and beta‐subunit minK may help to promote maintaining of AF. Keywords: Atrial fibrillation; sinoatrial node; HCN channel; remodeling. BRADYARRHYTMIAS P071 PREDICTIVE VALUE OF ELECTROCARDIOGRAPHY AND ELECTOPHYSIOLOGICAL STUDIES IN CONDUCTION ABNORMALITIES AFTER CORE VALVE‐MEDTRONIC AORTIC VALVE IMPLANTATION‐ PRELIMINARY RESULTS Kostopoulou A; Karyofillis P; Livanis E; Voudris V 2nd Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece Aim: Surgical aortic valve replacement is associated with complete heart block (CHB) requiring permanent pacing in 3 to 6%. Reports have shown a higher incidence of conduction disease in patients (pts) undergoing percutaneous aortic valve implantation (PAVI). The purpose of our study was to assess the value of the surface electrocardiogram (ECG) and the electrophysiology study (EPS) as predictors of conduction abnormalities after PAVI. Methods: Twenty seven consecutive pts mean aged 81 ± 6 years with severe aortic stenosis and normal or slightly impaired left ventricular function (mean LVEF 53 ± 10%) who underwent Core Valve‐Medtronic implantation were included. The baseline 12‐lead surface ECG was analyzed for the recording of basic rhythm and conduction abnormalities. A basic EPS study was performed a day before for the measurement of the basic intervals PA, AH, HV, the effective refractory period (ERP) of the atrioventricular (AV) node and the Wenckebach cycle length (WCL). Results: At baseline evaluation 21 pts were in sinus rhythm and 6 in chronic atrial fibrillation. The mean PR and QRS were 185 ± 25 msec and 118 ± 27 msec. Six pts had a LBBB and 3 LAH. The basic EPS measurements were: AH 93 ± 17 msec, HV 51 ± 11 msec (34–90 msec), AV‐ERP 288 ± 59 msec, and WCL 386 ± 72 msec. All pts, except 1, had HV intervals <70 msec. Nine pts (33%) required permanent pacing due to CHB after PAVI. Seven pts developed LBBB during the first 4 days. Four of the 9 pts that had a pacemaker implantation had restored normal rhythm at first‐month follow‐up. Student's T test showed that in pts with pacemakers compared to those without, the AH interval was prolonged at significant levels. The HV interval and AV‐ ERP measurements were higher but not significantly whereas the QRS width did not differ. Conclusions: Preliminary data show that patients with pre‐existing conduction abnormalities revealed in an EPS study may be susceptible to development of complete AV block after PAVI. P072 HIGH PREVALENCE OF AMYLOID DEPOSITION IN SUBCUTANEOUS FAT TISSUE IN PATIENTS WITH BRADYARRHYTHMIA Omi W; Hanaoka R; Takatori O; Saeki T; Kasashima S; Kawashima A; Sakagami S Department of Cardiology, Kanazawa Medical Center, National Hospital Organization Background: Most of cases with amyloidosis progress asymptomatically, and is diagnosed when cardiac involvement is already at end stage. Additionally, the diagnosis is sometimes cumbersome and accompanied with complication. These factors make early diagnosis difficult. Aim: To assess the usefulness of subcutaneous fat sampling during pacemaker implantation and to validate the prevalence of systemic amyloidosis in patients with bradyarrhythmia who required permanent pacemaker. Patients and Methods: We enrolled 15 consecutive patients (79 ± 12 years old, 7 males) who required pacemaker implantation (containing 4 patients, generator exchange). Four patients had sick sinus syndrome and 11 had atrioventricular block. In all cases, echocardiography did not show typical findings suggesting cardiac amyloidosis. Pacemaker was inserted to infraclavicular precordia. Subcutaneous fat tissues were taken during surgery and specimens were evaluated by the pathologists. Results: Pacemaker implantation and subcutaneous fat sampling were performed successfully and safely in all cases, and interstitial amyloid deposition was confirmed in 9 cases (60%). Gastro and/or colon endoscopy were performed in 4 patients of them, and intestinal amyloid deposition was confirmed in 2 patients. Conclusion: Subcutaneous fat sampling during pacemaker implantation was safety and helpful for diagnosis of systemic amyloidosis. Our data suggests that systemic amyloidosis could be more frequent than we supposed, and that contribute to bradyarrhythmia even in the absence of other typical manifestation. P073 CASE REPORT: COMPLETE HEART BLOCK FOLLOWING PARAPHENYLENE DIAMINE (PPD) HAIR DYE POISONING Suliman AAA; Ibrahim GIA Alshaab Teaching Hospital – Khartoum‐Sudan Introduction: Paraphenylene diamine (PPD) [C6H4 (NH2)2] is an aromatic amine not found in nature and it is produced commercially by many industrial companies. It is widely used in industrial products. PPD is the most common constituent of hair dye formulations. PPD is commonly used in its raw form for cosmetic purposes in Africa, Middle East and Indian subcontinent while it is rarely used in the West. In Sudan, PPD is mixed with henna leaves of Lawsonia Alba, which is a non toxic herb used to decorate the hands and feet in special social events. PPD intoxication is a life threatening condition, commonly manifested as acute upper respiratory tract obstruction and acute kidney injury but seldomly affects the heart. Case Presentation: We are reporting this case of a 26 year old female from Aljazeera State in Sudan, who presented complaining of dizzy spells and severe fatigue following swallowing of hair dye intentionally (suicide attempt). She was seen initially at her local hospital where she was found to be bradycardic. Her HR was 40 bpm and she was referred to our cardiology department at AlShaab Teaching Hospital. Upon arrival, the patient looked fatigued but was fully conscious, BP 110/50, HR 40/min and her systemic examination was unremarkable. ECG showed complete heart block with wide complex escape rhythm of 38 bpm. Her blood tests showed mildly elevated renal profile and CPK with normal cardiac biomarkers. Echo showed normal systolic function. Temporary pacemaker wire was immediately inserted and kept under monitoring. Over the next two weeks she remained in complete heart block with intrinsic HR of 38bpm. After two weeks of temporary pacing, a DDDR pacemaker was inserted. Two years after initial presentation, the patient still remains in complete heart block and is pacemaker dependent. Conclusion: This is the first reported case of permanent complete heart block, requiring PPM implantation, following PPD intoxication without evidence of of myocardial injury. P074 BRADYCARDIA AS A CAUSE OF ANGINATHE NEW BRADYANGINA SYNDROME Duque M; Herrera AM; Múnera JS; Medina E; Marín J; Uribe W School of Medicine, Universidad CES – Department of Cardiology, Clínica CES, Medellín, Colombia Background: Angina is defined as a sensation of pressure or retrosternal pain with a rather specific pattern of irradiation, with physical or emotional stress, or even at rest, and secondary to a decrease in myocardial oxygen supply. Bradycardia is defined as a persistent or transitory decrease in heart rate below 60 beats per minute, due to primary, secondary, and reversible or irreversible causes. There is an association between heart rate and cardiac output. Could it be possible that a reduction in the heart rate results in a decrease in cardiac output to a point that it is responsible for myocardial ischemia, and as such, angina?Materials and Methods: This is a retrospective – prospective study of patients with angina of unknown origin and sinus bradycardia diagnosis that were admitted in our cardiology service between august 1st 2007 and august 31st 2009. Diagnostic approach included coronariography, or non invasive measures as stress echocardiography or myocardial perfusion test with radiotracers. Patients were treated with pacemaker implantation, discontinuation of medications with negative chronotropic effect and/or follow up in those with transitory or non pharmacologic causes of bradycardia. After performing the interventions, all patients were followed up and evaluated in search of the presence of angina or bradycardia, and persistence of symptoms. Results: A total of 60 patients were evaluated, 70% were men. Mean age of 52.5 ± 16.3 (SD) years. Pacemaker implantation was performed in 78.3% of patients. Medication associated with bradycardia was discontinued in 11.7% of patients. During follow up, 100% of patients did not report having new episodes of angina after the intervention was performed. Conclusion: With coronary disease discarded, the study of rhythm anomalies as a potential etiology of the symptomatology should be performed. The association between bradycardia and angina could be newly defined as "Bradyangina syndrome". P075 SINUS OF VALSALVA ANEURYSM AS A REVERSIBLE CAUSE OF COMPLETE HEART BLOCK (A CASE REPORT) Alasti M; Omidvar B; Mali S; Majidi S Department of Cardiology, Jundishapur University of Medical Sciences, Ahvaz, Iran A 43 year old lady was referred to our center for temporary intravenous pacemaker insertion. She had a history of dizziness and one episode of syncope since two days ago. She did not have any risk factor of coronary artery disease. There was no significant past medical illness. Laboratory data including serum potassium and cardiac enzyme levels and sedimentation rate were within normal limits. The ECG showed complete AV block with ventricular escape rate of 30–35 beat/min. The QRS complexes were wide with LBBB morphology pattern (Figure 1‐A). Transthoracic echocardiography showed mildly enlarged left ventricle with normal contractility, mild aortic regurgitation and an aneurysm of sinus of valsalva eroding into the upper part of interventricular septum (Figure 2‐A). 64‐slice CT scan disclosed a large sinus of valsalva aneurysm originating from right sinus of valsalva (Figure 2‐B). Right sided heart catheterization and selective coronary angiography showed normal pulmonary artery and wedge pressures and normal epicardial coronary arteries. Aortography in LAO and RAO projections showed a large aneurysm of right coronary sinus of valsalva and mild aortic regurgitation (Figure 3‐A&B). The patient underwent surgery and the mouth of aneurysm was closed with a Gortex patch. In addition, an epicardial pacemaker was implanted. The ECG taken two weeks later disclosed sinus rhythm with prolonged AV interval and bifascicular block and no pacing (Figure 1‐B). In rare cases, the aneurysm erodes into the interventricular septum. Direct pressure by the expanding aneurysm and low grade inflammation can lead to atrioventricular conduction defects. It is interesting in our patient that the rhythm returned to sinus after surgical decompressing of interventricular septum. It looks reasonable that unruptured sinus of valsalva aneurysm eroding into the interventricular septum is operated as soon as possible, preventing development of complications such as heart block. CARDIAC IMAGING P076 CLINICAL IMPLICATION OF EVALUATING LEFT ATRIAL ARTERY AND LEFT ATRIAL RIDGE BEFORE CATHETER ABLATION FOR ATRIAL FIBRILLATION WITH MULTIDETE‐
CTOR‐ROW CT Kimura R; Inoue K; Toyoshima Y; Doi A; Masuda M; Sotomi Y; Iwakura K; Fujii K Sakurabashi Watanabe Hospital Objective: The anatomy of the left atrial ridge (LAR) is important for deciding strategy of catheter ablation (CA) for atrial fibrillation (AF). The branch of the left atrial circumflex artery (AC) runs within LAR, and it could exert the cooling effect during CA. We studied the morphology of LAR and AC with multidetector‐row CT (MDCT). Methods: Twenty‐six patients (age 60 ± 12 years, male 16) undergoing CA for AF (13 with paroxysmal AF and 13 with persistent AF) were enrolled. MDCT was performed prior to CA. Results: The left atrial volume (LAV) (98.6 ± 46.8 ml vs. 58.9 ± 21.9 ml, P < 0.05) and the thickness of the LAR (3.15 ± 0.60 mm vs. 2.54 ± 0.85 mm, P < 0.05) was significantly greater in persistent AF group. AC was observed by MDCT in 4 cases (30.7%) in proximal AF group and in 2 cases (15.4%) in persistent AF group. There were no significant differences in LAV and the thickness of LAR between groups with and without visible AC. The time (21.7 ± 11.4 min vs. 18.2 ± 8.61 min) and the number of CA (37 ± 23 vs. 31 ± 13) for left pulmonary vein isolation were greater in the patients with visible AC, but this difference did not reach statistical difference. Conclusion: The evaluation of the LAR with MDCT was useful for deciding strategy of AF ablation. The clinical implication of AC in AF ablation needs further investigation. P077 MULTIDETECTOR COMPUTED TOMOGRAPHY CAN DETECT LEFT VENTRICULAR MECHANICAL DYSSYNCHRONY IN HEART FAILURE PATIENTS UNDERGOING CARDIAC RESYNCHRONIZATION THERAPY Kimura R; Koyama Y; Inoue K; Toyoshima Y; Doi A; Masuda M; Sotomi Y; Iwakura K; Fujii K Sakurabashi Watanabe Hospital Background: Cardiac resynchronization therapy (CRT) is widely accepted as the adjuvant treatment of patients with severe heart failure. However, approximately 30% of patients receiving CRT are non‐responders. In order to improve the efficacy of CRT, the selection of appropriate patients based on the preoperative evaluation of the extent of left ventricular dyssynchrony is important. Several echocardiographic indices for the evaluation of dyssynchrony are proposed, but recent study shows their limitations. Objective: We sought to determine the feasibility of MDCT (Multidetector CT) to detect left ventricular mechanical dyssynchrony in heart failure patients. Methods: Eight patients with heart failure (mean left ventricular ejection fraction 22.8%) who were the candidates for CRT underwent electrocardiogram‐gated contrast‐enhanced 64‐slice MDCT (Philips Brilliance 64, EBW Workstation) and axial multiphase reformats were constructed. With visual observation, patients are divided into two groups: group D (with apparent left ventricular dyssynchrony, 4 patients), and group N (without apparent dyssynchrony, 4 patients). The short‐axis image of the left ventricle at the level of papillary muscle was divided into 6 segments. We determined the time from R wave to maximal wall motion for each 6 segments and defined the maximum difference in time‐to‐maximal wall motion of all 3 pairs of opposing segments as wall motion delay (WMD). Echocardiographic measurements including septal‐to‐posterior wall motion delay (SPWMD) were performed in all patients. Results: WMD was significantly greater in group D compared with group N (32.5 ± 9.6% RR vs. 10.0 ± 7.1% RR, P < 0.05). SPWMD was greater in group D, but it did not reach statistical significance (233 ± 60 ms vs. 161 ± 93 ms, p = 0.12). Conclusion: MDCT is useful for the observation and the evaluation of left ventricular dyssynchrony with its ability to clearly visualize the cross‐sectional moving images of left ventricle. P078 COMBINED USE OF THREE‐DIMENSIONAL ROTATIONAL ANGIOGRAM OF LEFT ATRIUM AND CIRCULAR MULTI‐ELECTRODE ABLATION CATHETER FOR PULMONARY VEIN ISOLATION Tang M; Gerds‐Li J‐H; Kriatselis C; Zhang S Department of Arrhythmia, Fuwai Cardiovascular Hospital, Chinese Academy of Medical Science, Beijing Background: A novel circular pulmonary vein ablation catheter (PVAC) has been introduced for pulmonary vein isolation (PVI). Accurate delineation of left atrium‐pulmonary vein (LA‐PV) anatomy is important for this technique. The aim of this study was to test the 3‐dimensional rotational angiogram of left atrium (3D RTA) can facilitate PVI using PVAC technique. Methods: Twenty patients with paroxysmal atrial fibrillation (AF) were enrolled in this study. The 3D RTA was reconstructed and registered with live fluoroscopy in all the patients. AF ablation was performed with PVAC catheter in the navigation of registered 3D RTA. Results: The 3DRTA image was successfully reconstructed and registered with the live fluoroscopy in all patients (100%). The LA‐PV anatomy was delineated clearly in all patients. Navigation of the PVAC inside the registered 3D RTA, ensured accurate placement within the atrium to perform ablation, and the PVAC was correctly placed inside the PV ostium to verify the PVI. All the PVs were isolated. Total procedural time was 87.5 ± 12.1 minutes, and fluoroscopy time was 20.1 ± 6.3 minutes. Follow‐up after 7.1 ± 1.5 months showed freedom from AF in 70% (14/20) patients. No PV stenosis was observed. Conclusions: Intraprocedurally reconstructed and registered 3D RTA can clearly delineate the LA‐PV anatomy in real‐time, this study demonstrates the feasibility and reliability of combining use of 3DRA and PVAC in AF ablation procedure. CARDIAC RESYNCHRONISATION THERAPY P079 LONG TERM OUTCOMES IN ISCHEAMIC VERSUS NON‐ISCHEAMIC DILATED CARDIOMYOPATHY AFTER CARDIAC RESYNCHRONIZATION THERAPY Mantziari L; Vassilikos V; Kamperidis V; Paraskevaidis S; Dakos G; Chatzizisis Y; Giannakoulas G; Karvounis H; Styliadis IH First Cardiology Department, AHEPA Hospital, Aristotle University of Thessaloniki, Greece Background: Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure. Response to CRT and long term survival may be affected by a plethora of factors, heart failure aetiology being one of them. Aim of this study was to assess differences between patients with ischemic cardiomyopathy (ICM) and non‐ischemic dilated cardiomyopathy (DCM) treated with CRT. Methods: Data from CRT implantations for standard indications were retrospectively analysed. Differences in baseline characteristics, clinical and echocardiographic response to CRT and long term outcomes were sought between ICM and DCM. Results: A total of 166 patients were included, 51% with ICM and 49% with DCM. Mean baseline EF was 24 ± 5% and baseline NYHA class 3.0 ± 0.2 and did not differ between ICM and DCM. DCM patients were younger (61 ± 11 vs 69 ± 9 years, P < 0.001) and included more females (24% vs 2%, P < 0.001). QRS duration was similar between ICM and DCM (169 ± 24 vs 163 ± 25, p = 0.162) but left bundle branch block (LBBB) morphology was more frequent in DCM (89% vs 77%, p = 0.035). Atrial fibrillation prevalence and LV lead implantation site were similar. At 6 months, clinical improvement, defined as reduction ≥1 NYHA class, was 76% in both groups, and LVEF increased ≥15% in 75% of DCM vs 70% of ICM patients (p = 0.770). After a mean follow up of 24 ± 21 months DCM patients showed better survival (log rank p = 0.006) and a trend for better event‐free survival (log rank p = 0.055). After adjusting for age, gender and QRS morphology, DCM remains an independent predictor of better survival. Conclusions: Patients with DCM treated with CRT are younger, are more frequently female and have higher prevalence of LBBB. Even though short‐term response to CRT is similar between ICM and DCM, long term survival is better for DCM patients. P080 MORLET WAVELET ANALYSIS OF THE QRS COMPLEX AS A NOVEL TOOL FOR PREDICTING RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY Vassilikos V; Mantziari L; Dakos G; Kamperidis V; Kalpidis P; Paraskevaidis S; Maglaveras N; Chouvarda I; Karvounis H; Styliadis IH First Cardiology Department, AHEPA Hospital, Aristotle University of Thessaloniki, Greece Background: Among eligible patients for cardiac resynchronization therapy (CRT), those with wider QRS and left bundle branch block (LBBB) are more likely to respond. The wavefront pattern of myocardial ventricular activation in LBBB may differ between responders and non responders. Aim of the present study was to explore the differences in the QRS complex components between responders and non‐responders. Methods: We conducted a pilot prospective study in 39 consecutive patients (age 64 ± 10 years, 31 males) with heart failure and LBBB treated with CRT according to established guidelines. Signal averaged electrocardiograms were recorded before implantation and QRS decomposition was performed using the Morlet wavelet transformation. Wavelet parameters expressing the mean and maximal (max) energy were calculated in three orthogonal axes (x,y,z) and in the vector magnitude (vm), in each of three frequency bands. Response was defined as clinical improvement by one or more NYHA classes at 6 months follow up. Results: Baseline QRS duration was 166 ± 23 ms, left ventricular ejection fraction (LVEF) 26 ± 7% and LV end systolic volume (LVESV) 163 ± 49 ml. Thirty patients (77%) were identified as responders and had wider baseline QRS (171 ± 22 vs 142 ± 11ms, p = 0.005) and lower mean and max energies in all frequency bands on x axis as compared to non‐responders. Wavelet parameters on x lead could predict response to CRT with 76–79% sensitivity and 83% specificity. Conclusions: This pilot study showed that wavelet transformation of the amplified QRS complex may contribute in discriminating among patients who are more likely to benefit from CRT. A larger prospective study is deemed necessary to validate our findings. P081 DEMOGRAPHIC PROFILE OF CARDIAC RESYNCHRONISATION THERAPY (CRT‐D/CRT‐P) RECEIPIENTS AT OUR CENTRE – FIVE YEARS (2006–2011) EXPERIENCE Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Cardiac resynchronization therapy (CRT‐D/CRT‐P) is the emerging and proven modalities of treatment in patients (pts) with severe left ventricular (LV) dysfunction. Our center evaluated demographic profile of CRT in our pts over five years. Objective: To evaluate demographic profile of pts being referred for CRT‐D/CRT‐P in our center. Population/Methods: We studied 352 pts with severe LV dysfunction who were implanted CRT‐P/CRT‐D from 2006–2011. We analysed distribution by% of pts who received CRT‐D/CRT‐P, their age, gender selection, NYHA class, QRS duration (QRSd), etiology and comorbid conditions. In pts with QRSd (120–150 msec), we analysed mechanical dyssynchrony with Tissue Doppler Imaging (TDI). Indices chosen were atrioventricular (AV), interventricular and intraventricular dyssynchrony. Pts with 2/3 dyssynchrony indices were included. Results: Out of 352 pts (85.6% males, 14.4% females); mean age of pts 62.9 ± 17 yrs, with no statistical difference in mean age (59.3 ± 11.6 yrs for males vs 57.9 ± 10.4 yrs for females). 79% were diabetic and 60% hypertensive. CRT‐P was given to 79%, CRT‐D to 21%. 69.6% had ischemic etiology, 30.4% idiopathic dilated cardiomyopathy. Mean ejection fraction (EF) 22 ± 9%, mean QRSd 146 ± 18 msec. 2% in NHYA class II, 68% in NYHA class III and 30%in ambulatory NYHA class IV as a group, in females 46% were in NYHA class III and 54%in ambulatory class IV and in diabetics 43% were in NYHA class III and 57% in ambulatory class IV. Conclusion: We analysed demographic profile of pts who received CRT‐D/CRT‐P. The rate of implantation in females in our center is lower than expected. Also, females were older with higher NYHA class. The guidelines must be implemented carefully to avoid gender selection biases. We also concluded that diabetics were older with higher NYHA class vs non‐diabetics and hypertensives. In this study 2% population got CRT in NYHA classII in accordance with recent European guidelines for CRT. P082 LEFT VENTRICULAR PACING USING ACTIVE FIXATION LEADS IN CHALLENGING CORONARY SINUS ANATOMY Ahmad Fazli AA; Azlan H; Surinder K; Zunida A; Tay GS; Noor Ashikin S; Razali O National Heart Institute, Kuala Lumpur, Malaysia Introduction: The placement of leads in the distal coronary sinus is required for left ventricular stimulation in cardiac resynchronization therapy as well as for ventricular pacing whereby the right ventricle is inaccessible. Challenging coronary sinus anatomy may lead to instability, lead dislodgements and phrenic stimulations. We hypothesise that usage of an active fixation lead mechanism will overcome these limitations with stable lead performances. Methods: Patients who had implantation of 4F active fixation leads (SelectSecure Model 3830, Medtronic Inc, Minneapolis, USA) due to failed conventional left ventricular leads from May 2009 until July 2011 were selected for the study. Pacing parameters were tested at implantation and if found unreasonable, the lead is then unscrewed and fixed at a new location until the pacing parameters were satisfactory. We analysed pacing parameters at implantation and follow up as well as monitoring for lead related complications in these patients. Results: A total of 28 patients received implantation of the 4F active fixation leads. Among these, 71.4% were due to lead instability, 14.3% were selected for recurrent dislodgements, and 14.3% for phrenic stimulations. All 28 patients had successful implantations. Pacing threshold at implantation was 1.37 ± 0.59V and lead impedance was 809 ± 393 ohms. There were no significant difference in the pacing thresholds and lead impedances at 1 month, 3 months and 6 months follow up. The lead thresholds were 1.35 ± 0.86V, 1.33 ± 0.77V and 1.65 ± 0.98 V respectively (p = NS). Impedances were 624 ± 188 ohms, 666 ± 252 ohms and 624 ± 202 ohms respectively (p = NS). No lead related complications were encountered. Conclusions: Obstacles in lead placement for left ventricular stimulation due to challenging coronary sinus anatomy can be safely overcome by the use of 4F active fixation leads with stable pacing parameters. P083 AV NODE ABLATION IS NOT A PREDICTOR OF MORTALITY IN PATIENTS WITH ATRIAL FIBRILLATION TREATED WITH CARDIAC RESYNCHRONIZATION THERAPY Trucco E; Tolosana JM; Borras R; Calvo N; Arbelo E; Berruezo A; Sitges M; Castel MA; Brugada J; Mont L Hospital Clinic, Thorax Institute, Cardiology Department, Barcelona, Spain Background: There is a controversy about whether the AVJ node ablation (AVJ) improves the response and reduces the mortality of patients with permanent atrial fibrillation (AF) treated with cardiac resynchronization therapy (CRT). The aims of our study were: 1) to analyze if AVJ ablation reduced the mortality of patients in AF treated with CRT; 2) to analyze the predictors of mortality in this group of patients. Methods: This is a prospective and observational study. A cohort of 154 consecutive patients with permanent AF treated with CRT from 2000 to 2010 in our center was analyzed. Patients were divided into two groups: group 1: patients with AVJ ablation or need for continuous ventricular pacing due to complete AV block and group 2: those without AVJ ablation and non AV block. Patients were seen at the outpatient clinic at 6‐month intervals and at any time they required further evaluation due to a worsened clinical condition. Results: Of 154 patients: 78 (50.6%) were classified in group 1 and 76 (49.4%) in group 2. Basal echocardiogram and clinical parameters were similar in both groups. At 12 months, overall mortality was 21/154 (14.2%); 9/78 (11.5%) group 1 vs. 12/76 (15.7%) group 2 (p 0.486). In a univariate analysis the predictors of mortality were: plasma creatinine levels and NYHA functional class IV. After adjusting for these variables in a Cox regression model, the independent predictors of mortality were: basal NYHA functional class IV (HR 3.73, 95% CI [1.45–9.59], p = 0.006) and plasma creatinine levels (HR 1.93, 95% CI [1.00‐ 3.70], p = 0.048). Conclusions: AVJ ablation did not decrease the mortality of patients in AF treated with CRT. Basal NYHA functional class IV and poor renal function were the independent predictors of mortality in this group of patients. P084 A PROSPECTIVE AND RANDOMIZED STUDY USING A NUMERICAL MODEL ABLE TO PERSONALIZE AV AND VV DELAYS IN CARDIAC RESYNCHRONIZARION THERAPY Di Molfetta A; Forleo GB; Minni V; Panattoni G; Cioè R; Papavasileiou LP; Magliano G; Santini L; Capria A; Romeo F Department of Cardiology, University of Tor Vergata‐Departement of Cardiovascular Engineer CNR, Rome AV and VV setting is a critical issue in CRT. A numerical model (NM) able to simulate patients condition and optimize AV and VV was developed. The aim of this study was to assess if the developed algorithm dedicated to CRT‐optimization could increase clinical, electrical and echocardiographic outcome. Forty patients (PT) were enrolled in a prospective study and randomized into two groups. Group A (B) contains PT programmed by NM (commercial ones). PT were studied before CRT, 3 (_3) and 6 (_6) months after CRT to evaluate: left ventricular end systolic and end diastolic volumes (Ves, Ved), QRS, 6 minute walking test (S) and total Minnesota scores (M). In group A the AV and VV were changed at each follow up according to NM indications. No significant statistical differences were observed at the baseline (Ves_A = 194 ± 102 ml, Ves_B = 157 ± 56 ml; Ved_A = 252 ± 113 ml, Ved_B = 213 ± 72 ml; QRS_A = 156 ± 44 ms, QRS_B = 150 ± 43; S = 127 ± 88 m, S_B = 132 ± 90; M_A = 29 ± 19, M_B = 33 ± 21) A significant statistical difference in left ventricular remodeling concerning the reduction of Ved (A_3 =−25%, B_3 =−10%, p = 0.001; A_6 =−30%, B_6 =−10%, p = 0.0009) and Ves (A_3 =−23%, B_3 =−12%, p = ns; A_6 =−35%, B_6 =−12%, p = 0.002) were observed. A more evident increase of S distance was observed in A (A_3 =+219 m, B_3 =+198 m; A_6 =+279 m, B_6 =+195 m). No significant statistical difference in the reduction of QRS width was reported (A_3 =−16%, B_3 =−10%; A_6 =−9%, B_6 =−18%) and in M (A_3 =−8.9, B_3 =−14.25; A_6 =−9.25, B_6 =−16). A dynamic and personalized CRT can improve ventricular remodeling, without affecting QRS decreasing. Moreover, NM can be a support to select candidates to CRT estimating in advance the benefit effect of CRT on a specific patient. P085 THE EFFECT OF CARDIAC RESYNCHR‐
ONIZATION THERAPY ON THE LEFT VENTRICULAR FUNCTION: EVALUATION OF ELECTROCARDIOGRAPHIC AND ECHOCARD‐
IOGRAPHIC CHANGES Marinskis G; Maneikiene V; Jonaityte D; Zasytyte I; Aidietis A Clinic of Cardiac and Vascular Diseases, Vilnius University, Faculty of Medicine Aim: To evaluate the effect of cardiac resynchronization therapy on the left ventricular function by analyzing changes in left ventricular ejection fraction (LVEF) and QRS complex width. Patients and methods: A retrospective study was held in Vilnius University Hospital Santariskiu clinics. We analyzed 55 patients (18 women, 37 men, age 61.5 ± 14.5 years) who had biventricular pacing system implantation because of II‐IV NYHA heart failure. Primary implantation was performed for 45 patients, system upgrade – for 10. We analyzed the data of electrocardiograms and heart ultrasound before and after implantation (QRS width, LVEF and clinical status). Microsoft Excel and STATISTICA software was used for data processing and statistical analysis. Student t‐test was used to evaluate the difference between continuous variables in two groups. Pearson correlation coefficient was used to measure the correlation between the changes of QRS width and LVEF. p ≤ 0.05 was considered statistically significant. Results: QRS width average before implantation was 185 ± 26 ms, after – 152 ± 19 ms (P < 0.05). QRS width decreased by mean value of 31 ± 22 ms (P < 0.05). QRS width remained the same in 4 patients. LVEF mean value before implantation was 26 ± 10%, after – 31 ± 9% (P < 0.05). On average LVEF after the implantation increased by 6 ± 10% (P < 0.05). Changes in QRS width correlated with LVEF changes (r =−0.276, p = 0.048). The broader QRS complexes were before treatment, the more significantly they shortened after implantation of resynchronization system (r =−0.52, p = 0.00078). Clinical status (followed from 3 to 76 months after treatment) of 23 (42%) patients improved, 21 (38%) remained stable, 3 (5%) worsened, 8 patients (15%) died. Conclusions: In responders to cardiac resynchronization therapy, shortening of QRS complex correlates with improvement of left ventricular function. P086 PRESERVED CONTRACTILE AND CORONARY FLOW RESERVE ARE PREREQUISITE FOR POSITIVE RESPONSE AFTER CARDIAC RESYNCHRONIZATION THERAPY Djordjevic‐Dikic A; Nikcevic G; Raspopovic S; Jovanovic V; Tesic M; Djordjevic S; Milasinovic G Pacemaker Center, Institute for Cardiovascular Disease, Clinical Center of Serbia, Belgrade, Serbia Background: Cardiac resynchronization therapy (CRT) has become a mainstay in heart failure management, but still 30% of patients failed to respond to such therapy. In patients with non‐ischemic dilated cardiomyopathy, abnormal coronary flow reserve and absence of contractile reserve are independent prognostic markers of bad prognosis. Aim: The aim of this study was to investigate the potential impact of coronary flow reserve (CFR) and myocardial contractile reserve on left ventricular function recovery following CRT implantation. Method: Eighteen patients with heart failure (EF 26 ± 5%) and QRS duration of 159 ± 23 ms, underwent transthoracic Doppler echocardiography adenosine test to evaluate CFR and dobutamine echocardiography test to assess global contractile reserve (improvement in LVEF), before CRT implantation. Responders were defined by decrease in end‐systolic volume (ESV) ≥15%, 6 months after CRT. Results: Fourteen patients were responders, whereas 4 were nonresponders. At inclusion these groups did not differ in LVEF, ESV, EDV, QRS duration, 6 min walk test distance and coronary flow velocity at rest. Before CRT implantation, responders, compared with nonresponders, showed a greater increase in coronary flow velocity during hyperemia, and consequently higher CFR: 2,39 ± 0,74 vs. 1,68 ± 0.29, p = 0.03. During dobutamine test responders also had higher LVEF, p = 0.02, as well as after 6 months: 45 ± 12% vs. nonresponders 28 ± 8%, p = 0.013. By univariate analysis, LVEF during dobutamine infusion (p = 0.02) and coronary flow velocity during hyperemia (p = 0.04) were predictors for improvement of left ventricular function after CRT. Conclusion: Our results showed that prerequisite for positive response to CRT are preserved CFR and microcirculation and a presence of contractile reserve. P087 PREDICTORS OF THE RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY IN PATIENTS WITH NONISCHEMIC DILATED CARDIOMYOPATHY Vaikhanskaya TG; Kaptsiukh TM; Sidorenko IV; Kovalenko ON Republican Scientific and Practical Center of Cardiology, Minsk, Belarus Purpose: The aim of our study was to identify the significant finding of surface electrocardiogram (ECG) to predict the response to CRT in patients (pts) with nonischemic dilated cardiomyopathy (DCM). Metods: 34 pts with DCM nonischemic aethiology HF (82,4% male; 48,5 ± 10,7 years; NYHA class 3,0 ± 0,3; QRS 167 ± 21ms; LVEF 24,7 ± 2,8%) had CRT implanted. Pts were classified as symptomatic responder (CRT‐R) if they were experienced ≥5% absolute increase LVEF and improvement NYHA class ≥1 at 6 months after CRT. We (independent 3 doctors)assessed all the clinical characteristics including 12 lead ECG parameters before and after CRT and compared the findings between CRT‐R and non‐responders (CRT‐NR). Results: 15 pts (44,1%,14 male and 3 female) were CRT‐R and 19 pts (55,9%,3 female) were CRT‐NR. At baseline there were no significant differences in age, gender, NYHA, QRS width, 6‐MWT, maxV O2, LVEF, LV end‐diastolic and end‐systolic volume and pharmacology therapies between two groups. When compared width QRS,QR,RS,amplitude wave in 12 lead ECG after CRT, responders had a greater RS interval shortening in V1 lead (ΔRS in V1 −16 ± 4,5 ms vs. −8,4 ± 4,9 ms; p = 0,000) and increase R wave in V1 (ΔR in V1 1,4 ± 0,8 mm vs.0,6 ± 0,7 mm; p = 0,004), and at baseline width RS in V1 were significant differences between two groups (RS in V1 55,3 ± 12,4 ms vs. 43,2 ± 13,1 ms; p = 0,01). By multivariate logistic regression analysis identified presence reduction of RS interval and increase R wave in V1 during pacing as independent predictors of response to CRT. Conclusions: The reduction of RS interval and increase R wave in V1 lead during pacing CRT and baseline greater RS in V1 was significantly correlated with improvement of both LVEF and functional capacity. Future studies on larger population are needed to confirm that RS interval in V1 lead may reliable to predict CRT‐R in pts nonischemic DCM with indication to CRT. P088 VECTOR ELECTROCARDIOGRAPHIC AND HEMODYNAMIC RESPONSE TO ATRIOVE‐
NTRICULAR DELAY OPTIMIZATION IN HEART FAILURE PATIENTS RECEIVING CARDIAC RESYNCHRONIZATION THERAPY Ståhlberg M; van Geldorp I; van Deursen C; Strik M; Francois R; Francesco F; Auricchio A; Prinzen F Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Introcuction: The purpose of this study was to evaluate the vector electrocardiographic (vECG) and hemodynamic response to atrioventricular delay (AVD) optimization in heart failure patients receiving cardiac resynchronization therapy (CRT). Methods: In 19 CRT recipients different AVDs were programmed in steps of 20 ms ranging from 60 ms to each patients maximal AVD before loss of capture during atrial overdrive pacing (90 bpm). ECG was recorded continuously for subsequent analysis of frontal plane vECG. At each AVD, stroke volume (SV) was measured using echocardiography (LVOT‐VTI, average of 10 beats in each setting). The AVD yielding the largest SV was considered optimal. Results: Mean maximal AVD was 270 ± 60 ms. Two different pattern of QRS response to AVD programming was observed. During CRT at short AVDs 8 patients (group 1) displayed a reduction in QRS width > 5% (mean: −23 ± 7%) while in 11 patients (group 2) no significant QRS shortening occurred (mean: +9 ± 15%). A significant, CRT induced, increase in SV over most AVDs was only observed in group 1 patients. Patients in group 2 had significantly shorter baseline QRS width (138 ± 22 vs. 170 ± 28 ms, p = 0.01) and significantly longer optimal AVDs compared to group 1 (220 ± 40 ms vs. 170 ± 50 ms, respectively, p = 0.02). Only in group 2 QRS width was shorter at optimal AVD than at short AVD (‐10 ± 10ms vs. +10 ± 10 ms in group 1, p = 0.02). In group 2 only, vector length was significantly shorter at AVDs > 230 ms compared to at AVD 60 ms which indicates fusion with intrinsic activation. Conclusions: Patients with relatively short QRS duration show little or no resynchronization (QRS reduction) with CRT at short AVD but may benefit from very long AVD, where QRS is reduced. This resynchronization is probably due to fusion with intrinsic activation, as indicated by vector length shortening on the vECG. P089 SINUS RHYTHM RECOVERY IN PATIENTS WITH CHRONIC ATRIAL FIBRILLATION AND DILATED CARDIOMYOPATY WHO UNDERWENT CRT IMPLANT (SIBILLA STUDY) Turco P (1); D'Onofrio A (2); Stabile G (3); Solimene F (4); La Rocca V (5); Cavallaro C (2); Iuliano A (3); Donnici G (4); Vecchione F (2); De Simone   (5); Sibilla Study (1) Hesperia Hospital, Modena, Italy. (2) Monaldi, Napoli, Italy. (3) C. Mediterranea, Napoli, Italy Cardiac resynchronisation therapy (CRT) has been demonstrated to be beneficial also in patients with atrial fibrillation (AF); in some patients sinus rhythm occur after CRT. In this patients we evaluate the feasibility of electrical cardioversion (EC) to restore sinus rhythm and the EC efficacy in preserving SR at follow‐up. We enrolled 41 consecutive patients with symptomatic heart failure despite optimal medical treatment, left bundle branch block (QRS duration ≥120 ms), left ventricular ejection fraction ≤35% and chronic (more than one year) AF, who underwent CRT‐D implant. In all patients, an atrial lead was used. We scheduled one or more internal, by means of device, or external EC in all eligible patients. Results: Major population characteristics are reported in the table. Mean ± SD orPercentageGender (Male)75%Age (Years)71,6 ± 9,2Ischemic Heart Disease54%Hpertension61%Diabetes24%NYHA functional class III/IV93%/ 7%QRS width (ms)138 ± 16LV ejection fraction (%)23,6 ± 5,7Left atrial diameter (mm)51,3 ± 7,8 At a mean of 2,7 ± 1,8 months 19/41 (46%) patients underwent at least one EC. No complications occurred. EC was effective in restoring SR in 13 patients (68%); an intention to treat analysis shows a success rate of EC procedure (SR) in 31% (13/41). Eleven among thirteen patients (85%) with effective EC remained in SR at a mean follow‐up of 9,2 ± 7,6 months. Spontaneous conversion was observed in two patients. Atria; Calcuim channel; Cellar electrophysiology; Aging EC was feasible in less than 50% of patients with chronic AF post CRT; however SR was persistent at six months in greater than 30% of population, suggesting an atrial lead may be considered at implant. P090 CEPHALIC VENOUS ACCESS FOR CRT WITH SUBCLAVIAN AND CEPHALIC VEIN TORTUROSITY AND ANOMALY Xu Y; Wang J; Qiao Q; Zhang S; Hua W Hangzhou 1st People's Hospital, Fu Wai Hospital, China Introduction: Subclavian venous access can be applied for the majority of cardiac resynchronization therapy (CRT) device implantation. However, puncture failure occurs occasionally. Case History: A 70‐years‐old man fulfilled CRT criteria. At first, several attempts were made to puncture the left subclavian vein, until arterial blood was aspirated. Puncture of subclavian vein then was abandoned out of concern for the risk of pneumothorax or hemothorax. Cephalic cutdown were performed. A 16‐gauge, 8.3‐cm angiocath was inserted into the cephalic vein, through which contrast was injected to perform venogram. Cephalic and subclavian venous anomalies were revealed. The proximal cephalic vein devided into two branches, the upper one joined the external jugular vein while the lower one, which was small and torturous, joined the axillary vein laterally at the level of superior border of the second rib, and subclavian vein was also small. A 150‐cm 0.89‐mm hydrophilic glide wire was introduced into the lower branch of the cephalic vein and advanced toward the heart under venographic guidance. A 9‐F 14‐cm sheath was then advanced over the glide wire, once the tip of the sheath unit was positioned in the superior vena cava, the dilator was removed and 2 other standard 50‐cm 0.97‐mm guidewires were introduced. The sheath was peeled away while the 3 guidewires were held in place. A left ventricular (LV) lead delivery system was advanced over the glide wire to position the LV lead. When an acceptable lead position had been attained, the delivery system was removed by tearing. A 8‐F sheath was advanced over one of the 50‐cm guidewires to position the atrial lead. This sheath was peeled away when a suitable position had been attained. Then a 8‐F sheath was placed over the final guidewire to position the right ventricular lead. All leads were fixed separately. A CRT device was implanted. Conclusion: Cephalic venous access is a feasible alternative to subclavian access for CRT. P091 TRANSAPICAL ENDOCARDIAL LV PACING FOR CRT, FIRST EXPERIENCE IN FIVE PATIENTS Karpenko Y; Volkov D Odessa State Medical University, Ukraine Background: CRT is approved method for HF treatment in selected groups of patients (pts). Transvenous method of implantation is common. Endocardial LV pacing seems promising by the fact of rapid physiologic LV depolarization pattern and absence of anatomical limits committed to the transvenous procedures. Life‐long taking of oral anticoagulants is obliged. Objective: To analyze experience of the few first LV endocardial pacing for CRT. Methods: 5 pts (4 men, age 57—74) with LBBB (QRS 170 ± 24 ms), advanced HF NYHA III (EF – 27 ± 9%) were implanted with DDD (3 pts) and DDDRV (2pts) for CRT with transapical endocardial LV lead placing as a part of the procedure. All of them had been on warfarin due to persistent‐permanent AFib. Two pts had repeated transvenous LV lead dislocations, one – no anatomical conditions for transvenous LV lead placement, one – LV lead exit block after repositioning and the last – deterioration after apical RV pacing. After thoracotomy the apex of LV was punctured and conventional screw‐in endocardial lead were inserted into LV by Seldinger method via pill‐away introduser using hemostatic purse‐string sutures. In 3 pts endocardial LV 3D activation mapping (NavX, S.J.M, USA) to find the optimal pacing site were done before final fixation. Then the electrode was tunneled to the pocket. Results: CRT was available in all pts with acute thresholds less than 1,5V,led to dramatic reduction of QRS duration (135 ± 17 ms) and good immediate and mid‐term clinical results (EF – 34 ± 12%). One patients had raise of LV capture threshold up to 3V with adequate pacing with 4,5V amplitude. LV 3D activation mapping during procedure revealed the "latest" point near LV apex in two pts with further implantations in that area which is discordant with existed theory of the best postero‐lateral regions for LV CRT delivery. Conclusion: Endocardial LV pacing for CRT is safe, useful and was at least as effective as traditional methods in our small group. P092 CARDIAC RESYNCHRONISATION THERAPY IN ATRIAL FIBRILLATION PATIENTS – ANY OUTCOME DIFFERENCES TO SINUS RHYTHM PATIENTS? Dusceac D; Iancu A; Capraru C; Bostan I; AlHassan A; Ciudin R "C.Davila" Univ of Medecine, "C C Iliescu" Institute of Cardiovascular Diseases, Bucharest, Romania Cardiac resynchronisation therapy (CRT) is been the therapy of choice in patients (pts) with severe heart failure (HF) and left bundle brunch (LBB) QRS morphology. Left ventricular ejection fraction (LVEF) less than 35%, optimal medical therapy and NYHA class III/IV are also major indications for CRT. Atrial fibrillation (AF) prevalence is high in pts with CRT indication but number of such pts enrolled in major CRT clinical trials is not so. We have study 94 pts who underwent CRT for severe HF and we have followed them for a mean of 3.2 years (from 9 years to 11 months). 60 pts had dilated non‐ischaemic etiology and 32 pts were of ischaemic etiology. 1 pt had hypertrophic non obstructive cardiomyopathy. 22 pts (23.4%) were in AF. We compare there outcome in terms of NYHA class, LVEF, mitral regurgitation degree, quality of life (QoL) and clinical and echo parameters evolution. There was no significant difference in NYHA class reduction or LVEF improvement between sinus rhythm (SR) and AF pts.Pts in SR have marginally done better in terms of mitral regurgitation reduction, 6 min walk test and QoL(Minnesota score). Non–responders percent was mainly the same: 26% in AF pts and 23% in SR pts group. If after 3 months following the initial implant the pacing percent was less than 80% despite optimal medical therapy we performed AVN ablation. We conclude that pts in AF can benefit from CRT almost as SR pts but more data and longer follow‐up period is needed. P093 THE CHOICE OF APPROACH TO LEFT VENTRICULAR LEAD IMPLANTATION FOR PERMANENT PACING Osadchy A; Marinin V; Kurnikova E; Lebedev D Almazov Federal Heart, Blood and Endocrinology Centre Objective: to improve surgical results of cardiac conduction disorder by prevention and correction of left ventricle dyssynchrony on the back of permanent pacing. Design and Methods: We observed 257 patients was exam and treated. Task 1 – to study the electrophysiological indices of LV lead, considering the delivery way (n = 80). Task 2 – to evaluate the effect of pacing on hemodynamics and CHF course, consider the lead position (n = 90). Task 3 – to study the anatomy of the venous system of the heart according to coronary angiography (CAG) (n = 107). In each task were formed comparable groups without significant clinical and demographic differences. Task 3 – by etiology patients were divided into 2 groups: 1 – with CHD, 2 – without CHD; we assess the effect of heart chambers enlargement to anatomy of cardiac veins. Venous anatomy was studied considering the zone of myocardial infarction. Results: Task 1 – in 1 group at 21% of cases problems with left ventricular lead was observed, but in 2 group these were absent. Differences in duration of operation, acute and chronic pacing thresholds were not obtained. Task 2 – ECHO: at 1 group ↑LVEDV, MR, ↓EF were significantly; at 2 and 3 group remodeling of heart chambers with normal EF were observed. At 1 group appearance of patients with IV f.cl. (NYHA), at 2 group ↓ quantity patients with III f.cl. were observed. At 3 group quantity patients with II f.cl. were decrease, patients with IV f.cl. weren't register. Task 3 – in all groups CS ostium, MCV, GCV were visualized at 100%. Conclusion: in patients before cardiac resynchronization device implantation is necessary to study the anatomy of cardiac veins and determination the optimal lead position (by tissue Doppler imaging). CAG allows to study the anatomy of cardiac veins and in combination with results of tissue Doppler imaging – permit to select the surgical approach (endovascular or thoracoscopical). P094 CARDIAC RESYNCHRONIZATION THERAPY IN POTENTIAL HEART TRANSPLANT CANDIDATES Sasov M; Liska B; Goncalvesova E; Margitfalvi P; Svetlosak M; Hatala R National Cardiovascular Institute, Bratislava, Slovakia Selected patients (pts) with end‐stage HF benefit from CRT and CRT might decrease or postpone the need for heart transplant (HTx). Aim of this study was to analyze in clinical practice the implementation of the latest ESC guidelines on CRT in HTx candidates. 311 pts with LVEF ≤ 35% referred for HTx eligibility in the years 1996 – 2009 at our institution were included in the analysis. This comprised 207 pts randomly selected from pts without realized HTx and 104 pts who finally underwent HTx (data taken from last evaluation prior HTx). Their mean age was 49.8 ± 11.4 years, 263 pts (85%) were male. The etiology was dilated CMP in 169 pts (54%), CAD in 87 pts (28%), hypertensive heart in 25 pts (8%), valvular disease in 11 pts (4%) and other in 19 pts (6%). Permanent atrial fibrillation (AF) was present in 50 pts (15%) and LBBB in 93 pts (30%). Results: In the entire cohort 110 pts (35%) fulfilled the criteria for CRT. Prevalence of CRT candidates in the subgroup of patients who finally underwent HTx was 51% (53 pts). In candidates for CRT, permanent AF was present in 14 pts (13%) and LBBB in 72 pts (65%). Optimal criteria for achieving CRT response (NYHA III/IV, QRS≥150 ms, LBBB, sinus rhythm) were fulfilled in the entire cohort by 43 pts (14%). Overall, CRT devices were implanted in 22 end‐stage HF pts (7%), 17 of them fulfilled optimal criteria for achieving CRT response. In multivariate analysis the presence of LBBB (P < 0.001) but not QRS duration was independent predictor for criteria fulfillment. Conclusions: More than 1/3 of chronic HF pts eligible for HTx fulfilled criteria for CRT. This proportion was higher (51%) in the subgroup of transplanted pts. CRT was underused in this specific patient cohort with only 20% of pts fulfilling actual indication criteria receiving a CRT device. However, this proportion increased to 40% when optimal criteria for achieving CRT response are considered. P095 FEATURES OF HOLTER MONITORING OF ECG IN CRT PATIENTS Basova VA; Rogacheva NM; Krasnoperov PV; Petruneva TS; Schneider YuA Medical Academy of Postgraduate Study Purpose: to assess the significance and features of Holter Monitoring of ECG in CHF patients with CRT devices. Methods: 112 ECG Monitoring records of patients with severe heart failure were analyzed before and after biventricular pacemaker implantation. 19 patients had coronary artery disease and 32 patients – nonischemic cardiomyopathy. 9 patients was in IV heart failure NYHA class, 32 – was in III NYHA class and 10 – was in II NYHA class. 38 CRT‐P and 13 CRT‐D devices were implanted in our clinic. Results: Holter Monitoring features in CHF patients before biventricular pacemaker implantation were distal type of LBBB (QRS > 170 ms in 13 cases), changing the degree of intraventricular conduction (Δ QRS = 30 ms), high ventricular ectopy (PVC > 100/hour – 7 patients (17%), paired PVC – 2 (4,8%), polymorphic PVC – 3 cases (7,3%), nonsustained VT–– 10 (24,4%), sustained VT – 5 patients (12,2%). Reduction in heart rate variability was registered in 34 patients (SDANN). Biventricular pacing percentage, existence and number of native QRS (own AV conduction) and fusion biventricular pacing with native QRS. The most of patients had biventricular pacing >90%. All patients were separate into 2 groups: "responders" (37) and "nonresponders" (14). Patients of the 1st group ("responders") reduced ventricular ectopy, increased heart rate variability (just in patients with sinus rhythm). However patients of the 2nd group ("nonresponders") had biventricular pacing <80% (3 cases), high ventricular ectopy (2 cases), existence of the fusion biventricular pacing with native QRS complexes > 20% of 24 hours recording (3 cases). Conclusions: It's important to pay attention for biventricular pacing percentage, existence and number of native QRS and fusion biventricular pacing with native QRS complexes during the ECG records analysis. Holter Monitoring of ECG is indicated to CRT patients who didn't response to the therapy. P096 TRIPLE‐SITE VENTRICULAR PACING IN PATIENTS WITH BORDERLINE NARROW QRS AND NYHA III‐IV CARDIAC FAILURE Calovic Z; Vicedomini G; Cuko A; Saviano M; Petreta A; Vitale R; Pappone C Villa Maria Cecilia Hospital, Cotignola, Italy Two‐fifths of heart‐failure patients who receive cardiac resynchronization therapy (CRT) are not benefitting clinically from the device therapy. Purpose: We hypothesized that among others, one of the possible reasons for this failure could be found in group patients who received CRT with a borderline QRS interval of 120 ms. (assuming they meet LVEF% requirements and other criteria). Materials and Methods: In 10 consecutive patients who fullfill "classic" criteria for CRT‐P/D, but borderline QRS duration of 120 ± 5 ms, NYHA III/IV class and echocardiography evidence of dyssynchrony, we performed CRT implantation placing additional CS lead over left ventricle and in that way obtained unify‐right with bifocal LV pacing. CS electrodes were implanted at two separate location of the LV, so the distance between the electrodes would be as far as possible. We use „Y connector" to connect two CS leads in one LV port of the pacemaker. RV electrode was implanted either in septal or apical portion of the heart. Six min hall‐walk test and echocardiography were performed 1 and 3 months after the implantation. Results: All implants were successful. No complications, either peri or post‐procedural, were observed in the patients. After 3 months follow‐up no patients died. Only one patient has no clinical improvement in hearth functional class. The rests of the 9 pts were improved at least one NYHA class, with the increase in LVEF (29,5% vs 38,9%). There was also significant increase in 6 min walking test (P < 0.05), 1 and 3 months, respectively. Conclusion: In our observational study, we found that triple‐site ventricular pacing is feasible and efficacious during 3 months pacing in patients with serious heart failure, borderline narrow QRS and significant ventricular dyssynchrony on TDI. Further bigger study and longer follow‐up is needed for pure clarification of this therapy. P097 PACING MODE SELECTION IN CRT PATIENTS: SEQUENTIAL OR SIMULTANEOUS BIVENTRICULAR PACING Krasnoperov PV; Rogacheva NM; Basova VA; Petruneva TS; Schneider YuA Medical Academy of Postgraduate Study Purpose: to study the results of sequential or simultaneous biventricular pacing in CRT patients, to assess is VV interval optimization need or not. Methods: 51 patients (M‐42, 59,7 ± 7,3 years) with cardiomyopathy (ischemic – 19, nonischemic – 32) were enrolled in the study. 38 CRT‐P and 13 CRT‐D devices were implanted. All patients had such examinations as clinical, ECG, two‐dimensional echocardiography, tissue Doppler imaging. Sequential or simultaneous biventricular pacing was programmed after operation before discharge. We optimized VV interval with LV outflow tract VTI. We particularly paid attention to clinical status: NYHA functional class, and echocardiographic parameters: LV volumes, LV ejection fraction (EF) at baseline, before discharge and in a 6 month after CRT implantation. Patients with improvements of ≥1 NYHA class at 6‐month follow up were classified as clinical responders. Patients with reduction of >15% in LV end‐systolic (LVESV) or/and end‐diastolic volume (LVEDV) and improvement in the LVEF of >5% were classified as echocardiographic responders. Results: 51 patients were separated depending into 2 groups depending on pacing mode. The 1st group – 29 patients with sequential biventricular pacing. VV interval was optimized after CRT implantation. The 2nd subgroup – 22 patients with simultaneous biventricular pacing. The results of 6 month follow up showed significant reduction of LV sizes and volumes in patients of the both groups. But the 1st group demonstrated biventricular pacing more systolic function improvement: EF, dP/dt, EPSS. Conclusions: Biventricular pacing is effective method of treatment patients with congestive HF. Sequential and simultaneous biventricular pacing lead to reverse LV remodeling. Systolic function increase significantly with sequential biventricular pacing. VV interval optimization is indicated to non‐responders. P098 COMPARATIVE STUDY OF INTERVENTRICU‐
LAR DELAY OPTIMIZATION IN CARDIAC RESYNCHRONIZATION THERAPY USING ELECTROCARDIOGRAPHY VERSUS USING ECHOCARDIOGRAPHY An C; Yang D; Chen K; Xu J; Fang X; Sun N; Liu F; Su H; Huang X; Yan J; Department of Cardiology, Anhui Province Hospital Anhui Institute of Cardiovascular Disease Objective: To assess ECG‐optimized Interventricular Delay Interval (V‐V) in cardiac resynchronization therapy. Methods: 30 CRT patients with dilated cardiomyopathy and ischemic cardiomyopathy, NYHA class III ∼IV, were studied, aging from 42 to 79 (63.3 ± 10.6) years. After one month follow‐up, the patients were programmed to only LV (Left ventricle) pacing and only RV (Right ventricle) pacing, respectively. V‐V interval optimization was performed by ECG as follows: calculating the time from pacing spike to beginning of earliest deflection of QRS complex in precordial leads, first activating epicardial LV lateral wall (named as T1) and secondly during RV pacing (named as T2). Difference between T1 and T2 was regarded as a surrogate measurement of interventricular delay and defined as the best optimal V‐V interval. Echocardiography was performed to measure the optimal V‐V interval using maximal aortic VTI. Results: By echocardiography, there were 20 patients and 5 patients showed the optimal LV synchrony with LV preactivation at 30 ms, 70 ms respectively, while 3 patients gained the most benefit from simultaneous pacing at 0∼5 ms, 2 patient achieved the maximum benefit with RV preactivation at 30 ms. With ECG, 19 patients and 5 patients benefited the most with LV preactivation at 30 ms, 70 ms, respectively. 4 patients got the best benefit with simultaneous pacing at 0∼5 ms, and 2 patients benefited most with RV preactivation at 30 ms. Good concordance was found between the ECG‐optimized and echocardiography‐optimized V‐V interval (K = 0.937). Conclusions: For CRT patients, the optimal V‐V interval can be achieved by ECG which shows a good correlation with UCG. Key words: cardiac resynchronization, electrocardiography, echocardiography. P099 EFFICACY OF CRT IN CHF WITH ATRIAL FIBRILLATION WITHOUT ABLATION OF AV NODE, BUT ACHIEVED STRICT RATE CONTROL Mareev YV; Golitsin SP; Sapelnikov OV; Kiktev VG; Latypov RS; Grishin IR; Saidova MA; Shitov VN; Akchurin RS Russian Cardiology Research Complex, Moscow, Russian Federation Aim of our study was to compare effect of CRT therapy in CHF patients with low EF and wide QRS in sinus rhythm (which have been proven) and permanent atrial fibrillation without ablation of AV node. Our hypothesis was that patients with atrial fibrillation and good pharmacological rate control with indication for CRT by EF and QRS duration would have comparable effect from CRT as patients with sinus rhythm. Methods: We used The Minnesota Living_with_Heart_Failure_Questionnaire, 6 minutes walk test, measurement of EF by echocardiography (GE Vivid 7). Percent of biventricular pacing we calculated by using of 24 hours ambulatory monitor. We examined patients before implantation of CRT and after six month. Statistical significance was evaluated with Wilkokson analysis. Results: We included 24 patients: 8 patients with permanent atrial fibrillation and 16 patients with sinus rhythm. 7 of 8 patient with permanent atrial fibrillation had >85% biventricular pacing. This patient had algorithm VSR – his "fusion" complex has same Doppler VTI as biventricular complex. There ware no death in both groups of patients. Functional class by NYHA decreased from 3.1 to 2 (P < 0.05) in group of permanent AF and from 2.9 to 1.6 (P < 0.05) in group of sinus rhythm. MLHFQ decreased from 55 to 39 (P < 0.05) in patients with permanent AF and from 49 to 35 (P < 0.05) in patients with sinus rhythm. 6 minutes walk test increased from 306 to 384m (by 66 m, p< 0.05) in patients with permanent AF and from 368 to 408 (by 40 m, P < 0.05) in patients with sinus rhythm. EF increased from 26.6% to 31.6% (by 5%) in group of permanent atrial fibrillation and from 23.3% to 33.4%(by 10.1%, P < 0.05) in group of sinus rhythm. Conclusion: Patients with permanent AF without ablation of AV node have comparable effect from CRT as patients with sinus rhythm. Limitation: We exclude from study patients with mean heart rate more than 95 bpm. P100 LOSS OF CARDIAC RESYNCHRONIZATION THERAPY: INCIDENCE, CAUSES AND OUTCOMES Colchero T; Arias MA; Domínguez‐Pérez L; Jiménez‐López J; Puchol A; Pachón M; Lázaro‐Salvador M; Rodríguez‐Padial L Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain Background and Objectives: The benefits OF cardiac resynchronization therapy (CRT) are directly related to the maintenance of continuous biventricular pacing. The loss of the TRC is a common clinical problem that limits the potential benefits of this therapy in patients with heart failure. We describe the experience in our center by identifying the causes, incidence and results of loss of CRT. Method: Retrospective, observational study of all patients who were implanted with a CRT device for a period of 43.2 months. Results: We analyzed data from 97 patients. 64.4% were male and mean age was 66 years. The indication for CRT was ischemic dilated cardiomyopathy in 41.8% of cases. 63,2% of patients were implanted with a cardioverter defibrillator system added. During a mean follow‐up of 43,2 months, 15 patients died and a total of 37 (37.8%) patients experienced transient or permanent loss of CRT. Six patients had more than one reason for loss of CRT. The most frequent cause was the presence of atrial tachyarrhythmias (12.3%), followed by dislodgement of the LV electrode (8.2%), increased threshold of the LV electrode (7.2%), extracardiac stimulation (4.1%), increased threshold for the VD electrode (4.1%), ventricular oversensing (3.1%), atrioventricular sensing (3.1%), infection (1%) and clinical intolerance to CRT (1%). The loss of the CRT was resolved in 79.1% (n = 34) of cases and was permanent in 20.9% (n = 9). Univariate analysis was performed to identify possible predictors of loss of CRT but there was no statistically significant difference in any of the variables. Conclusions: Despite technical advances in CRT, the loss of it is a very common clinical condition and difficult to solve in an appreciable percentage of cases. A close monitoring of patients with CRT is essential to identify and solve all the problems associated with this therapy. P101 A NOVEL 3D ELECTROMAGNETIC NAVIGATION SYSTEM REDUCES FLUOROSCOPY TIME AND RADIATION EXPOSURE IN LEFT VENTRICULAR LEAD PLACEMENT Heist EK; Valderrabano M; More R; Ryu K; Greenberg S Massachusetts General Hospital, Boston, MA Introduction: CRT implantation is often associated with extended fluoroscopy time and results in radiation exposure to physicians, patients, and staff. A novel 3D electromagnetic navigation system (MediGuide™, St. Jude Medical, St. Paul, MN) can be utilized to facilitate lead delivery with minimal fluoroscopy using specialized sensor‐enabled delivery tools. We report on our initial experience with the MediGuide™ system and tools, and its effect on reducing fluoroscopy time and radiation exposure during placement of left ventricular (LV) leads. Methods: In six canines, LV lead placement was performed by three operators in one or more coronary sinus (CS) branches using both Conventional (Conv) and MediGuide™ approaches in random order. The Conv implant used traditional tools – 0.014 CPS Courier® Guidewire, CPS Aim® inner and CPS Direct® outer catheters (St. Jude Medical, Sylmar, CA) and the MediGuide™ system implant used sensor‐enabled equivalent tools. Total fluoroscopy time, radiation exposure and lead delivery time were recorded from the time of CS cannulation to the time of final LV lead placement. For statistical evaluation, two‐sided Wilcoxon Signed Rank Sum Test was used. Results: The LV lead was successfully placed in 11 CS branches in 6 canines (1.8 ± 0.8 branches/canine) using both methods. The MediGuide™ system resulted in a 93% reduction in median values of fluoroscopy time (P = 0.001, 0.9 ± 2.0 [median = 0.1] vs 2.2 ± 2.0 [median = 1.5] min) and a 94% reduction in median values of radiation exposure (P = 0.005, 13.8 ± 32.5 [median = 1.7] vs 49.5 ± 45.3 [median = 27.2] uGym2), as measured by dose‐area product. Lead delivery times were similar (MediGuide™:237 ± 193 vs Conv: 186 ± 117 sec, P = 0.27) between the two methods. Conclusions: The MediGuide™ navigation system significantly reduced total fluoroscopy time and radiation exposure during LV lead implantation without compromising final lead location or total procedure time compared to the Conv implant strategy. P102 A NOVEL 3D ELECTROMAGNETIC NAVIGATION SYSTEM IS ACCURATE AND RELIABLE FOR LEFT VENTRICULAR LEAD PLACEMENT WITHOUT FLUOROSCOPY GUIDANCE Valderrabano M; Greenberg S; More R; Ryu K; Heist EK The Methodist Hospital System, Houston, TX Introduction: Fluoroscopic exposure during left ventricular (LV) lead placement remains a major concern. A novel 3D electromagnetic navigation system (MediGuide™, St. Jude Medical, St. Paul, MN) was developed to minimize fluoroscopic exposure by displaying the real‐time location of sensor embedded delivery tools superimposed on pre‐recorded coronary sinus (CS) venograms. We report on the accuracy and reliability of the MediGuide™ system in an in vivo setting with varying heart rates and C‐arm angulations. Methods: In six canines, CS venograms were obtained in three different fluoroscopic projections (RAO, LAO, AP) at three different heart rates (range: 60–140 bpm) for each projection. A MediGuide™ sensor embedded into a 0.014 guidewire was then introduced sequentially into two distinct CS branches. Location of the guidewire sensor detected by MediGuide™ was projected in real time on the pre‐recorded venograms and recorded as a movie file during pacing at the same rates that were used for venogram acquisition. The performance of the MediGuide™ system was assessed by analyzing the displacement between the projected sensor icon and the CS target branch on individual movie frames over three consecutive cardiac cycles. Results: In all six canines, the MediGuide™ sensor‐enabled guidewire could be visualized and tracked without fluoroscopy. The sensor icon was displayed within 1.7 mm of the target branch 90% of the time for all C‐arm angulations and heart rates. The MediGuide™ system accuracy was not affected by heart rate variations up to ± 30 bpm from the original rate that was used to acquire the venogram. In addition, the accuracy results were not affected by various C‐arm angulations (90% Quantiles – RAO: 1.3 mm; LAO: 1.7 mm; and AP: 2.0 mm). Conclusions: The MediGuide™ system provided accurate and reliable tracking of sensor‐enabled tools at various heart rates and C‐arm angulations for LV lead placements without fluoroscopy guidance. CHANNELOPATHIES P103 LIMITED VALUE OF INTRA‐CARDIAC ELECTROPHYSIOLOGICAL STUDY (EPY) IN SCD RISK EVALUATION IN PATIENTS WITH INHERITED ARRHYTHMIAS Zaklyazminskaya EV; Podolyak DG; Shestak AG; Nechaenko AM; Dzemeshkevich SL Perovsky Russian Research Centre of Surgery RAMS Background: Intracardiac electrophysiological (EP) study is considered as one of the methods to evaluate the risk of malignant cardiac arrhythmias and sudden cardiac death (SCD). But the predictive value of this method is still under the question. Material and Methods: Invasive EP study with 3 consequent extra‐stimuli was performed using CardioLab 4,0 Pruca installation. Genetic screening included direct Senger sequencing of SCN5A, KCNQ1, KCNH2, KCNE1, TRPM4, MOG1 and KCNE2 genes. Results and Discussion: We did perform EP study in 4 index patients with inherited arrhythmic syndromes. One patient (21 y.o., female, SCD case in the family) had idiopathic ventricular tachycardia with moderate shortening of QT interval till 390 ms. Three patients (males 38 y.o., 40 y.o., and 44 y.o.) had genetically confirmed Brugada syndrome with spontaneous Brugada type‐1 ECG. Patients were carriers of p.Y87C, p.R893H, and p.S1787N mutations in SCN5A gene. We failed to induce ventricular tachycardia in those patients. Nevertheless, for 3 patients ICDs were implanted, and one patient with p.Y87C mutation in SCN5A refuse the ICD implantation. During 1 year of follow‐up female patient had 2 appropriate shocks, male patients with Brugada syndrome did not experienced any shocks for now. Conclusion: We suspect that patients with lack of inducible ventricular tachycardia during EP study cannot be definitely considered at low‐risk of SCD. Presence of strong familial history of sudden death or genetic confirmation of diagnosis has to be taken into account in decision‐making about ICD implantation. This study was partly supported by grant No02740110783, Russian Ministry of Education and Science. P104 FAMILIAL SUDDEN NOCTURNAL CARDIAC DEATH ASSOCIATED WITH J WAVES AND ST SEGMENT ELEVATION PREDOMINANTLY IN INFERIOR AND LATERAL LEADS: EARLY RIPOLARIZATION SYNDROME OR BRUGADA VARIANT? Menichetti F*; Ottonelli AG; Svetlich C; Lilli A; Magnacca M; Chioccioli M; Casolo G Cardiology Unit, Versilia Hospital, Italy. *Cardiology Unit, University of Pisa, Italy A 43‐year‐old man with a family history of sudden nocturnal death (his father, his brother and his cousin died respectively at the age of 35, 49 and 50 year‐old) was presented to our Hospital for cardiologic evaluation. Before any further examination, the cardiologist drew the family tree and observed some correspondences: all died patients were male and had experienced SCD during night‐time. The authors could examine the ECG for one of them, revealing an ER pattern with prominent J waves in infero‐lateral leads. This ECG alteration was also observed in other six living family members who started a medical screening for arrhythmogenic cardiomyopathy: no structural heart disease was found at MRI scan. All these features are very similar to those which belong to Brugada Syndrome patients (sudden death syndrome associated with right bundle branch block and ST elevation in V1 trough V3), except that J wave and ST segment elevation was not seen in the right precordial leads, but rather in the inferior and lateral leads. All patients were tested with sodium channel blockers (Ajmalina) infusion, but none ECG conversion was observed. After one year, all patients were free from syncope, chest pain and palpitations, but a very close follow up is still going on and they were referred for improved genetic analysis, looking for specific channel mutations. A growing number of case reports and case‐control studies indicate that at some instances, ER is associated with increased risk of idiopathic ventricular fibrillation. Our report further strengthens the hypothesis of a causal relationship between ER and family sudden nocturnal death and suggests to consider ER as a variant of Brugada syndrome. The authors hope that his case report can stimulate investigators to address the many unresolved questions in this rapidly evolving field. P105 A CASE REPORT OF BRUGADA SYNDROM PATIENT WHO TAKES QUININE AFTER BEING IMPLANTED ICD Dong J; Sun J; Zhang Z; Yuan Y; Feng L; Deng Z Department of Cardiology Zhong Shan People's Hospital, Guangdong, China Background: The Brugada syndrome (BrS) is regarded as a rare genetic disease importantly because of the mutation of SCN5A nowadays. It easily causes unexpected sudden cardiac death by malignant ventricular arrhythmia. The effective treatment is the Implantation of ICD which is an external cardiac defibrillator automatically. Quinidine is the effective durg which is an Ito retardant of sodium channel. Quinine is a levorotatory form of Quinidine. Methods: To observe occurrence of malignant ventricular arrhythmia in one patient with Brugada syndrome who was implanted ICD in Jun in 2006. From Jun of 2006 to July of 2009, metoprolol and Amiodarone had been regularly taken also. During that time, there were total 15 times Ventricular tachycardia or ventricular fibrillation events. So metoprolol and Amiodarone were stopped by the patient himself. Then Quinine which is regarded as Quinidine by himself was took. It was regularly took from 200 mg to 600 mg each day. The patient voluntarily takes it about 2 years for no recurrence of malignant ventricular arrhythmia. The Quinine is produced by Actavis in England. Results: Malignant ventricular arrhythmia never recurs from July in 2009 by now and his ECG is changed. Conclusions: Quinine is possibly as effective as Quinidine to Brugada syndrome. But it is need to make further investigation. ECG P106 ALTERATIONS IN ATRIAL ELECTROPHYSIOLOGY AFTER HEMODIALYSIS: AN ANALYSIS OF THE P WAVE DURATION AND P WAVE DURATION AMONG CHRONIC KIDNEY DISEASE PATIENTS IN THE UNIVERSITY OF SANTO TOMAS HOSPITAL (USTH) Ona RL; Ramirez MF University of Santo Tomas Hospital, Espana, Manila, Philippines Hemodialysis causes significant changes in hemodynamic status and metabolic milieu in chronic kidney disease (CKD) patients. Electrocardiographic parameters which reflect atrial electrophysiology, exemplified by p wave duration and p wave dispersion, may indirectly reflect these hemodynamic and metabolic changes. Prolonged P‐wave duration (Pmax) has been shown in some studies to be a useful predictor of atrial fibrillation development in various clinical settings. This study aimed to determine the effect of hemodialysis on the p wave duration and p wave dispersion among patients with CKD. This is a prospective study of patients undergoing hemodialysis at the USTH. A 12 L ECG at a standard rate of 25 mm/sec was taken before and immediately after the hemodialysis. P wave duration (Pmax) was measured with electronic digital caliper in all 12 leads by one observer. P wave dispersion (Pwd) was measured. Pmax and Pwd were compared pre and post dialysis using paired student's T‐test. A total of 43 CKD patients with mean age of 55.23 ± 14.3 (age range 22–86 years old), 20 males and 23 females were included in the study. Mean pre‐dialysis Pmax was 72.44 ± 6.58. Mean Post dialysis Pmax was 75.39 ± 8.86. The mean difference between pre‐dialysis and post dialysis Pmax was −2.95 ± 5.55 (P 0.001). Mean pre‐dialysis Pwd was 15.51 ± 5.64. Mean post dialysis Pwd was 19.51 ± 7.29. The mean difference between pre‐dialysis and post‐dialysis Pwd was‐4 ± 6.2 (P0.0001). Among CKD patients undergoing hemodialysis, in our study p wave duration and p wave dispersion significantly increased after hemodialysis indicating prolongation of atrial conduction time. Longer duration of hemodialysis and increase in the amount of ultrafiltrate significantly increase the maximum p wave duration and p wave dispersion. These findings may suggest that the observed p wave prolongation is most likely due to changes in metabolic milieu rather than effect of extracellular volume changes. P107 THE 12‐LEAD ECG IN PERIPARTUM CARDIOMYOPATHY Tibazarwa K; Lee G; Mayosi BM; Carrington MJ; Stewart SS; Sliwa K Hatter Institute for Cardiovascular Research in Africa, University of Cape Town Background: The prognostic value of the 12‐lead electrocardiogram (ECG) in the deadly syndrome of peripartum cardiomyopathy (PPCM) is unknown. Aim: To determine the prevalence of major and minor ECG abnormalities in PPCM patients on diagnosis, and to identify any ECG correlates of persistent LV dysfunction and/or clinical stability at six‐months follow‐up, where available. Methods: 12‐Lead ECGs were performed on 78 consecutive PPCM patients presenting to two tertiary centres in South Africa on diagnosis, and 44 cases at six‐month follow‐up. Blinded Minnesota coding identified major ECG abnormalities and minor ECG changes. Results: The cohort mainly comprised young Black‐African women (mean age 29 ± 7 years and median body mass index of 24.3 [IQR 22.7–27.5]kg/m2). The majority of cases (n = 70, 90%) presented in sinus rhythm (mean heart rate 100 ± 21 beats/min). At baseline, at least one ECG abnormality/variant was detected in 96% of cases. Major ECG abnormalities and minor variations were detected in 49% (95%CI 37–60%) and 62% (95%CI 51–74%) of cases, respectively; the most common being T‐wave changes (59%), p‐wave abnormality (29%) and QRS‐axis deviation (25%). Of the 44 cases (56%) reviewed at 6‐months, normalisation of the 12‐lead ECG occurred in 25%; the most labile ECG features being heart rate (mean reduction of 27 beats per min; P < 0.001) and abnormal QRS‐axis (36% vs. 14%; p = 0.014). On adjustment, major T‐wave abnormalities on the baseline 12‐lead ECG were associated with lower left ventricular ejection fraction (LVEF) at baseline (average of −9%, 95%CI −1 to −16; p = 0.03) and at six‐months (‐12%; 95%CI −4 to −24; p = 0.006). Similarly, baseline ST‐segment elevation was associated with lower LVEF at six‐months (‐25%; 95%CI −0.7 to −50; p = 0.04). Conclusions: This unique study shows almost all women with PPCM have an "abnormal□ 12‐lead ECG. Pending more definitive studies, the ECG appears useful as both a screening and prognostic tool in resource‐poor settings. P108 INFLAMMATION MODULATES VENTRICULAR REPOLARIZATION IN CHILDREN WITH KAWASAKI DISEASE Fujino M; Kuriki M; Horio K; Omeki Y; Uchida H; Eryu Y; Boda H; Miyata M; Hata T; Yamazaki T Fujita Health University Introduction: The instability of myocardial repolarization is generally mediated by myocardial failure. We assessed the hypothesis that transmural dispersion of repolarization is increased in the inflamed myocardium in patients with acute‐phase Kawasaki disease. Method: Consecutive 27 infants (M:F = 15:12) with Kawasaki disease aged 2.6 ± 2.2 years and age‐matched control infants were included. RR interval, QT interval and Tp‐e time (CM5 lead) were calculated using analysis software (Acqknowledge Ver. 3.9, Biopac Systems Inc., CA, USA). Tp‐e time was corrected by Fridericia equation (Tp‐eC). These parameters were compared in the acute phase (6.9 ± 3.0 days after onset) and recovery phase (23.0 ± 13.3 days after onset) or control. The relationship between Tp‐e/QT, Tp‐eC and C reactive protein, body temperature on admission were evaluated by regression analysis. Results: 1) The Tp‐e/QT in the acute phase were significantly higher than that in the recovery phase and control group (P < 0.05, P < 0.005, respectively).2) The Tp‐eC in the acute phase was significantly higher than that in the recovery phase and control group (P < 0.05, P < 0.01, respectively).3) In acute phase, significant positive correlation was observed between Tp‐e/QT and C reactive protein or body temperature (r = 0.677 and 0.672, respectively). Further, between Tp‐eC and C reactive protein or body temperature (r = 0.482 and 0.583, respectively). Conclusions: Transmural dispersion of repolarization assessed by Tp‐e/QT and Tp‐eC was increased by inflammation in the acute phase of Kawasaki disease, which exhibits the sub‐clinical lability of ventricular repolarization. These repolarization properties of the myocardium were considered a useful indicator to assess arrhythmogenesis in patients with Kawasaki disease. P109 FRAGMENTED ECG IN CHAGAS' CARDIOMYOPATHY (FECHA STUDY) Rodriguez C; Baranchuk A; Femenia F; Lopez‐Diez JC; Muratore C; Valentino M; Retyk E; Galizio N; Di Toro D; Alonso K; on behalf of the FECHA Study Investigators IECTAS Maracaibo, Venezuela Background: Implantable cardioverter defibrillators (ICD) proven to be an effective therapy to prevent sudden death in patients with CChC. Identification of predictors of appropriate therapies delivered by the ICD remains a challenge. Aims: To determine whether surface fragmented ECG helps in identifying patients with CChC and ICDs at higher risk of presenting appropriate ICD therapies. Methods: Retrospective study involving 14 centers from Latin America. All patients with CChC and ICDs were analyzed. Pacing dependent patients were excluded. Clinical demographics, surface ECG and ICD therapies were collected. Bivariate and multivariate analyses analysis were performed. Results: A total of 98 patients from 14 Latin American centers were analyzed. Four cases were excluded due to pacing dependency.63.8% were male, mean age was 55.4 ± 10.4 years old (26/75), mean LVEF was 39.6 ± 11.8%. Secondary prophylaxis was the reason for implanting in 71.3% of the cases. Fragmented surface ECG was found in 56 patients (59.6%). Location of fragmentation was inferior in 57.1%, lateral 35.7% and anterior 44.6%. Rsr pattern was the more prevalent (57.1%). Predictors of appropriate therapy in the multivariate model were: increased age (p = 0.01), secondary prevention indication (p = 0.01) and ventricular pacing >50% of the time (p = 0.004). Male gender presented a positive trend (p = 0.07). The presence of surface ECG fractionation did not identify patients at higher risk of presenting appropriate therapies delivered by the ICD (p = 0.87); regardless of QRS interval duration. Conclusions: Fragmented surface ECG is highly prevalent among patients with CChC. It has been found to be a poor predictor of appropriate therapies delivered by the ICD in this population. P110 THE ASSOCIATION BETWEEN MYOCARDIAL IRON LOAD AND VENTRICULAR REPOLARIZATION PARAMETERS IN ASYMPTOMATIC BETA‐THALASSEMIA PATIENTS Kayrak M; Gul EE; Acar K; Abdulhalikov T; Ozbek O; Kaya Z; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Previous studies have demonstrated impaired ventricular repolarization in patients with β‐TM. However, the effect of iron overload with cardiac T2* magnetic resonance imaging (MRI) on cardiac repolarization remains unclear yet. We aimed to examine relationship between repolarization parameters and iron loading using cardiac T2*MRI in asymptomatic β‐TM patients. Methods‐Materials: Twenty‐two β‐TM patients and 22 age and gender matched healthy controls were enrolled to the study. From the 12‐lead surface electrocardiography, regional (QT duration, corrected QT duration, QT dispersion, corrected QT dispersion) and transmyocardial (T peak to T end interval, T peak to T end dispersion, and [T peak‐T end]/QT ratio) repolarization parameters were evaluated digitally by two experienced cardiologists. All patients were also undergone MRI for cardiac T2* evaluation. Main Results: Of the QT parameters, QT duration, corrected QT interval, and QT peak duration were significantly longer in the β‐TM group compared to the healthy controls. Tp‐Te and Tp‐Te dispersion were significantly prolonged in β‐TM group compared to healthy controls (p = 0.02 and p = 0.03, respectively). Only (Tp‐Te)/QT was similar between groups (p = 0.32). There was no any correlation between cardiac T2* scores and repolarization parameters. Conclusion: Although repolarization parameters were prolonged in asymptomatic β‐TM patients, this prolongation were not correlated with cardiac iron overload. P111 ELECTROCARDIOGRAPHIC LATE POTENTIAL RATES ARE SIGNIFICANTLY INCREASED IN RHEUMATOID ARTHRITIS PATIENTS FREE OF ATHEROSCLEROTIC RISK FACTORS WITH PRESERVED LEFT VENTRICULAR FUNCTION Canataroglu A; Tekin K; Cagliyan CE; Ortoglu G; Tufan MA; Sahin DY; Koc M; Sakalli H Adana Numune Training and Research Hospital, Departement of Rheumatology Aim: Sudden cardiac death (SCD) and conduction disturbances due to atherosclerosis is a common manifestation of Rheumatoid Arthritis (RA). Objective of this study is to investigate electrocardiographic late potentials (LP) by using signal averaged electrocardiogram (SAECG) in patients with RA with no traditional atherosclerotic risk factors. Presence of LP's had been considered as a substrate for increased SCD in patients with cardiovascular disease. There is no previous study investigating LP's in RA patients. Methods: A total of 34 patients with RA (RA Group) and 32 healthy controls had been included in our study. All of the RA patients and controls had neither history of cardiovascular disease nor cardiac risk factors. SAECG recordings and calculations were made due to Simson method in all of them. Individuals positive for the following 2 of 3 criteria were considered to have electrocardiographic late potential (LP): 1. Filtered QRS duration (FQRS) > 110 ms 2. Root mean square voltage (RMS) in the last 40 ms < 25 mV and 3. Low amplitude duration (LAD) < 40 mv of > 38 ms. Results: SAECG calculations were made from a mean of 350 cardiac cycles and mean noise level was 0.79 ± 0.22 mV. Continous variables were compared by using t test.FQRS levels were significantly higher (82.14 ± 11.6 mV vs 77.00 ± 8.4 mV; p: 0.044) in the RA group. RMS levels were lower (63.51 ± 43.7 vs 82.87 ± 35.6 mV; p: 0.052) and LAD levels were higher (28.93 ± 12.0 vs 25.25 ± 6.5 ms; p: 0.124) in RA group, and the differences weren't statistically significant. Electrocardiographic LP's were observed in 12 patients with RA whereas none of the controls had LP'S (35.3% vs 0%; P < 0.001). Conclusion: Cardiac LP's seem to be significantly increased in RA patients free of traditional atherosclerotic risk factors with preserved left ventricular function. Carefully designed prospective studies including higher numbers of this patient group are needed for more accurate results. P112 ELECTROCARDIOGRAPHIC P WAVE CHARACTERISTICS IN PATIENTS WITH THALASSEMIA MAJOR: P‐INDEX AND INTERATRIAL BLOCK Kayrak M; Acar K; Gul EE; Abdulhalikov T; Ozbek O; Ucar R; Alibaşiç H; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Although previous studies have documented a variety of electrocardiogram abnormalities in beta‐thalassemia major (β‐TM), little is known about P‐wave indices (P max, P min, and P dispersion), an independent risk factor for development of atrial fibrillation (AF). P index (Pi) and interatrial block (IAB) as novel parameters may more accurately predict AF and has not been previously investigated in β‐TM patients. We aimed to examine relationship between P‐wave parameters (traditional and novel) and iron loading using cardiac T2*MRI in asymptomatic β‐TM patients. Methods‐Materials: Twenty‐two β‐TM patients and 22 age and gender‐matched healthy controls were enrolled to the study. P‐wave duration was measured in all 12‐leads of the surface ECG. The difference between maximum and minimum P‐wave durations was defined as Pd. The standard deviation of the P‐wave duration across the 12 ECG leads accepted as a Pi. P wave duration above and equal 110 milliseconds was defined as interatrial block (IAB). All P‐wave parameters were evaluated digitally by two observers. All patients were also undergone MRI for cardiac T2* evaluation. Cardiac T2* score under 20 msec was considered as iron overload status. Main Results: P max, P min, and P index were significantly prolonged in the β‐TM group compared to the healthy controls (p = 0.005, p = 0.014, and p = 0.034, respectively). Only P disp was found similar between groups (p = 0.46). The prevalence of IAB was 41% and 73% in patients with β‐TM and healthy controls (p = 0.033). P‐wave parameters of patients with cardiac T2*<20 msec and T2*≥ 20 msec were comparable in patients with β‐TM. There was no correlation between P‐wave parameters and cardiac T2*MRI values. Conclusion: The present study demonstrated that Pi and IAB frequency were increased in patients with β‐TM. These novel parameters may be useful measurement tools in predicting AF in the recent group. P113 ASSOCIATION OF P WAVE DURATION AND DISPERSION WITH BLOOD PRESSURE RESPONSE TO EXERCISE IN NON‐HYPERTENSIVE PATIENTS Yao RC; Mancera JR; Asido CD; Ramirez MF University of Santo Tomas Hospital Objective: We hypothesize that hypertensive blood pressure responses to exercise stress test may be associated with prolonged P‐wave indices among non‐hypertensive patients. Methodology: Non‐hypertensive patients without known structural heart disease 18 years old and above with negative stress tests were included. Resting 12‐lead ECG at a paper speed of 25mm/s and 1mV/cm were recorded. An electronic caliper was used to measure P‐wave duration and dispersion. Patients were classified into normal systolic blood pressure (SBP), normal diastolic blood pressure (DBP), hypertensive SBP, and hypertensive DBP groups. Mean P‐wave indices were compared using independent samples T test. Results: 76 patients were eligible with mean age of 43.77 ± 12.16. 46% were male; 12.7%, smokers; 7.6%, diabetic; and 21.5%, dyslipidemic. Mean P‐wave dispersion in the hypertensive SBP group was higher than the normal SBP group (0.0512 ± 0.0234 vs 0.0386 ± 0.0200 P = 0.032). No significant difference in P‐wave dispersion between the hypertensive DBP and normal DBP groups was seen. P‐wave duration was prolonged in the hypertensive DBP group (0.113 ± 0.0147 vs 0.103 ± 0.0142 P = 0.031). Conclusion: Among non‐hypertensive patients, hypertensive systolic blood pressure response to exercise was associated with more prolonged P‐wave dispersion while hypertensive diastolic blood pressure response to exercise was associated with more prolonged P‐wave duration. P114 INFLUENCE OF THE ELECTRICAL AXIS OF THE HEART TO QRS DURATION AFTER BIVENTRICULAR PACEMAKER IMPLANTATION Kazakevicius T; Zabiela V; Kazakevicius L; Sileikis V; Sedlickaite D; Puodziukynas A Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania Background: Biventricular (BiV) pacing is indicated for treatment of heart failure patients with interventricular or intraventricular dyssynchrony and left bundle branch block (LBBB). Shortening of QRS duration is expected during implantation of BiV pacemaker. We observed differences in changes of QRS morphology, duration and electrical axis before and during simultaneous, left and right ventricle pacing. Aim of our study was to find correlation between these parameters. Methods: Electrical axis of the heart (QRS vector) was calculated using mathematical formula of P.N.Singh and M.Sajjad Athar Tanθ== (I+2III)/(I√3) before pacemaker implantation, during left (LV), right (RV) and simultaneous (BiV) ventricle pacing. Correlation was calculated between axis and duration of QRS complex. Results: Duration of QRS complex changed in all 27 consecutive patients with statistically significant (P < 0.001) mean difference 43.7 ± 10.6 ms. Observed correlation between QRS complex width during BiV pacing and following parameters: 1Electrical axis of preoperative (initial) QRS complex (correlation coefficient was −0.87),2Preoperative duration of QRS complex (correlation coefficient was +0.92),3Duration of QRS complex during LV pacing (correlation coefficient was +0.93). Best results (narrowness of QRS) were achieved when QRS axis before implantation was between 60° and 76°– normal or slightly to the right axis (37.5% of patients) then the QRS with LBBB and left axis morphology. Conclusions: According to our data LBBB and normal axis morphology of preoperative QRS complex predispose greater narrowing of QRS complex after implantation of biventricular pacemaker. Duration of preoperative and LV pacing QRS depends on ventricular conduction properties and has influence for postoperative QRS duration. P115 DAILY MONITORING OF ELECTROCARDIOGRAM IN DIAGNOSTICS OF PARASYSTOLES IN CHILDREN Dolgikh VV; Zurbanov AV; Denisova TV; Rychkova LV Scientific Centre of Family Health and Human Reproduction Problems of Siberian Brunsh of RAMS The Aim: To evaluate the frequency of parasystoles in the structure of the heterotropic heart rhythm disorders among children and adolescents. Materials and Methods: We surveyed 125 children aged 7–17 years with the idiopathic extrasystoles. All patients were examined by electrocardiography (ECG) in 12 standard leads and it was done 24‐hour monitoring ECG. The Results: According to the results of standard ECG in 81 children was found supraventricular extrasystoles, in 44 children – ventricular extrasystoles. Parasystolic signs, namely: the coupling interval variability, fusion complexes, multiplicity of interectopic intervals were found on standard ECG with 15 children (12%). Ectopic inflow in this group registered in atrioventricular node in one child (0.8%). 14 (11.2%) children has the diagnosis of ventricular parasystole. It should be noted that the multiplicity of the interectopic intervals on the standard ECG happened only among 3 people. Long‐term ECG recording complemented our group of surveyed with parasystoles, which con‐sisted of 4 children with ventricular and 1 child with atrial parasystole and parasystoles from atrio‐ventricular node. Thus, the total number of patients with parasystoles was 21 (16.8%). According to the daily monitoring, the number of registered parasystoles, with account fusion complexes was from 5 to 13 thousand per day. The coupling interval variability had increased significantly compared to the standard ECG and ranged from 100 to 230 msec, an average of 140 msec. Conclusion: therefore, the results showed a significant prevalence of parasystoles, as well as advantage of daily monitoring in the diagnosis of this dysrhythmia. P116 ACUTE EFFECTS OF ENERGY DRINK ON CARDIOVASCULAR FUNCTION AND ELECTROCARDIOGRAPHIC PARAMETERS AMONG HEALTHY YOUNG ADULTS Elcano JW; Ramboyong RE; Ramirez MF The Medical City Background: Energy drinks are consumed by teens, young adults, athletes and medical students at an alarming rate despite their unproven safety. The reported association of energy drinks to arrhythmias after its consumption remain controversial. The purpose of this study was to determine if consumption of energy drink among healthy young adults was associated with any acute cardiovascular physiologic effects as measured by blood pressure (BP), heart rate and electrocardiographic (ECG) parameters that are markers of increased arrhythmia risk. Method: A total of 103 healthy young adults were randomized to either an energy drink or placebo. Heart rate, blood pressure and ECG were taken immediately before, thirty minutes, one hour and two hours after consumption of the assigned beverage. P wave dispersion (PWD), P wave variability, QT interval, corrected QT interval (QTI rc), RR interval, QRS duration and morphology, and the presence of ST changes relative to the isoelectric line, T wave inversions, Atrial premature complexes (APCs) and Ventricular premature complexes (PVCs) were accounted for. Results: Both systolic and diastolic blood pressure were significantly increased in the treatment compared to placebo group at thirty minutes, one hour, and two hours, but there was no significant difference in the heart rate for all time frames. The PWD values were significantly longer in the treatment group at thirty minutes. There were no statistically significant differences in the QRS duration and QT interval between placebo and treatment. Two subjects developed premature ventricular complexes at one hour and two hours post energy drink ingestion. There were no ST segment shifts nor T wave inversions noted. Conclusion: These results suggest that acute ingestion of energy drink can cause systolic and diastolic BP elevation but no significant change in heart rate. No significant arrhythmia was observed in our study. P117 ST SEGMENT DEPRESION MORPHOLOGIES DURING SUPRAVENTRICULAR TACHYACRDIA Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A Instituto Cardiovascular de Buenos Aires (ICBA) Objetive: ST segment depression is a known high risk marker in coronary syndromes. It's value remains unknown in the presence of certain arrhythmias. The aim of this study is to determine the different morphologies in ST depression and its prevalence during supraventricular tachycardia (SVT). Method: Patients selected for paroxysmal SVT radiofrequency ablation were included. Only nodal re‐entrant tachycardia was included without bundle Branch block or other arrhythmias. CAD history and coronary risk factors were analyzed. ST segment depression was defined as equal or greater than 0.1 mv measured 80 ms after J deflection in more than one contiguous leads. Horizontal and descendent morphologies were considered pathologic and ascendant ST depression as normal. We compared the group which developed pathologic ST segment depression and normal. Results: A total of 162 patients, (age 48 ± 17 years, 67.6% female, 41.89% showed coronary risk factors and 8.78% coronary artery disease history); 39.86% presented STD (10.13% ascendant, 6.81% descendent and 25.67% horizontal). The group that did not developed STD presented a higher mean age, coronary risk factors and coronary artery disease history. The group that developed STD were younger (45 ± 17 vs. 50 ± 16 years, p = 0.05) with less CRF (49.51% vs.25%, p = 0.04) and the arrhythmia had a shorter cycle length (258.99 mseg vs. 343.46 mseg, p = 0.05). Pathological STD was observed in 44 cases (29.72%); those presenting this condition were even younger compared to the ones with non pathological STD or without STD (43 ± 17 vs. 50 ± 16 years, p = 0.03) and had a higher prevalence of female sex (78% vs. 63%, p = 0.09). Conclusion: These results suggest that STD is a length cycle phenomenon and it is most commonly seen in healthier populations, questioning its value as a high risk marker in certain arrhythmias. This result should be analyzed in further prospective trials. P118 HAVE FRAGMENTED QRS ANY PROGNOSTIC VALUE IN CRT‐D PATIENTS? Cipolletta L; Luzi M; Brambatti M; Guerra F; Matassini MV; Capucci A Cardiologic Clinic, Università Politecnica delle Marche, Ancona, Italy Fragmented‐QRS on electrocardiogram (ECG) is a marker of depolarization abnormality that can be correlated with a higher risk of sudden cardiac death. The purpose of this study is to analyze the responsiveness to CRT‐D and cardiac event rate in patients with fragmented‐QRS. We studied 58 patients, candidated to CRT‐D(mean age 70.8 ± 6.8 years, mean EF 24 ± 9%, NYHA III) with an echocardiogram and a 12‐lead ECG before and after implant. 3 readers, blinded to clinical outcome, analyzed ECG. Fragmented‐QRS in narrow QRS were defined as: presence of a notching in R or S wave in two or more contiguous leads. Fragmented‐QRS in patients with wide QRS were defined as ≥2 notches in the R or the S wave. Non‐responders were defined as patients with no improvement of NYHA class and no increase of ejection fraction (EF) at 3 months >10% than baseline. Interventricular dyssynchrony was measured considered an aorto‐pulmonary pre‐ejection delay >40 msec. Spontaneous fragmented‐QRS prevalence was 66% in all patients; stimulated fragmented‐QRS prevalence was 52% in ischemic and 59% in non‐ischemic patients. Elderly (≥65 years) have a 2.8‐fold higher risk to have a stimulated fragmented‐QRS (p = 0.005). At 6 months follow‐up, the incidence of non‐responders to CRT is higher in patients with stimulated fragmented‐QRS (88% vs 45%; p = 0.031). Patients with spontaneous non‐fragmented‐QRS have a greater reduction of left ventricular dyssynchrony (‐34.9 ± 11.7 ms vs −11.3 ± 26.0 ms, p = 0.030); patients without stimulated fragmented‐QRS showed a greater increase of left‐ventricular EF (12.9 ± 12.3% vs 6.23 ± 9.7%, p = 0.009) at 6 months. In our study fragmented‐QRS is not predictive of arrhythmic events. Non‐fragmented QRS is associated with an improvement of echocardiographic parameters, thus it could be a good marker in identifying responders. Instead, the persistence of stimulated fragmented‐QRS is associated with lack of response to CRT making this subgroup less likely to benefit from CRT. GENETICS P119 COMMON NOS1AP GENETIC VARIANT IS ASSOCIATED WITH SUDDEN CARDIAC DEATH IN DCM AND ALL‐CAUSE DEATH IN ICM Pei J; Che J; Zhan Y; Pu J State Key Lab Translational Cardiovascular Medicine, Cardiovascular Institute and Fu Wai Hospital Background: QT interval duration was an intermediate phenotype for sudden cardiac death (SCD) and a surrogate marker of SCD risk. Recent studies have shown that genetic variations in affecting QT interval and occurrence of cardiac events in healthy subjects and CAD respectively. Objective: We set to investigate whether the affecting QT interval gene variants are related to SCD in patients with CHF in a prospective study of Chinese Han populations. Methods: Using haplotype tagging SNPs (htSNPs) to choose 6 SNPs of three candidate‐genes (KCNJ2, KCNJ11, NOS1AP) in modulating QT interval. 6 marker SNPs were genotyped to assess the effect of variant alleles on QTc and the association with SCD risk in patients with CHF. Results: The successful follow‐up rate was 86.06%(1117 cases) including 303 (85.59%) cases of DCM and 814 (86.29%) cases of ICM with the median follow‐up time of 48 months (0.58∼70 months). 298 (26.68%) cases died in total, including 133 cases of DCM and 215 cases of ICM. Of them 60 cases (45.11%)of DCM and 67 cases (40.6%)of ICM had SCD. We found that the A allele of rs12567209 in NOS1AP was significantly not associated with adjusted QT interval in additive model but involved in the prognosis of CHF. After adjusting for age, gender, and suspected risk factors, patients carrying the A allele of rs12567209 had an increased risk of SCD (HR with 4.165 for 95% CI 2.052–10.382) and cardiac death (HR with 1.893 for 95% CI 1.205–3.887) in DCM. However, in ICM patients carrying the A allele of rs12567209 was only associated with cardiac death (HR with 1.524 for 95% CI 1.278–1.78). Conclusions: The A allele of rs12567209 in NOS1AP is associated with increased risk of SCD in patients with DCM and all‐cause death in ICM. The A allele of rs12567209 in NOS1AP is an independent protective factor against SCD in patients with DCM. Key words: genetics variant; QT interval; sudden cardiac death; predictor P120 A PROTECTIVE ROLE OF KCNE1 G38S POLYMORPHISM AGAINST SUDDEN CARDIAC DEATH IN PATIENTS WITH DILATED CARDIOMYOPATHY Galati F; Galati A; Massari S Department of Biological and Environmental Science and Technologies, University of Salento, Lecce, I Introduction: Dilated cardiomyopathy (DCM) is a myocardial disease with a multifactorial etiology. During recent years it has become evident that genetic factors can play a crucial role in its etiology, pathogenesis and prognosis. So we decided to investigate the effects of G38S polymorphism in the KCNE1 gene, that encodes for the β subunit of Iks potassium channel, in ischemic and idiopathic DCM (EF ≤ 35%). Methods: G38S polymorphism was genotyped by RFLP‐PCR in 132 subjects with idiopathic and ischemic DCM, treated with an ICD for primary prevention of sustained ventricular tachycardia (TV) or ventricular fibrillation (FV). Patients were followed at 6‐month intervals. Results: During a median follow‐up time of 47 ± 13 months, 60 patients (45,5%) developed almost one episode of TV/FV. We observed a prevalence of SS genotype in subjects without life‐threatening arrhythmias, although not statistically significant. Hypertension and diabetes could increase mortality and morbidity in DCM. So we divided our population into two groups, depending on the presence (I group – 78 pts) or absence (II group – 54 pts) of these diseases. Group I didn't show any difference in the distribution of alleles. In group II only 1/25 of homozygous carriers of the S38 allele developed severe ventricular arrhythmias, while 48,00% of GG38 patients (12/25) experienced at least one episode of TV/FV: this distribution was statistically significant (P < 0,05). So the incidence of TV/FV was lower in SS homozygotes (1/10; 10% vs 90%) than in G carriers (24/44; 55% vs 45%– P < 0,025). Conclusion: These results suggest that S38 allele can act as protective factor against malignant arrhythmias in patients with DCM without hypertension and/or diabetes. IMPLANTED CARDIOVERTER DEFIBRILLATORS P121 SURVIVAL, INCIDENCE AND TIME‐DEPENDENCE OF APPROPRIATE THERAPY IN PATIENTS RECEIVING ICDS FOR PRIMARY PREVENTION: LONG‐TERM FOLLOW‐UP IN A TERTIARY SINGLE CENTER Kanoupakis EM; Koutalas EP; Mavrakis HE; Kallergis EM; Saloustros IG; Goudis CA; Psathakis E; Petousis S; Vardas PE Cardiology Dpt, University Hospital of Heraklion Crete Introduction: Despite the increased utilization of ICDs for primary prevention of sudden cardiac death, there is a limited number of long‐term follow‐up data regarding outcomes of this population in a routine clinical practice, outside the context of controlled clinical trials. In the present, analysis we examined the survival, the incidence and time‐dependence of appropriate ICD therapy for ventricular arrhythmias in patients who underwent ICD implantation at our institution. Methods and Results: We acquired data from patients with ischaemic, non‐ischaemic dilated and hypertrophic cardiomyopathy as well as patients with inherited channelopathies who received an ICD from 1996 to 2009 for primary prevention. Of 377 ICD recipients 44 deaths were observed (11.7%). Median survival was 8.9 years (95% CI: 86–95). 87 patients (23.1%) had appropriate ICD therapy. Median shock time was 6.9 years (95% CI: 41–72). Incidence of first appropriate ICD therapy was 7.7% in the first year postimplant, increased to 12.5% in year 2, while in year 5 it was 58.3%. Comparing Kaplan‐Meier curves between ischemic and nonischemic patients, nonischemic patients seem to receive shocks at a significantly higher rate than ischemic patients (p = 0.04). Conclusion: In a routine clinical practice primary prevention population, mortality rate remains low. The risk of first appropriate ICD therapy persists over long lifetime and necessitates continuing device therapy irrespective of shock‐free intervals. P122 INTRAVASCULAR DEFIBRILLATOR (INNERPULSE PICD): IMPLANTATION AND REMOVAL TECHNIQUES Merkely B; Geller L; Molnar L; Neuzil P; Reddy V; Tondo C; Natale A; Bednarek J; Bartus K; Sanders WE, Jr Heart Center Semmelweis University, Budapest, Hungary Background: A percutaneously placed, implantable intravascular defibrillator has been developed (PICD). This is the first defibrillator for which removal techniques were developed in conjunction with a femoral vein implantation method. Objective: This study evaluated the initial implant techniques and tools as well as the acute removal procedure in a canine model. Methods: Ten hounds were anesthetized and a custom sheath was introduced into the femoral vein. Two guidewires were placed in the jugular vein and the PICD advanced via the femoral vein over a wire into the vasculature. Utilizing a delivery catheter the device was positioned such that the titanium electrodes (cathodes) were located in the superior vena cava and the inferior vena cava (IVC). A self‐expanding Nitinol anchor was advanced to the jugular via the second wire and deployed to secure the PICD in the vasculature. With a lead placement catheter the RV coil electrode (anode) was positioned in the RV apex. The catheters and wires were removed with an average implant time of under 18 minutes. For removal, the IVC segment of the PICD was snared utilizing a custom catheter. The RV lead was separated from the body of the PICD by cutting the lead inside a protective sheath. A novel catheter with a surgical cutting wire was then advanced over the device. The PICD was used as a rail to advance the cutting wire to the anchoring region. The silicone segment of the PICD was detached from the Nitinol anchor by the cutting catheter and the entire device was removed via the femoral vein. The RV lead was then snared. A cutting wire was positioned at a specific detachment region at the tip and the lead was cut and removed through the femoral vein. Results: Each procedure, both implant and removal, required less than 20 minutes. All implants and removals were successful with no complications. Conclusions: The PICD can be rapidly and safely implanted and removed in canines. P123 LONG‐TERM RESULTS OF ICD IMPLANTATION Revishvili A; Lomidze N; Neminushiy N Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia Purpose of Study: Is to analyze the efficacy of ICD during long‐term follow‐up, estimate survival of patients with ICD, evaluate complication rate in the immediate and late postoperative periods. Material: 426 ICDs were implanted in our clinic in 1990–2010. Primary implantation was performed in 301 patients, in 125 cases the ICD were replaced because of battery depletion. Second and fourth generation of ICDs with epicardial leads were implanted in 11 patients with help of open chest surgery, for 2 patients from them (IV generation ICD) this methodic was used because of impossibility of transvenous implantation. Results: We evaluated long‐term results of 292 patients (237 male, age 12–82 years, average 50,5 ± 15,3 years, follow‐up period 1–178 months, average 39,9 ± 34,5). During this period 168 pts (57,5%) received ICD therapy, the interval between the implantation and the first therapy was 0,2 – 70 month, average follow‐up time in this group was 24,1 ± 19,3 month, in group of patients who did not get an ICD therapy – 15,5 ± 12,2 month (p = 0,04). Most of episodes of VT were terminated by electrical shocks (156) that were determined by tachycardia behavior and hemodynamic condition of patients. ATP was successful in 68 patients. Multifactorial analysis revealed that the only variable which influenced rate of ICD therapy was left ventricle ejection fraction (LVEF) which in group of patients who got ICD therapy was in the average 41,3 ± 16,8%, and in group of patients who did not get ICD therapy– 57,4 ± 15,7% (P < 0,03). Most important factor effecting survival was LVEF. Generally LVEF was 46,8 ± 15,7%, in deceased – 30,3 ± 16,9% (p = 0,001). Total cumulative proportional survival (Kaplan‐Meier) was 73% during 150 month. Conclusions: In our opinion LVEF is the most significant factor influencing: survival, occurrence of VT, VT number and accordingly occurrence of ICD therapy. P124 SPRINT FIDELIS DEFIBRILLATION LEAD: A NINE‐CENTRE EXPERIENCE IN SPAIN Domínguez‐Pérez L; Arias MA; Jiménez‐López J; Toquero J; Jiménez‐Candil J; Díaz‐Infante E; Tercedor L; Olagüe J; García Fernández J; Rodríguez‐Padial L Department of Cardiology, Hospital Virgen de la Salud Introduction and Objectives: Sprint Fidelis defibrillation leads are prone to early failure. Most of the series reported come from a single institution. This paper describes the clinical experience in nine Spanish hospitals. Methods: Clinical, implant, and follow‐up visits data of all patients with Sprint Fidelis lead were analyzed. All cases of lead failure were identified, medium‐term lead survival was calculated and possible predictors for lead failure were determined. Results: A total of 378 leads in 376 patients were studied. The mean age (male 85.7%) was 64.9 ± 13.6 years. The majority of patients (59.8%) had ischemic heart disease. Mean left ventricular ejection fraction (LVEF) was 0.334 ± 0.1445%. Left subclavian vein puncture was used in 74.8%. During a mean follow‐up of 30.9 ± 14.0 months, 16 lead failures have occurred with a lead survival of 96.1% at 36 months after implantation. Eleven of 16 lead failures were caused by failure of pace/sense conductors, 3 failures were caused by defects in the high‐voltage conductor, and 2 cases were caused by defects in both types of conductors. A less depressed LVEF was associated with an increased probability of lead failure (0.424 ± 16% vs. 0.330 ± 0.143%, p = 0.011). Three hospitals presented a rate of lead failure higher than 10%, being less than 5% in the remaining 6 hospitals. Conclusions: In this multicenter series of 378 leads, the three‐year estimated survival was higher than that reported in prior series. Clinical presentation of lead failures was similar to that reported previously. LVEF and hospital of implantation were variables associated to lead failure. P125 IMPLANTABLE CARDIOVERTER DEFIBRILLATOR THERAPY REDUCES ARRHYTHMIC MORBIDITY AND MORTALITY IN HIGH RISK PATIENTS WITH PRESERVED EJECTION FRACTION Tsiachris D; Gatzoulis KA; Dilaveris P; Arsenos P; Archontakis S; Sideris S; Kartsagoulis E; Vouliotis A; Kallikazaros I; Stefanadis C First Cardiology Clinic, University of Athens Medical School, Hippokration Hospital, Athens, Greece Background: Current guidelines for the primary prevention of sudden cardiac death have used a left ventricular ejection fraction (LVEF) ≤ 35% as a critical point to justify implantable cardioverter defibrillator (ICD) implantation in post myocardial infarction patients and in those with nonischemic dilated cardiomyopathy. We compared mortality and ICD activation rates among different ICD group recipients using a cut‐off value for LVEF ≤ 35%. Methods: We followed up for a mean period of 41.1 months 495 ICD recipients (442 males, 65.6 years old, 68.9% post myocardial infarction patients, 422 with LVEF ≤ 35%). Prevention was considered primary in patients who fulfilled guidelines criteria or had inducible ventricular arrhythmia during programmed ventricular stimulation for patients with LVEF > 35%. Results: Over the course of the trial, 84 of 495 patients died; 69 experienced cardiac death (6 sudden) and 15 non cardiac death. ICD recipients with LVEF ≤ 35% compared to those with preserved LVEF (mean LVEF = 43%) had a greater incidence of total mortality (18% vs. 11%, log rank p = 0.028) and cardiac death (15.4% vs. 5.5%, log rank p = 0.005). There was no difference in the cumulative incidence for appropriate therapy between patients with LVEF ≤ 35% and those with LVEF > 35% (56.9% vs. 65.8%, log rank p = 0.93). Similarly, no difference was observed between the two groups in the incidence of ICD shocks or antitachycardia pacing (34.6% vs. 45.2%, log rank p = 0.35 and 50.2% vs. 57.5%, log rank p = 0.98, respectively). In the multivariate analysis the presence of advanced New York Heart Association stage predicted both total mortality (HR = 2.69, 95% CI 1.771–4.086) and cardiac death (HR = 3.437, 95% CI 2.163–5.463). Conclusions: ICD therapy may protect heart failure patients at early stages from arrhythmic morbidity and mortality, based on an electrophysiology‐guided risk stratification approach. P126 PREDICTORS OF INAPPROPRIATE THERAPY IN PATIENTS WITH IMPLANTABLE CARDIOVERTER‐DEFIBRILLATORS AND CHAGAS' CARDIOMYOPATHY Rodriguez C; Miranda R; Femenia F; Lopez‐Diez JC; Serra JL; Muratore C; Valentino M; Retyk E; Galizio N; Baranchuk A; on behalf of the FECHA Study Investigators IECTAS Maracaibo, Venezuela Introduction: Implantable cardioverter defibrillators (ICD) proven to be an effective therapy to prevent sudden death in patients with Chagas' Cardiomyopathy (CChC). Identification of predictors of inappropriate therapy delivered by the ICD would allow implementing medical or ICD programming interventions. Methods: Retrospective study involving patients with CChC and ICD from 14 centers in Latin America, follow up of 33 ± 20 months. Demographics, surface ECG and clinical and ICD follow up were collected. ICD therapies were reviewed by 2 independent investigators. Chi‐square and logistic regression were performed. Results: A total of 94 patients were analyzed. Mean age 55 ± 10 years old (26/75), 62 male (63.8%). Mean left ventricular ejection fraction (LVEF) was 39.6 ± 11.8%. Secondary prophylaxis was the reason for implanting an ICD in 71.3% of the cases. During a follow up of 33 ± 20 months, 19 patients (20%), presented inappropriate therapies. Univariate analysis can be seen in Figure 1. Multivariate analysis adjusted by age and LVEF showed that paroxysmal atrial fibrillation (AF) (OR 2.4, 1.2–3.6; p = 0.01), QRS>150 ms (OR 1.6, 1.1–2.3; p = 0.04) and B‐Blocker therapy (OR 0.93, 0.84–0.97; p = 0.04) remained statistically significant. Conclusion: In patients with CChC and ICD, paroxysmal AF and QRS>150 ms increased the risk of inappropriate therapies. The use of B‐blockers therapy was protective. P127 VENTRICULAR TACHYCARDIA WENT UNDETECTED BY ICD? A CASE REPORT Tan VH 1; Lee LL 1; Goh YS 1; Tong KL 1; Chow J 1; Tan BY 21 Changi General Hospital, Singapore; 2National Heart Centre, Singapore Introduction: ICD shock occurred in about 10–20% of patients who received ICD therapies. However, there is paucity of data on ventricular arrhythmia undetected by ICD. We attempt to describe a case of VT which was undetected by ICD and subsequent management. Case Description: 53 years old man, a sudden cardiac arrest survival (developed VT at rate of 168 bpm or 357 ms cycle length). He was later diagnosed to have arrhythmogenic right ventricular dysplasia (ARVD) and underwent ICD implantation (Medtronic Maximo VR 7232) in November 2010. Initial ICD setting include VT zone (430 ms, 140 bpm), FVT via VF (250 ms, 240 bpm), VF zone (320 ms, 188 bpm), wavelet threshold, onset, stability and SVT discrimination were on. He was on oral sotalol 40 mgbd. He started to feel lethargy 1 day prior to admission in June 2011. He went to seek general practitioner advice and ECG was done which showed VT and was immediately referred to hospital. On arrival at emergency department, ECG showed VT (176 bpm, 341 ms). He was given intravenous amiodarone for an hour but unsuccessfully cardioverted. He subsequently underwent synchronised cardioversion and returned to sinus rhythm. ICD interrogation revealed VT occurring at rate of 390–430 ms. It was recognized by the device as gradual onset tachycardia and therefore no shock was given. R wave sensitivity was 0.3 mv. Defibrillation threshold check was normal. Blood investigations showed no evidenced of sepsis or electrolytes abnormality. Adjustment was made in which the onset and stability was off. He did not experienced further ventricular arrhythmia during hospitalization and was subsequently discharged from hospital with sotalol 80 mgbd. He was follow up 2 weeks later at outpatient and ICD check showed 1 episode of VT with appropriate shock. Conclusion: ARVD patient who received ICD for secondary prevention and receiving high dose sotalol may required minimum detection enhancement to avoid undetected VT episode. P128 SELECTION OF ICD RECIPIENTS – GENDER DISCRIMINATION SINGLE CENTER EXPERIENCE OF FOUR YEARS (2007 – 2011) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: In clinical trials of primary and secondary prevention of sudden cardiac death, mainly male patients (pts.)have been selected to be implanted with a cardioverter defibrillator (ICD), which can be explained only in part by a lower prevalence of coronary disease in women, in younger age groups. Objective: To evaluate the gender distribution of ICD implantation from a single center in Indian population with left ventricular (LV) dysfunction. Population/Methods: We studied 252 pts with moderate to severe LV systolic dysfunction that were implanted ICD in our department (from 2007–2011) in New Delhi. We analyzed the distribution by gender, age and etiology. Results: Out of 252 pts (90.8% were males and 9.2% were females); the mean age of pts was 63 ± 15 yrs however there was no significant difference regarding mean age (56.5 + 9.8 years for males vs. 55.4 + 9.6 years for females). 66.4% had ischemic etiology, 29.5% had idiopathic dilated cardiomyopathy, 3.1% had hypertrophic cardiomyopathy, 1.0% had arrhythmogenic right ventricular cardiomyopathy. Indication for primary prevention was in 32.5%, while 67.5% of pts. had the ICDs implanted for secondary prevention as a whole group, out of which 91% of females had the ICDs implanted for secondary prevention. The mean ejection fraction (EF) was 26%± 9% as a whole group, while the mean EF for females was 24%± 5%. 15% of patients were in NYHA functional class I, 49% in class II and 36% were in class III as a group, while in the female population, 40% were in class II and 60% were in class III. Conclusion: The rate of implantation of ICDs in females in Indian population is lower than theoretically expected. Also, the female population was older with higher NYHA class. The guidelines must be implemented carefully to avoid gender selection biases. P129 CLINICAL OUTCOMES IN IMPLANTED CARDIOVERTER DEFIBRILLATOR POPULATION: SINGLE CHAMBER VS DUAL CHAMBER Forleo GB; Vecchio F; Papavasileiou L; Mahfouz K; Topa A; Ticchi C; Schirripa V; Magliano G; Santini L; Romeo F Division of Cardiology, Department of Internal Medicine, University of Rome "Tor Vergata" Introduction: Implanted cardioverter defibrillator (ICD) has been demonstrated to offer life‐saving therapies in patients with high risk of sudden cardiac death. The type of ICDs implanted could influence the occuence of inappropriate discharges due to supraventricular tachycardia misclassification. The aim of our study was to evaluate the outcomes of patients implanted with dual‐chamber (DC) versus single chamber (SC) devices. Methods: We analyzed 285 consecutive patients underwent ICDs implantation at our Institution between September 2003 and November 2010. We subdivided patients into "single chamber device" (n = 164, 147 males, age 64.4 ± 12.2 years) and "dual chamber device" (n = 121, 102 males, age 66.8 ± 11,1 years) groups based on the type of device implanted. Results: After a mean follow‐up of 24.1 ± 18.4 months, no significant differences were found in the incidence of appropriate discharges (40 vs 25 patients, p = ns) and in the occurrence of inappropriate therapy (11 vs 7 patients, p = ns). The type of ICD does not influence the incidence of TVNS (50 vs 28 patients, p = ns). Surprising our analysis shows a significant lower mortality in single chamber device group (13 vs 26 patients, p = 0.004). Further analysis would be necessary to explain such a data which should be confirmed in a wider population study. Conclusions: In our experience type of device does not influence the occurrence of ICD therapies and the incidence of ventricular arrhythmias. P130 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS AN D QUALITY OF LIFE Forleo GB; Cioè R; Magliano G; Panattoni G; Papavasileiou LP; Minni V; Topa A; Mahfouz K; Santini L; Romeo F Department of Cardiology, University of Rome "Tor Vergata," Rome, Italy Purpose: Implantable cardioverter defibrillators (ICDs) reduce mortality in patients at high risk for sudden cardiac death. Quality of life (QoL) of these patients is often reduced, however, due to clinical, social problems, behavioral factors and psychological distress. The aim of the study is to evaluate the quality of life of patients with ICDs. Materials and Methods: We investigated 65 consecutive patients (56 males, age 65.68 ± 6.6 years) who received ICDs between December 2005 and August 2010 at our institution. All subjects were interviewed after a mean follow up of 14.59 ± 13.93 months, using the Short‐Form Health Survey (SF‐36). The SF36 includes eight independent scales. For each variable item scores are coded, summed, and transformed on to a scale from 0 (worst possible health state measured by the questionnaire) to 100 (best possible health state). Results: The SF36 shown a score of 51.44 ± 28.98 for physical functioning, a score of 35.98 ± 40.46 for role limitations due to physical problems, a score of 33.33 ± 45.86 for role limitations due to emotional problems, a score of 50.00 ± 22.77 for energy/fatigue, a score of 59.70 ± 21.16 for emotional well being, a score of 67.05 ± 26.13 for social functioning, a score of 70.80 ± 26.55 for pain and a score of 49.24 ± 16.48 for general perception of health. Conclusion: The study show that from a patient's perspective, QoL of subjects with ICDs is compromised, both psychologically and physically. They have difficulty performing the work or other activities, as a result of their clinical and psychological status. Often their psychosocial involvement is caused by fear of shocks and fear of death. The results suggest the importance of dialogue between the physician and the patients, which should be reassured and helped to overcome their limitations. P131 PROGNOSTIC FACTORS IN PATIENTS AFTER CARDIAC DEFIBRILLATOR IMPLANTATION Raspopovic S; Kircanski B; Nikcevic G; Jovanovic V; Pavlovic S; Zivkovic M; Milasinovic G Pacemaker Center, Clinical Center of Serbia Introduction: The aim was to establish different prognostic factors of patients after implantation of an ICD, including all cause mortality and occurrence of appropriate ICD therapy and new hospitalization rate. Method: All patients with ischemic and non‐ischemic cardiomyopathy(CMP), low left ventricular ejection fraction (LVEF ≤ 35%) and only ICD implanted during 2006 and 2007 in our center, and at least one follow up (FU) examination were included in the study. Patients baseline characteristics were over‐viewed, including etiology of CMP, QRS duration, New York Heart Association (NYHA) functional class, presence of hypertension, atrial fibrillation (AF), diabetes, hyperlipidemia, previous myocardial infarction (MI), QRS duration. Follow up charts were examined, regarding the last FU date, occurrence of arrhythmia, appropriate ICD therapy, death and new hospitalization due to heart failure(HF), arrhythmia episodes or upgrade of the system. Results: A total of 77 patients fulfilled inclusion criteria, 88,3% male, average age 62,4 years and 65% with ischemic CMP. Hypertension was found in 66%, AF in 36%, previous MI 58,4. There were 19,5% with diabetes and 42.9% with hyperlipidemia. NYHA class≥II had 91% and QRS≥120 ms was present in 44%. Mean FU was 34 months. Overall mortality rate was 25%(SCD 11%, nonSCD 68%, non cardiac death 21%). Arrhythmia episodes (VT/VF) showed in 52%, ICD therapy experienced 53% of patients, appropriate in 95% of cases. Hospitalization rate after ICD implantation was 21%. There were no significance between subgroups regarding mortality in patients with ischemic/non ischemic CMP (p>0,05, diabetes, and atrial fibrillation. There were significance between subgroups regarding mortality in patients with hypertension and wide QRS. Conclusion: Identifying different prognostic factors is very important for outcome in a specific population like ICD patients. P132 PROBLEMS OF ICD THERAPY IN CHILDREN RELATED TO LEAD IMPLANTATION TECHNIQUE Ivanitskiy EA; Kropotkin EB; Tsaregorodtsev AP; Kasimtseva TA The Federal Centre of Cardiovascular Surgery The aim of this study was to analyze the problems of ICD therapy in children according to our own experience. Methods: Four patients were enrolled in the study, age 5 – 13 years. Two ICDs were implanted for primary prevention and two ICDs – for secondary prevention of sudden cardiac death. One patient had corrected triad of Fallot, one patient had long QT syndrome and sick node syndrome, one patient had Brugada syndrome and one patient had dilated cardiomyopathy before the ICD implantation. Two ICDs were implanted by using transvenous approach with endocardial leads. One ICD was implanted via sternotomy by using two epicardial pacing leads and one epicardial shock patch. One ICD was implanted via left thoracotomy by using epicardial pacing leads. The shock lead in the last patient was positioned subcutaneously in the fifth intercostal space. Results: There were problems related to sensing disorders, ineffective shocks and inappropriate shocks in one patient who had endocardial leads. In this patient all endocardial leads were then removed by using laser extractor. New endocardial leads were successfully implanted via transvenous approach in this case. Conclusion: Epicardial approach for ICD implantation in children seems to be attractive because of less problems with leads and ICD therapy. Sometimes it is very effective to use both epicardial and subcutaneous approach for ICD leads implantation. In elder age in this category of patients we still have a possibility to use transvenous approach when lead and/or device replacement is needed. P133 ELECTROCARDIOGRAPHIC FINDINGS, COMORBIDITIES AND DEVICE THERAPIES IN OCTOGENARIAN IMPLANTABLE DEFIBRILLATOR RECIPIENTS IN INDIAN POPULATION ‐FOUR YEARS EXPERIENCE (2007–2011) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Sudden cardiac death (SCD) is significant cause of mortality. Large, multicenter, randomized trials have shown efficacy of implantable cardioverter‐defibrillator (ICD) for primary and secondary prevention of SCD. The incidence of SCD increases with age. Many elderly patients (pts.) qualify for ICD, pts aged ≥80 years (octogenarians) are underrepresented in clinical trials of ICD as comorbidities in old age may negate the beneficial effects of ICD.Many pts who meet standard criteria for an ICD are older than those included in clinical trials of ICD, its use in these patients requires further definition. Objective: To assess baseline ECG findings, arrhythmia episodes, and severe nonarrhythmic illness or death in patients aged ≥80 years at ICD implantation, and to compare them with younger pts. Population/Methods: We studied 86 pts, ≥70 years old who underwent ICD implantation with respect to comorbidities, ECG findings and device therapies. Pts were divided in 3 groups based on age: age 70–74 (group 1; 38 pts), age 75–79 (group 2; 26 pts), and age ≥80 (group 3; 22 pts). Results: ECGs: Octogenarians were more likely to have sinus bradycardia (SB) and left bundle branch block (LBBB) compared to younger pts. There was no difference among groups in the proportion of pts with atrial fibrillation or any degree of AV block. Therapies: There was no difference in any appropriate or inappropriate therapy per patient‐year. Nonarrhythmic Death/Morbidity: There was no difference in time to death or serious illness. Conclusion: This was the study to evaluate the therapies received by octogenarians after ICD in Indian population at our centre. The higher incidence of SB and LBBB might influence the number of pacing sites in octogenarian patients. These pts have similar rates of arrhythmic episodes and development of severe comorbidities as septuagenarians, and they should not be denied ICD implantation based solely on age. P134 INTRAOPERATIVE DEFIBRILLATION THRE‐
SHOLD TESTING AND POSTOPERATIVE LONG‐TERM EFFICACY OF IMPLANTABLE CARDIOVERTER‐DEFIBRILLATOR IMPLANTATION Tianyi G; Yu Z; Baopeng T; Jinxin L; Xianhui Z; Guojun X; Yanyi Z; Yaodong L; Jianghua Z Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi, China Introduction: To determine the defibrillation threshold of implantable cardioverter‐defibrilla‐
tors and outcomes of treatment. Methods: Sixty‐four patients received implantable cardioverter‐defibrillators implantation. During implantation, defibrillation threshold was determined by defibrillation safety margin. All patients were followed‐up for 12–48 months after the implantation. Results: The overall defibrillation threshold was 14.27 ± 2.56 J and defibrillation safety margin was 18.40 ± 1.89 J. Malignant ventricular arrhythmias occurred in 42 patients after implantable cardioverter‐defibrillators implantation including 500 episodes of non‐sustained ventricular tachycardia and 289 episodes of persistent ventricular tachycardia. Following antitachycardia pacing treatment, 265 episodes were treated successfully by one antitachycardia pacing treatment (91.69%), 12 episodes were treated successfully by two antitachycardia pacing treatment (4.15%). 12 episodes were converted by low energy electrical cardioversion (4.15%). A total of 175 ventricular fibrillation episodes were identified. of which 18 episodes automatically terminated before treatment.146 episodes were converted by one cardioversion with defibrillation energy of 13.21 ± 2.58 J and 11 episodes were converted by two cardioversions with defibrillation energy of 16.19 ± 2.48 J. Conclusions: It is safe and feasible to determine defibrillation threshold by defibrillation safety margin measurement during implantable cardioverter‐defibrillators implantation. Keywords: Implantable cardioverter‐defibrillator, defibrillation threshold, ventricular arrhythmia PACING P135 ASSESSMENT OF LEFT VENTRICULAR FUNCTION AND SYNCHRONY IN PATIENTS WITH RIGHT VENTRICULAR OUTFLOW TRACT AND APICAL PACING‐ AN INTERMEDIATE TERM FOLLOW UP STUDY Sharma G; Varghese MJ; Salahuddin S; Seth S; Juneja R; Bahl VK All India Institute of Medical Sciences, New Delhi, India Introduction: Pacing from the right ventricular outflow tract (RVOT) may preserve left ventricular function and dyssynchrony compared with right ventricular apical (RVA) pacing. We evaluated permanently paced patients from the two sites at 6 months post implantation. Methods: 30 consecutive patients with baseline normal LV function were evaluated. Detailed echocardiographic (VIVID 7, GE Medical Systems) assessment was done to assess left ventricular ejection fraction (LVEF) and ventricular dyssynchrony, during forced ventricular pacing. Dyssynchrony parameters assessed were interventricular mechanical delay (IVMD), septal‐posterior wall mechanical delay (SPWMD) and tissue Doppler parameters including dyssynchrony index and maximum time delay in peak tissue velocities in twelve left ventricular segments (MaxTPV). Results: 20 patients had pacemaker leads in the RVOT position. Mean age of the population was 57 ± 12 years (22 males). The mean time to echocardiographic assessment at follow‐up, from the time of pacemaker insertion was 246 ± 77 days. At follow‐up, there was no significant difference in LVEF between the two groups (61.7 ± 5.8% vs 61.8 ± 8.6%; RVOT vs RVA groups respectively, P‐0.97). The RVOT group showed a trend towards improvement in interventricular synchrony with IVMD of 28.7 ± 16.4 msec as compared to 39.1 ± 10.5 msec in the RVA group (p‐0.08). Similarly, the SPWMD showed a trend towards benefit in the RVOT group (22.9 ± 1.4msec vs 29.6 ± 4.30msec, p‐0.07). Tissue Doppler parameters of LV synchrony were also significantly better in the RVOT group (Dyssynchrony index: 3.9 ± 2.2 vs 6.2 ± 3.4, p‐0.03; Max TPV: 19.65 ± 4.9msec vs 36.5 ± 16.1msec, p‐0.0002; for RVOT vs RVA groups respectively). Conclusion: At an intermediate term follow up, patients with RVA pacing have significant ventricular dyssynchrony as compared to RVOT pacing. The left ventricular systolic function in the relatively short follow up is preserved in both sites of pacing. P136 AN ATRIOVENTRICULAR CONDUCTION TEST AT 90 BPM IDENTIFIES THE PATIENTS WITH A LOW RIGHT VENTRICULAR PACING PERCENTAGE Stazi F; Mampieri M; Verde M; Cardinale M Dipartimento Apparato Cardiocircolatorio, A. O. San Giovanni Addolorata. Roma. °CLI Foundation Introduction: High percentages of right ventricular pacing (RVP) are associated with increased mortality and heart failure. The use of the algorithms of RVP reduction such as AAISafeR® (Sorin Group) and MVP® (Medtronic) allows to obtain very low percentage of RVP in patients with preserved atrioventricular conduction. Picking out the patients that can take advantage of these algorithms it would be therefore very useful. Aim of the study was to assess if an atrioventricular conduction test at 90 beats per minute (bpm) enables to identify the patients who can have a low RVP percentage using the algorithms of RVP reduction. Methods: One hundred thirtythree patients (82 M, 51 F, age 75 ± 11 years, AAISafeR®= 121, MVP®= 12) underwent an atrioventricular (AV) conduction test at 90 bpm during atrial pacing at the time of the pacemaker (PM) (n = 113, 52 for sinus node disease, SND, and 61 for atrioventricular block of any degree, AVB) or defibrillator (ICD) (n = 20) placement, both provided of an algorithm of RVP reduction. Results: One hundred patients (65 M and 35 F, age 75 ± 12) who underwent PM (n = 80, 51 for SND and 29 for AVB) or ICD (n = 20) placement had 1:1 AV conduction (group 1) while thirtythree subjects (17 M and 16 F, age 78 ± 9) all with PM placement (32 for AVB and 1 for SND) had AV conduction defects (group 2). 73 ± 209 days after the procedure the mean RVP percentage was 6 ± 17% in group 1 and 76 ± 35% in group 2 (P < 0,0001). Conclusions: An 1:1 AV conduction during atrial pacing at 90 bpm identifies the subset of patients who will have a low RVP percentage with the RVP reduction algorithms. P137 PERFORMANCE OF ACTIVE VERSUS PASSIVE FIXATION LEADS IN PACEMAKER RECIPIENTS – ACUTE AND CHRONIC PARAMETERS; OUR CENTER EXPERIENCE OF TEN YEARS (2001–2011) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Innovation in pacemaker technology has lead to development of steroid eluting fixation leads‐ active(screw‐in) & passive(tined) leads leading to significant reduction in acute & chronic pacing thresholds, lead impedance & decrease in rate of lead dislodgement. For unknown reasons, screw‐in leads are used more often, despite that tined leads have lower chronic thresholds. This may have significance in pacemaker battery longevity and avoiding early replacements. We compared basic parameters of two leads at our center over ten years of follow up. Objective: To examine time course of atrial(A), ventricular(V), or A+V pacing threshold, P & R amplitude and impedance in patients (pts) who underwent single or dual chamber pacemaker implant respectively (rly) between 2001–2011. Population/Methods: We studied 3568 pts. A & V acute & chronic pacing thresholds at 0.4 ms, P & R amplitude & impedance were measured at implantation & 6 months. Results: At implantation, mean acute A & V threshold for tined & screw‐in lead‐ 0.53 ± 0.23V, 0.68 ± 0.4 V; 0.83 ± 0.25V, 0.88 ± 0.33V rly. P & R amplitude 3.8 ± 1.6mV, 11.1 ± 4.2mV; 2.9 ± 1.8mV, 10.7 ± 3.9mV rly & impedance 578 ± 93Ω, 693 ± 98Ω 602 ± 103Ω, 703 ± 98Ω rly. Mean chronic A & V threshold for tined & screw‐in lead‐ 0.33 ± 0.18V, 0.49 ± 0.1V; 0.76 ± 0.2V, 0.79 ± 0.28V rly. P & R amplitude 4.2 ± 1.6mV, 13.8 ± 4.0mV; 3.2 ± 1.5 mV, 11.9 ± 2.9mV rly & impedance 498 ± 76Ω, 608 ± 85Ω 546 ± 96Ω, 612 ± 88Ω rly. Conclusion: We concluded that acute & chronic atrial and ventricular pacing threshold with screw‐in lead was significantly higher than with tined lead. There was significant increase in chronic P and R‐wave amplitude with tined vs screw‐in lead, also decrease in chronic impedance was noticed in tined vs screw‐in lead but not statistically significant. Henceforth, one should give good thought in selection of leads as this may have great impact on pacemaker longevity and on economic aspect of health care. P138 LONG TERM OUTCOME OF VDD AND DDD PATIENTS: A SINGLE CENTER EXPERIENCE Campana A; Manzo M; Brigante MR; Melchiorre G; Matrone A; Avallone B Heart Department A.O.U. San Giovanni di Dio e Ruggi D'Aragona. Salerno, Italy Background and Objective: VDD/VDDR pacing is used less frequently than recommended by guidelines. Aim of the present study was to demonstrate that VDD pacing is effective and safe, if performed in indicated patients, and to compare long‐term follow‐up results of VDD versus DDD pacemaker patients in terms of: reliability, rate of atrial fibrillation (AF) onset and device replacements during observation period. Methods and Results: A retrospective analysis was conducted on 364 patients who underwent their first implantation of DDD/DDDR or VDD/VDDR pacemaker in our center between January 1995 and December 2000. Main indication for pacemaker implantation was sinus node disease and/or advanced A‐V conduction dysfunction in 177 patients with DDD/DDDR pacemaker (Group D) and advanced atrioventricular block in 187 patients with VDD/VDDR pacemaker (Group V). The median follow‐up was 8 years (25th‐75th percentile: 4–10). Twenty‐six patients (15%) in Group D and 20 (11%) in Group V developed persistent or permanent AF. The incidence of AF was 2.2 per 100 patient‐years in Group D and 1.5 in Group V (p = 0.176). Pacemakers were replaced during follow‐up in 96 patients (54%) in Group D and in 43 patients (23%) in Group V (P < 0.001). In total, 163 patients died during follow‐up: 92 in Group D (52%) and 71 in Group V (39%). The risk of death proved to be significantly higher in Group D than in Group V (V vs D: HR = 1.48, 95%CI 1.08–2.01, p = 0.014). Conclusions: In our cohort, VDD pacing proved just as reliable as DDD pacing, more long‐lasting and no more arrhythmogenic. P139 ADVERSE EFFECTS OF SUSTAINED ATRIAL OVERPACING IN SICK SINUS NODE PATIENTS WITH PAROXYMAL ATRIAL FIBRILLATION Menezes A Jr; Rassi S; Moura MC Catholic University Of Goias Background: The atrial Dynamic overpacing for atrial tachyarrhythmias prevention is an attempt to pace the atrium with a higher rate than the coupling episodes of atrial premature beats of the patients, inhibiting their focus and avoiding the occurrence of short‐long cycle. Instead, some authors have been demonstrating that the increase in atrial and ventricular stimulation may determine the development of persistent atrial fibrillation. (GILLS, A. HRS, 2009). Objective: Observe the evolution of paroxysmal atrial fibrillation in patients with DDD device and the overpacing algorithm on, initially to persistent or permanent atrial fibrillation (characterized as adverse effect of pacing mode). Methods: An observational, prospective, evaluating 35 patients with SSS and paroxysmal atrial fibrillation, pacemaker DDD, followed for 48 months. Rating telemetry, 24 hours Holter and transesophageal echo every 6 months. Results: The mean age was 67 ± 8 years, 65% male, 77% patients with Chagas' heart disease. Clinical evaluation showed a significant increase in complaints of palpitations, AF burden and MS (Mode Switch) with a significant increase after 36 months with P value < 0.003. Transesophageal echocardiography with a significant increase of Left Atrim (volume, dimension) (p <0.05). Seven patients were submitted to AV node ablation (for better control of symptoms). Conclusions: Dynamic atrial overpacing when continuously accomplished, instead of prevent atrial tachyarrhythmias might develop a worsening of atrial fibrillation in SSS pacemaker patients. P140 ABNORMAL SINUS NODE RESPONSE TO ADENOSINE PREDICTS THE OCCURRENCE OF SYNCOPE OR PRESYNCOPE IN PATIENTS WITH SICK SINUS SYNDROME Fragakis N; Antoniadis A; Koskinas K; Pagourelias E; Kyriakou P; Skeberis V; Geleris P Cardiology Unit, 2nd Propedeutic Department, Hippokration Hospital, Thessaloniki, Greece Background: Intravenous adenosine administration is a noninvasive diagnostic test for sick sinus syndrome (SSS). However, whether its effect on sinus node is associated with the clinical presentation of SSS remains elusive. We hypothesized that the sinus nodal inhibition by adenosine is more pronounced in SSS patients with previous syncope or presyncope as compared to SSS patients without syncopal or presyncopal attacks. Patients and Methods: We studied 44 patients with SSS, 33 with a history of syncope or presyncope and 11 without such history. Controls were 29 subjects undergoing electrophysiological studies for supraventricular tachycardia or unexplained syncope, none of whom had sinus nodal dysfunction. We calculated the corrected sinus node recovery time after 0.15 mg/kg intravenous adenosine (ADSNRT) and after overdrive atrial pacing (CSNRT). CSNRT values >525 msec were considered abnormal. Results: SSS patients with a history of syncope or presyncope had notably prolonged ADSNRT as compared to SSS patients without such history (median: 4900, IQR: 920 – 8560 msec vs. median: 160 IQR 0–563 msec; P < 0.001). Also, SSS patients with a history of syncope or presyncope had significantly longer ADSNRT than CSNRT (median: 4900, IQR: 920–8560 msec vs. median: 680 IQR: 359–1650 msec, P < 0.01). On the other hand, SSS patients without a history of syncope or presyncope showed no difference between ADSNRT and CSNRT values (median: 160 IQR: 0 – 563 msec vs. median 380, IQR: 200–455 msec, p = 0.72). The sensitivity of CSNRT in the diagnosis of SSS was 57% and the specificity 100%. A cut‐off of 1029 msec for ADSNRT yields the same sensitivity with a specificity of 96.4%. Conclusions: Patients with SSS and a history of syncope or presyncope exhibit an exaggerated sinus nodal suppression by adenosine. Prolonged ADSNRT is suggestive of a more severe underlying sinus node dysfunction, and this may be useful in the risk‐stratification and effective management of patients. P141 CARDIAC PACING TRENDS IN SOUTH KOREA FOR THE LAST 10 YEARS: CHANGES FROM SINGLE CHAMBER PACING TO DUAL CHAMBER PACING Jang SW; Rho TH; Choi MS; Shin WS; Kim JH; Oh YS; Lee MY; Cho EJ; Kim DB; Kim JH Devision of Cardiology, Department of Internal Medicine, The Catholic University of Korea A nationwide cardiac pacing survey has been undertaken annually in South Korea. We compared the 2010 survey with the 2000 one. Data were collected from the cardiac implantable electronic device manufacturers and distributors. The implantable cardioverter defibrillator was not included in this survey. In 2010, the number of total implants, new implants, and replacements were 2932, 2153, and 779, respectively. Those numbers are 162%, 133%, and 295% increases, respectively, as compared with the 2000 data. A number of new implants per million population was increased from 19 to 43. However, according to the 2009 world survey, it was still lower than other Asian Pacific countries including Japan (272), Taiwan (172), Hong Kong (124), and Singapore (94). As for the pacing mode, VVI(R) was decreased from 38% to 26%, and DDD(R) was increased from 44% to 60%. The major indications for new implants were a sinus node dysfunction (41%) and an advanced atrioventricular block (54%), and female patients constituted 59% of total implants, which were similar to the 2000 survey. Possible reasons for a small number of cardiac pacing implantation in South Korea, as compared with other Asian countries with similar economic background, could be differences in population profiles, physician's attitudes, cultural backgrounds, reimbursement problems, and a low incidence of conduction system disorders. In summary, the cardiac pacing implantation has markedly increased for the last 10 years. The dual chamber pacing has been replacing the single chamber pacing. Why the implants in South Korea are small is still questioning. P142 ADVERSE EVENTS RELATED TO TINED VERSUS SCREW‐IN LEADS IN PATIENTS RECEIVING DEVICE IMPLANTS – GENDER DIFFERENCES Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Devices‐Implantable cardioverter defibrillators (ICDs) & pacemakers (PMs) have reduced morbidity & mortality. However, gender differences may exist in adverse events attenuating benefits. Females unlike males are at high risk for procedural complications like high rates of bleeding, stroke & in‐hospital mortality after invasive procedures.Less is known about differences in complications in device recipients. Choice of lead (tined/screw‐in) may have major role. We addressed the issue in our patients (pts). Objective: To examine gender specific, adverse events related to type of lead in pts with device implants (2001–2011). Population/Methods: We studied 4398 pts & followed them for adverse events for three years after implantation. Results: PMs: 3568; 71.3% males, 28.7% females; mean age 62 ± 15yrs‐no significant gender difference (59.7 yrs males vs 60.1 yrs females). Females significantly got more tined vs screw‐in leads; males got nearly same. ICDs: 830; 91%males, 9%females; mean age 63 ± 14 yrs‐ significant gender difference (54.7 yrs males vs 60.1 yrs females). Females & males got more screw‐in vs tined leads. Females have more heart failure (78% vs 72%), worse NYHA class III (60% vs 51%), differences mainly found in females receiving ICDs. Females have more any adverse event (3.9% vs 3.0%) & major adverse events (1.4% vs 1.0%). The% of adverse events‐higher with screw‐in vs tined leads; females receiving tined leads in PMs or ICDs showed lesser major adverse events. Conclusion: In our center device related adverse events in females were multifactorial: Older age, higher% of comorbidities & risk factors, after adjusting these variables‐ smaller body size & anatomy such as thinner right ventricular wall, smaller blood vessel diameter; thus clear that screw‐in lead caused more adverse events in females vs males. Hence, choice of leads is a strong & independent factor associated with adverse events & one should exercise great efforts in choosing the leads especially in females. P143 ANTICOAGULATION PROTOCOLS FOR PERMANENT PACING IMPLANTATION: LESSONS TO LEARN? Sandhu K; Raju P; Ugni S; McIntosh R; Furniss S; Sulke AN; Lloyd GW; Patel NR Eastbourne District Hospital; East Sussex; England Please may we submit the following work to present as a poster at your conference?Introduction: High risk of complication in patients with anticoagulation is well recognised in patients undergoing permanent pacemaker implantation (PPM). We sought to investigate current practice in London and the South East. We focused on two different types of patient sub groups, those patient with atrial fibrillation and patient with metallic mitral valves. We looked at the number of days prior to device implantation warfarin was stopped, the INR that devices were implantations, what alternative anticoagulants were used prior to implantation after stopping warfarin and how soon after implantation warfarin was restarted. Method: A telephone survey of device implanting hospitals was undertaken in November 2009, detailing current practice with respect to anticoagulant use before and after implantation in two different sub groups. Results: 34 hospitals (London 22, South East 12), 27 NHS Trusts (London 19, South East 8) were sampled. Data was collected from registrars (19) and nurses (15) we have comprehensive images to reflect protocols in different hospitals that are within the same geographic region within the UK. Conclusion: Anticoagulant prescription protocol around PPM implantation varies widely in different NHS hospitals. The most common anticoagulant used before PPM was Enoxaparin in AF group and Unfractionated Heparin Infusion in MVR group. However no alternative anticoagulants were used in significant proportion in AF group before PPM but surprisingly an equal proportion had low molecular weight heparin in MVR group. In significant proportion of hospitals, anticoagulation was restarted after 24 hours in post PPM patients, which could increase the length of stay. It would be valuable to correlate complication rates with anticoagulation practice and produce guidance for a nationally agreed approach to anticoagulation in high risk groups. P144 SELECTIVE SITE PACING. IS IT BETTER TO STIMULATE THE LEFT THAN THE RIGHT VENTRICLE IN PATIENTS WITH CONVENTIONAL PACEMAKERS? Sapelnikov OV; Latypov RS; Grishin IR; Saidova MA; Akchurin RS Cardiology Research Center, Moscow Introduction: There are a lot of contradictory works dedicated to selective site pacing. Furthermore, BELIEVE and recent Bi‐LEFT trials showed no advantages of biventricular pacing in comparison with isolated LV‐pacing in patients with CRT‐indications. Materials: 4 groups of patients were included in this study. The 1st included 25 consecutive ventricular pacing lead implants in the interventricular septum (IVS), the 2nd – 14 patients with RVOT pacing, the 3d – 34 patients with right ventricle apex pacing and the 4th 8 patients with LV‐pacing. Patients in the last group were initially with LBBB. All the measurements were made after the procedure and in 6,12,24 months after the operation.In the period of study we observed the mean percent of ventricular pacing of 82 ± 5%. LV dyssynchrony was measured by means of Doppler investigation and tissue myocardial imaging (TMI). Results: Mean QRS duration in group 1 was 116 ± 11 ms before and 124 ± 14 ms two years after the procedure. In 2 group of patients these figures were 104 ± 10 ms and 120 ± 11 ms, and in 3 group of patients these figures were 106 ± 12 ms and 171 ± 15ms. In 4 group QRS‐duration was significantly wider (159 ± 15 ms before and 165 ± 14 ms after procedure), but the ECG pattern transformed from LBBB to RBBB. Immediately after implantation the values of electromechanical delay between IVS and left ventricle lateral wall (basal segments) were significantly higher during apical pacing (35 ± 5 ms in group 1, 30 ± 5 in group 2, 29 ± 5 group 4 and 54 ± 6 ms in group 3). In two years after implantation the difference between groups still was observed (38 ± 6 ms, 34 ± 5 ms, 27 ± 5 ms vs 68 ± 5 ms). Conclusions: The IVS and RVOT pacing allow an improvement in functional and hemodynamic parameters in acute study and shows stable effect in two years period of follow‐up. Despite of wider QRS‐duration, LV‐pacing demonstrates slightly lower parameters of interventricular dyssynchrony, especially in patients with initial LBBB. P145 POSSIBILITY TO SHORTEN PROGRAMMABLE AV DELAY BY CLOSER POSITIONING THE ATRIAL AND VENTRICULAR LEADS IN THE SEPTAL REGIONS Volkov D; Karpenko Y Institute of General and Urgent Surgery, AMS of Ukraine, Kharkov Objective: Fact of potentially negative effects of right ventricle's (RV) apical pacing on the pumping function is widely recognized in pacemakers (PM) practice. Strategies for overcoming this situation are using of alternative areas of implantation and special pacing algorithms. Nonetheless programming shortest possible AV delay (AVD) is preferring. The purpose of this study was checking the hypothesis that shortest paced and sensed AV‐conduction times recognized by PM are committed to a minimum distance between the electrodes in the right atrium (RA) and RV. Methods: The study included patients with Class I and II indications for DDD(R) pacing with intact 1:1 AV‐conduction during evaluation (n = 55, F‐21, age 65 ± 21). Patients with AV block II‐III degrees were excluded. Electrodes were implanted in four variants: RA appendage (RAA) – RV apex (RVA), n = 18; RAA – RV outflow tract (RVOT), n = 21; RA low septum (LAS) – RVA, n = 7; LAS – RVOT, n = 12. AV‐conduction defined as distance between PM channels' markers during RA sensing and pacing with programmed long AVD and three‐fold sensitivity threshold to RA and RV signals. Results: The electrodes were successfully implanted in all patients. AV conduction during RA sensing, ms: RAA – RVA 192 ± 40; RAA – RVOT 185 ± 32; LAS – RVA 156 ± 38; LAS – RVOT147 ± 35. AV conduction during RA pacing, ms: RAA – RVA 251 ± 37; RAA – RVOT 239 ± 44; LAS – RVA 215 ± 45; LAS – RVOT – 206 ± 39. Implantation of electrodes in the septal RA and RV areas led to a shortening of the AV conduction recognized by PM (LAS and RVOT positions). That was more dependent on the position of RA than RV leads. Conclusion: The position of the electrodes in the heart's chambers can influence the PM detection and thus AVD programming. Minimal distance between the electrodes at their location in the septal areas gave a combination of delayed detection in RA and stimulation the area close to the AV node and early detection in the RV. P146 IMPLANTABLE DEVICES‐RELATED INFECTI‐
ONS‐ANYTIME A POSSIBLE COMPLICATION? LONG TERM FOLLOW‐UP IN A SINGLE LARGE IMPLANTING CENTER Ciudin R; Mihaila M; Capraru C; Petre M; Bostan I; Ginghina C "C. Davila" University of Medecine, "C. C. Iliescu" Inst. of Cardiovascular Diseases Bucharest, Romania Infections involving implantable antiarrhythmic devices are often challenging to treat. Methods: From September 1997 to April 2010 we have implanted 4900 implantable devices and we identify from our records 36 patients (pts) presenting with late (>30 days following the implant) device‐related complications. Initial diagnosis of infection ranges from 30 days to 4.8 years following the primary implant, with a mean of 577 days. There were 18 male and the age group was 65,47 ± 17 years, ranging from 15 to 85 years old. Results: Device‐related late complications were diagnosed on 29 VVI, 3 DDD, 1 AAI pacemakers and 3 ICD (1 pt up‐graded to CRT‐D. In 5 pts there was a lead repositioning and in 3 pts a generator replacement. All the others were a primary implant.In 25 pts there was only a pocket related infection and in 9 pts we diagnosed as having an infective endocarditis (IE) as well. 2 pts had only IE. Staphylococcus Aureus (SA) was a probably cause for infection in 50% of the pts, in 21.3% methylino‐resistant SA was identify, Gram negative bacteria in 21.3% and Staphylococus epidermitis in 7.4%. Our treatment had included antibiotics for a mean of 10 days, device explantation for 16 pts and reimplantation on the other side in 11 pts, subpectoral in 4 pts and same site 1 pt. In 9 pts were extracted the leads as well. 4 pts with IE received a tricuspid prosthesis and the others epicardial leads. There were 2 postsurgery deaths. Late device‐related infections rate in our group was 0.73%. Implanted Cardioverter Defibrillators Devices‐related infections can complicate anytime a pacemaker/ICD implant. Incidence in our study was 0.73%. Treatment of device infections is often difficult to achieve and needs individualised hybrid antibiotics, intervention or surgical approach. P147 SUBCLAVIAN VEIN OBSTRUCTION IN PATIENTS WITH PERMANENT PACEMAKER Murat Y; Serdar B; Erdinç A; Selim E; Erdal G; Sefa S; Nursen P İzmir Atatürk Teaching Hospital Introduction: The number of patients with permanent pacemaker has increased exponentially recently. Complications associated with the implantation procedure are uncommon, but also include venous thrombosis. Device‐associated venous thrombosis generally presents as unilateral arm edema. Treatment includes extremity elevation and anticoagulation. Venous thrombosis at the access site may be silent and may be detected during re‐implantation of a new lead due to lead failure or infection. This study investigated the incidence of silent venous thrombosis in patients who underwent pacemaker re‐implantation for various reasons. We also investigated risk factors for venous thrombosis in this patient population. Method: Fifty‐three patients who underwent pacemaker pulse generator and/or lead reimplantation in our institution were enrolled between 2007–2010. Prior to exchange procedure, patients underwent subclavian venography through the ipsilateral cubital vein. Results: Complete obstruction of the ipsilateral subclavian vein was detected in 5 patients. Of these 5, only 2 patients required implantation of a new pacemaker lead. Ipsilateral venous puncture was thought impossible in these patients. In these patients, pacemaker system was removed and reimplantation was performed through the contralateral subclavian vein. Comparison of basal characteristics of patients with or without subclavian vein obstruction (SVO) revealed nonsignificant difference. There was not significant difference between patients with or without SVO according to age, gender, number of previous replacements, number of leads, systolic function, Concomitant antiplatelet and anticoagulant medications were found comparable in both groups. Significantly increased history of pacemaker pocket erosion incidence was found in patient group with SVO (P < 0.05). Conclusion: The results of this preliminary study demonstrates that prior pacemaker pocket erosion creates a predisposition for ipsilateral SVO. P148 THE PREDICTOR FOR ATRIAL PACING DEPENDENCY AND NEED FOR RATE RESPONSE FUNCTION IN PATIENTS WITH HEART BLOCK Suga C; Hirahara T; Sugawara Y; Nakajima J; Wakaba H; Ako J; Momomura S Department of Cardiology, Jichi Medical University Saitama Medical Center, Saitama, Japan Background: Even patients with heart block (HB) sometimes develop to atrial pacing dependency suitable for rate response function. The purpose of this study was to determine if there was any predictor for atrial pacing dependency in HB patients. Methods: This study included 145patients (64males, mean age 71.7 ± 9.1 years) undergoing a dual chamber pacemaker (PM) implantation for sinus node dysfunction (SND) or HB from 2008 to July, 2010. Atrial pacing dependency at 6 months after PM implantation was compared between SND and HB. We compared patient characteristics, atrial rate, blood pressure (BP), echocardiographic measurements before PM implantation, lead location, and lower pacing rate according to atrial pacing dependency ≥20% or <20% in HB patients. Results: Though the number of HB patients with atrial pacing dependency ≥20% (39.8%) was fewer than SND patients (87.1%, P < 0.0001), 10.8% of HB patients had ≥50%, and 3.6% had ≥80% atrial pacing dependency. There were no significant differences between HB patients with atrial pacing dependency ≥20% and <20% in patient characteristics, BP, LV dimension, LVEF, and ventricular lead location. HB patients with atrial pacing dependency ≥20% had greater LAD (46.4 ± 5.5 vs 42.0 ± 6.9[mm], p = 0.0038), faster atrial rate (82.9 ± 13.7 vs 73.9 ± 14.3[bpm], p = 0.0055), more frequent RA appendage lead placement (72.7 vs 46%, p = 0.016), and greater lower pacing rate (60.6 ± 2.4 vs 58.8 ± 3.3[bpm], p = 0.0082). Multivariate analysis showed that LAD (OR: 0.907, 95%CI: 0.827–0.995, p = 0.0391), atrial rate (OR: 1.05, 95%CI: 1.002–1.1, p = 0.0408), and atrial lead location (OR: 0.253, 95% CI: 0.074–0.861, p = 0.0278) were independent predictors for atrial pacing dependency. Conclusions: A considerable number of HB patients developed atrial pacing dependency. HB patients who had enlarged LA and relatively slower atrial rate prior to PM implantation may develop to atrial pacing dependency and may benefit from rate response function. P149 A TECHNIQUE FOR IMPLANTING A RIGHT VENTRICULAR ELECTRODE IN PATIENTS SUFFERING FROM LEFT SUPERIOR VENA CAVA PERSISTENCE USING A CONVENTIONAL J GUIDE Mora G Universidad Nacional de Colombia Background: Locating pacemaker electrodes can become complicated by congenital abnormalities including alterations of the systemic upper veins, such as left superior vena cava (LSVC) persistence. Materials and Methods: The study was carried out from June 2001 to June 2009 involving all patients who were admitted to the Hospital Universitario Mayor, Instituto de Corazon de Bogota and Hospital Universitario Clinica San Rafael (Bogota‐Colombia) to have a pacemaker or cardiac defibrillator implanted. LSVC was diagnosed by fluoroscopic observation (anterior‐posterior view) of the course of the guide. The following technique was used for gaining access to the right ventricle. The electrode was initially introduced with a straight guide as far as the right atrium, this was then changed for a J guide and the electrode was pushed towards the lateral or anterolateral wall of the RA. The electrode tip was thus lying against the tricuspid valve. Once in this position, the guide was withdrawn 3–5 cm and the tip passed spontaneously into the right ventricle. If it were wished to leave it in the apex, then an anticlockwise rotation would have been needed before withdrawing the guide; on the contrary, if it were wished to place it in the septum or in the outflow tract, then it would have had to be rotation clockwise. Results: A total of 1,048 patients were admitted for pacemaker or cardiac defibrillator implant during the 8‐year study period, 974 received a left subclavian venous approach. There were 508 males and 466 females. LSVC persistence was found in four patients (0.46%) Fluoroscopy time for implanting the ventricular electrode ranged from 1 to 4 minutes, 40 to 92 minutes being taken to complete the whole procedure. Conclusions: We present a simple and rapid technique for electrode placement in patients with LSVC using usual J guide and active fixation electrodes with good success. P150 PACING IN TRICUSPID PROSTHESIS PACIENTS – WHAT ARE THE IMPLANTING OPTIONS? A 9 PATIENTS SERIES EXPERIENCE FOLLOW UP Ciudin R; Bolog M; Capraru C; Mihaila M "C Davila" Univ of Medecine, "C C Iliescu" Instit of Cardiovascular Diseases, Bucharest, Romania Tricuspid prosthesis (TP) patients (pts) having bradyarrhythmias pacing indication represent a difficult option for implanting technique. We present a such 9 pts series in whom we had to choose the implanting technique according with the underlying heart disease. Methods: There were 4 male and 5 women, mean age of 43.4 yars old (range from 24 to 61 years) in whom a TP was implanted for valvulopathy (mitral and TP 3 pts; aortic, mitral and TP 1 pt; TP only in 2 pts) and 3 pts receiving TP following infective endocarditis. Results: 5 pts had metallic TP and 4 pts tricuspid bioprosthesis (TbP). In all pts with TbP we implanted a trans TbP active fixation lead into the right ventricle. 2 Pts with TP have received a coronary sinus (CS) lead for left ventricle pacing and one pt a CS lead following a surgical implanted epicardial lead high threshold. 2 pts had only a surgical epicardial right ventricle lead. During our series follow‐up 1 pt had a high threshold in an active fixation trans TbP right ventricle lead and had to be replaced and 1 pt with CS lead had an intermittent high threshold. Conclusions: Choosing the implanting technique in tricuspid prosthesis pts is not an easy option and it depends of TP type and underlying cardiac diseases. Technical pacing problems could complicate evolution of pts with TP. P151 PATIENT PROFILE AND IMPLANTATION TRENDS IN RECIPIENTS OF PACEMAKERS AND IMPLANTABLE CARDIOVERTER DEFIBR‐
ILLATORS IN INDIA AT OUR INSTITUTE: 2006–2011 Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Early clinical success and advances in technology in implantable cardiac rhythm management devices(pacemakers [PM] and implantable cardioverter defibrillators [ICDs])have resulted in expansion of indications with dramatic increase in access and utilization. The indications for pacemaker have also expanded beyond treatment of bradyarrhythmias to cardiac resynchronization therapy in patients (pts) with heart failure and electromechanical dyssynchrony. Objective: We evaluated trends in cardiac rhythm management device implantation. Trends in primary device implantation and burden of device replacement, defined as ratio of replacement procedures to total number of primary and replacement procedures for all pts from 2006–2011 were analysed. Methods: All pts receiving PM and ICD over a period of five years were studied. Results: Total 1900 pts and 604 pts received PMs and ICDs respectively; 1680 received primary PMs and 530 ICDs; there were 220 PMs and 54 ICDs replacement. Women comprised 29% of PM and 9% of ICD pts. The mean ICD replacement burden was 8.9% (range 4–12%)and that of PMs was 11.5%, (range 8.2–15.6%). ICD pts had more comorbidities than PM pts. Conclusions: Firstly, rate of implantation of ICDs in females in our population is lower than expected. Also, females were older with higher NYHA class. Secondly, there has been marked increase in rate of ICD implants.The ICD pts were older, with greater comorbidities, while age of PMs pts has remained stable, with slower rate of increase in comorbidities. Analysis also revealed that replacement burden for PMs has remained constant, while that for ICDs has decreased, which may be ascribed to relative stability of the patient receiving PMs and on the other hand expanding indications for ICD implantation,resulting in increased number of primary ICD implants.These data suggest that monitoring is required, given the changing populations, their disparate clinical outcomes, and implications to the health care system. P152 EPICARDIAL DUAL CHAMBER PACEMAKER (DDD) IMPLANTATION WITHOUT STERNO‐
TOMY IN INFANCY Mitropoulos F; Tsoutsinos A; Kiaffa M; Rammos S Onassis Cardiac Surgery Center Congenital complete heart block (CHB) is a rare conduction anomaly occurring in 1/11.000 to 1/20.000 live births. The most common association is with maternal systemic lupus erythematosus. Usually the surgical strategy for epicardial dual chamber pacemaker implantation include sternotomy or partial lower sternotomy. We report the implantation of epicardial pacemaker in an 18 months old female infant, with CHB, without sternotomy, or cardiopulmonary bypass. Materials and Methods: The infant was born with complete heart block, (minimum heart rate 45 beats per minute) and normal cardiac anatomy. Gradually she developed symptomatic bradycardia (heart rate 25–45) with ventricular dysfunction. Through a 5cm curvilinear skin incision the pericardium was opened and the heart was visualized. The sternum was elevated with a retractor and the diaphragmatic surface or the right ventricle was exposed. An epicardial steroid eluding unipolar ventricular electrode was sewn through diaphragmatic surface of the right ventricle with 5–0 prolene. Then the right atrium was retracted in a caudal direction and a unipolar electrode was sawn to the right atrial appendage with 5–0 prolene.Through the same incision a pocket was created in the left upper quadrant below the left rectus abdominis muscle and a St. Jude generator was implanted. The infant tolerated the procedure without any hemodynamic compromise. The infant remained one day in the CTICU and she was discharged on postoperative day 5. At the first pacemaker check after implantation the parameters measurements were good. Conclusion: Non sternotomy, dual chamber epicardial pacemaker implantation can be achieved. Although technically more challenging it is feasible and safe and the aesthetic result is very gratifying. P153 PERMANENT PACING IN PATIENTS WITH PROLONGED ASYSTOLE AT THE HEAD UP TILT TEST Santini L; Capria A; Papavasileiou LP; Scarfò IS; Smurra F; Viele A; Schirripa V; Magliano G; Forleo GB; Romeo F Cardiology Department, University of Tor Vergata, Rome, Italy Introduction: Dual chamber pacemakers with rate drop response pacing algorithm (DDDR‐RDR) may be a therapeutic option for neutrally mediated cardioinhibitory syncope assessed trough a positive Head‐up tilt test (HUTT) in patients older than 40 years with a history of syncope. Aim of our study was to evaluate the outcome of such a therapeutic strategy. Methods: We selected 22 patients who underwent HUTT, aged 42–70 years. Patients were divided into two groups. Group A: 11 pts with cardioinhibitory syncope (asystole >4 seconds or atrio‐ventricular dissociation with heart rate lower than 30 bpm) addressed to PMK implantation; Group B: 11 pts with a milder cardioinhibitory response, in this group conservative treatment was preferred. A clinical follow‐up was performed after three years. Results: 9 pts in the group A accepted PMK implantation, 2 pts preferred conservative treatment. In patients with PMK cumulative atrial pacing was found to be greater than ventricular pacing (AP 40.28 vs 3.5% VP, P < 0.05). In addition, 254 episodes of rate drop response were adequately recognized and treated. Follow‐up was concluded in 67% of PMK pts. None of them presented new episodes of syncope. Regarding patients left with conservative treatment, follow‐up was concluded in 11 pts: syncope occurred in 3 pts; 2 patients were lost in the follow‐up. Conclusions: The higher percentage of cumulative atrial pacing shows in the more severe patients group a basal vagal hypertonic pattern which modulates sinus node function but not affecting the basal AV conduction. DDDR‐RDR pacing is a valid and effective option in selected patients with history of neurally mediated syncope and a severe tilt test‐induced cardioinhibitory syncope. Patients with a milder cardioinhibitory response at the HUTT seem to have a good response to conservative treatment. P154 AN UNUSUAL CAUSE OF CHRONIC INFECTIVE ENDOCARDITIS FOLLOWING A PACEMEKER IMPLANT‐AN ACHILE'S TENDON PROSTHESIS ABSCESS Ciudin R; Avram AM; Arama V "C Davila" Univ of Medecine, "C C Iliescu" Instit of Cardiovascular Diseases, Bucharest, Romania Device‐Related infection are often challenging as primary cause and there treatment is not always easy. We present a 67 years old male patient with 18 months history of fever and antibiotic treatment for infective endocarditis following his DDD pacemaker implant. He had undergone 4 previous pocket interventions with no obvious results. During his admission in our center the patient was stil having positive blood cultures with Gram negative germs including Pyocianic, recurrent septicemia, dermatitis and urinary infection. Pacemaker was removed and the 2 leads were extracted mechanically. We implanted a new system on the other side after antibiotic therapy but after a relatively afebrile period of 45 days he came back with recurrent fever. During his second admission we identified a local Achille's tendon abscess where the pt had a plastic orthopedic prosthesis many years before the implant. The abscess was opened, clean and debridment of inflammatory tissue was done. He had a very good recovery following his new antibiotic treatment. Conclusion: Unusual metastatic infection sites or abscesses could be the cause of recurrent infection or endocarditis resistant to antibiotic therapy in pts with device‐ related infections complications. P155 ROLE OF AF PREVENTIVE PACING ALGORITHMS IN LONG TERM MAINTENANCE OF LOW AF BURDEN AS PART OF HYBRID THERAPY IN SICK SINUS SYNDROME Simeonidou E; Papandreou A; Spyroulias G; Varounis C; Dagres N; Anastasiou‐Nana M; Manolis AS 2nd University Cardiology Dept, Attikon Hospital, Athens, Greece Among the non‐pharmacologic therapeutic modalities for management of atrial fibrillation (AF), atrial pacing for AF prevention presented an attractive strategy. Because of limited data regarding its long‐term impact, it still remains as controversial pacing indication. Aim of the study was to determine the long‐term efficacy of preventive pacing algorithms (AFPPA)on AF burden (AFB) in patients (pts) with sick sinus syndrome (SSS) and drug refractory paroxysmal AF. Methods: Study population: 51 pts (10 w, 41 m), mean age 61 ± 9 yrs with SSS, who apart from conventional indications of pacing suffered frequent episodes of AF, refractory to at least 2 antiarrhythmics (AAMs) and they received a PPM with incorporated AFPPA plus AAMs, group A. Another 51 pts (41m) with SSS and frequent AF, who received a conventional DDDR plus AAMs served as controls, group B. Mean LA:43 ± 8 mm. Atrial pacing LR was programmed at 70 bpm. There was an effort to promote native AV conduction by relevant pacing settings. Different AFPPAs were activated in each pt according to the AF onset mechanism. All pts underwent fu in regular basis and interrogation of the stored diagnostic AF data every 6 mos. AFB overtime was compared annually in the same group and between the 2 groups. Two‐way ANOVA for repeated measurements was used to assess the effects of AFPPA on AFB in the 2 groups. Logarithms were used for non‐normally distributed AFB. Results:Average time of fu: 50 ± 8 mos. Five pts in A 10%) and 10 pts (22%) in B group were progressed to permanent AF. Median AFB in A and B groups at baseline, 1 yr and 4 yrs were 3.0, 1.0, 1.2 h/day and 3.8, 3.2, 6.8 h/day respectively and differed between both groups over time (F = 15.88, P < 0.001. AFB improved significantly in the 1st yr only in group A and after 4 yrs deteriorated significantly only in group B. Conclusions: Although AFPPAs efficacy is slightly reduced over time they are useful in AF management of selected SSS pts, as part of hybrid therapy. PUBLIC HEALTH ISSUES P156 TRANSESOPHAGEAL ELECTROPHYSIOLOGICAL STUDY AND PACING – STILL THE OPTION FOR EMERGING COUNTRIES? Volkov D Institute of General and Urgent Surgery of Ams of Ukraine Background: Endocardial EP study and catheter ablation of supraventricular arrhythmias are the golden standards of medical care nowadays. Transesophageal electrophysiological study (TEEPS) and pacing (TEP) couldn't be an alternative, but useful supplement, especially in centers where EP service is absent or not fully available. Atrial flutter (AFl) is second common arrhythmia after atrial fibrillation (AFib), catheter ablation is the first line therapy for typical AFl, but there're a lot of local restrictions in Ukraine to apply this method widely. TEP can be used to interrupt AFl. Methods: We've been using CardioLab+ system (XAI Medica, Ukraine) for TEEPS and TEP by programmed and rapid pacing successfully in 293 tachycardia patients (pts) over last 5 years. Among them TEP for AFl were done in 95 pts (typical AFl – 76 pts). Diagnosis were established based on regular and transesophageal ECGs, AV conduction gaps, RP intervals during tachycardia and patterns of initiations and cessations by pacing and drugs. Results: AFls were converted to sinus rhythm in 86% of pts. 1) cardioversion to sinus rhythm during procedure – 61 pts; 2) induction of AFib with restoration of sinus rhythm up to 2 days – 21 pts; 3) induction and persistence of AFib – 6 pts; 4) recovery of AFl – 7 pts. Most unsuccessful results occurred in atypical AFl's pts. In remaining 198 pts different types of existed tachycardia were evaluated depending on listed above criteria of differentiation: AVRT – 91, AVNRT – 96, ectopic atrial tachycardia – 3, AFl and Afib – 8. No complications were observed. Near a half of pts had catheter ablations afterward. Conclusion: TEEPS is very cheap and useful tool for initiation and investigation of supraventricular arrhythmias in pts with non‐documented palpitations to establish indication for catheter ablation and to control its efficacy if needed. TEP is safe and effective instrument of sinus rhythm restoration in pts with AFls. P157 INTERACTION OF PORTABLE METAL DETECTOR USED IN AIRPORT CONTROLS WITH IMPLANTABLE PACEMAKERS AND CARDIO‐
VERTER DEFIBRILLATORS Tzeis S; Andrikopoulos G; Jilek C; Rassias I; Kolb C; Theodorakis G Cardiology Department, Henry Dunant Hospital, Athens, Greece Aim: Proper function of pacemakers (PMs) or implantable cardioverter‐defibrillators (ICDs) may be impaired due to interaction with electrical devices. Portable metal detectors generate an electromagnetic field that may interfere with PMs or ICDs. In the present study we sought to investigate whether a commercially available portable metal detector routinely used in airport controls interacts with PMs and ICDs. Methods: A total of 75 patients (28 ICD and 47 PM recipients) were tested with and without telemetry communication for electromagnetic interference when exposed to the electromagnetic field generated by a portable metal detector (PD140V – magnetic field Br.m.s. 2.71 μT, electric field Er.m.s. 2.2 V/m) placed over the implanted system under continuous ECG recording. Results: No interference with proper device function (sensing and pacing) was observed in any of the 75 patients tested. Telemetry interference was observed in 83% of patients with 12% of patients presenting a "pseudo‐oversensing" type of telemetry interference (noise recording on online print‐outs without impairment of proper pacing function documented with continuous ECG recording), 59% presenting loss of detection and 12% presenting both types of telemetry interference. Conclusion: Routinely used hand‐held metal detectors may frequently cause telemetry interference with ICDs and PMs without though interfering with proper device function. These findings support the safety of using portable metal detectors for control of PM and ICD recipients. SUDDEN CARDIAC DEATH P158 MULTIRESOLUTION WAVELET ANALYSIS OF HEART RATE VARIABILITY RISK STRATIFIES HEART FAILURE PATIENTS FOR BOTH SUDDEN CARDIAC DEATH AND TOTAL MORTALITY Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Aggelis A; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To evaluate the performance of non‐invasive predictors in arrhythmia risk stratification of heart failure patients (pts). Methods: We prospectively screened 230 patients (age: 64.5 ± 13.4 years, male: 83%, NYHA class: 2.3 ± 0.5, LVEF:32.6 ± 10.1, CAD: 82%,DCMP: 18%) with ECG, SAECG, ECHO and 24‐hour HOLTER. After 17 ± 16.1 months of follow up, pts were classified into the High risk (52 pts, mean Left Ventricular Ejection Fraction (LVEF): 29 ± 10.2%) and the Low risk (174 pts, mean LVEF:33.7 ± 9.9%, p = 0.003) groups according to three SCD surrogates: 1. clinical VT/VF (17 pts) 2.ICD's appropriate activation (22 pts) 3.confirmed SCD (13 pts).Total mortality (TM) was also considered as an end point and 37 deaths were recorded (arrhythmic = 13, pump failure = 17, non cardiac = 7). LVEF, filtered QRS (SAECG), NSVT > 1/24 hours, VPBs > 240/24 hours, Decelaration Capacity (DC) of heart rate, mean Heart Rate (HR), SDNN/HRV, QTc and the scale dependent wavelet‐ coefficient standard deviation [σwav (m)] of multiresolution wavelet analysis (MWA – Haar 8) of HRV were calculated and statistically analyzed for the two groups. Results:σwav (m) was a statistically significant predictor of SCD (Long rank test p = 0.0006). After Cox regression analysis adjusted for LVEF, gender, fQRS, NSVT episodes >1/24hours, VPBs > 240/24 hours, DC, HR, and SDNN, the σwav (m) remained an important and independent SCD predictor with HR:0.991 (P < 0.001) 95% CI: 0.986–0.995. Considering TM as end point σwav (m) was again a statistically significant predictor of TM (Long rank test = 0.0001) and after a new analysis of the same multivariable Cox model for TM, σwav(m) remained an important and independent TM predictor with HR: 0.990 (p = 0.003) 95% CI:0.983–0.996. Conclusions: In this heart failure pts cohort with a short term follow up, σwav (m) was an important and independent predictor both for SCD and TM. P159 PROGRAMMED VENTRICULAR STIMULATI‐
ON AS COMPARED TO THE NON INVASIVE RISK STRATIFIERS FOR SUDDEN CARDIAC DEATH PREDICTION AMONG SEVERE HEART FAILURE PATIENTS Gatzoulis K; Arsenos P; Dilaveris P; Gialernios T; Kartsagoulis E; Sideris S; Archontakis S; Tsiachris D; Aggelis A; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To examine the prediction ability of VT/VF inducibility on Programmed Ventricular Stimulation (PVS) for Sudden Cardiac Death (SCD) among Heart failure (HF) patients (pts). Methods: We screened 114 HF pts (age: 67 ± 11 years, male: 83%, LVEF: 29 ± 9.5, NYHA: 2.4 ± 0.5, CAD: 72%, DCMP: 28%) under optimum treatment with ECG, SAECG, ECHO and 24 hour HOLTER. All pts underwent also a PVS. After 14.1 ± 12.6 months of follow up the sample divided to the HIGH risk (24 pts) and the LOW risk (90 pts) groups according to three SCD events/surrogates: 1. clinical VT/VF 2. ICD's appropriate activation 3. confirmed SCD. Data calculated and statistically analyzed for the two groups. Results:HIGH RISKLOW RISKp(n = 24)(n = 90)valueLVEF (%)27.9 ± 9.5 30.3 ± 10.00.2QRS (ms)120 ± 33125 ± 320.6FQRS (ms)146 ± 29146 ± 300.9QTc (ms)471 ± 51469 ± 570.9Heart Rate69.7 ± 9 69.9 ± 9 0.9NSVT (episodes nb) 4.2 ± 7.7  22.2 ± 107.30.4VPBs (nb) 1483 ± 3355 2437 ± 41390.3VT/VF on PVS (nb/%)18 (75%)46 (51%) 0.03 After multiple logistic regression analysis adjusted for male, age, LVEF, and VT/VF on PVS the only independent and important SCD predictor was VT/VF inducibility on PVS with OR: 3.101 (p = 0.03, 95%CI: 1.101–8.731). Conclusions: In this small and preliminary HF sample the non invasive risk factors from electrocardiography and echocardiography failed to predict SCD on medium term follow up. On the contrary the induction of VT/VF on PVS was the only significant SCD predictor with sensitivity 75% and specificity 48%. P160 NORMOBARIC INTERMITTENT HYPOXIA TRAINING AS A METHOD OF SUDDEN CARDIAC DEATH PRIMARY PREVENTION IN THE PATIENTS WITH ISCHEMIC CARDIO‐
MYOPATHY Dubovik TA; Rachok LV; Shket AP; Khudnitskaya VS Republican Scientific and Practical Center of Cardiology The purpose of this research was to study the efficiency of using a course of normobaric intermittent hypoxia training (NIHT) before coronary bypass surgery (CABG) in the patients with ischemic cardiomyopathy (ICMP) and chronic heart failure (CHF) and its influence on the character of reperfusion complications and life‐ threatening arrhythmias development. Materials and Methods: Cohort of 60 patients with ICMP (n = 30 in the main and control groups) were included into the research. All patients had depressed left ventricle systolic function (LVEF) less than 35%. The main group patients underwent a NIHT before CABG. The indications for CABG were the presence of myocardium more than 50% with accumulation radiopharmaceutical over 50% during SPECT with 99 mTc‐MIBI. Functional state of LV was assessed by means of echocardiography and daily monitoring of the electrocardiogram. Results: The initial CHF severity of the patients in both groups was determined by depressed LVEF against the prevalence of sympathetic activity nervous system (NS). After a course of NIHT a shift in autonomic balance towards the prevalence of parasympathetic NS was marked (RMSSD increased from 28,6 ± 4,5 ms to 58,22 ± 6,1, p <0,05) as well as a reduction in the number of ventricular arrhythmias (VA) against the microcirculatory processes improvement. The main group were characterized with a more favorable recovery during the perioperative period after CABG. We revealed less frequent of ventricular fibrillation during cardiac resuscitation after artificial circulation, reduction of VA and high grade VA in the perioperative period in the main group. Conclusion: For the patients with ICMP and CHF with adequate mass of a viable myocardium, CABG is effective in SCD primary prevention. The use of NIHT in the preoperative period can increase the volume of the viable myocardium and thus helps to protect from reperfusion injury during CABG and provides a more favorable recovery during the perioperative period. P161 RISK STRATIFICATION OF SUDDEN CARDIAC DEATH IN PATIENTS WITH DILATED CARDIOMYOPATHY Vaikhanskaya TG; Melnikova OP; Gul LM; Frolov AV Republican Scientific and Practical Center of Cardiology, Minsk, Belarus Dilated Cardiomyopathy (DCM) is associated with risk of sudden death due to malignant ventricular arrhythmias. Objective: assessment of Holter monitoring predictors of life‐threatening ventricular arrhythmias (LTVA}: microvolt T‐wave alternans (mTWA) and heart rhythm turbulence(HRT) in patients (pts.) with nonischemic DCM. Materials and Methods: 67 pts. with DCM were examined (10,4% females, aged 44,3 ± 11,7 years) by Holter 24‐h (Oxford) and 7‐minute ECG recording (Intecard‐7, including 3 min of exercise test (25 Wt/m). Microvolt TWA detected by the software Intecard‐7 on a method modified moving average in 3 lead of ECG‐12 at exercise test. Results: Heart rhythm ventricular dysfunctions were revealed at 29 (43,3%) pts. with DCM: nonsustained ventricular tachycardia(VT)‐28 pts., sustained VT(1 pts.). On the basis of the received data the step‐by‐step discriminant analysis by which results following independent indicators have been included in mathematical model has been carried out: mTWA ≥ 56 mcV, pathological HRTS < 2,5 ms/RR, presence syncope and extQTc. For definition of risk LTVA for patient with DCM already at the first inspection it is possible to use classification equations. Definition of high risk LTVA for the individual patient is spent by substitution of the received indicators to each of two equations. The patient gets to that group for which classification function has the greatest value. Thus, the classification equations for risk revealing of LTVA in patients DCM look like: HI = 0,9 × mTWA+7,9 × HRTS + 7,3 × Syncope + 6,3 × QTc–31. Hit of the patient in 1 group testifies to high risk LTVA and more adverse forecast. Such category of patients is potential candidates for ICD/CRT‐D. Hit of the patient in 2 group testifies to more favorable forecast and low risk LTVA: LII = 0,6 × mTWA + 3,6 × HRTS + 9,2 × Syncope + 5,6 × QTc–42. In conclusion, sudden death risk stratification is of utmost importance for DCM as it is the main cause of death related to this disease. P162 REDUCED RMSSD FROM HEART RATE VARIABILITY ANALYSIS RISK STRATIFIES HEART FAILURE PATIENTS FOR SUDDEN CARDIAC DEATH Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Sideris S; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To estimate the performance of non invasive arrhythmia predictors in the risk stratification for sudden cardiac death (SCD) of heart failure (HF) patients (pts). Methods: We prospectively screened 230 pts (age: 64.5 ± 13.4 years, male: 83%, LVEF: 32.6 ± 10.1, NYHA class: 2.3 ± 0.5, CAD: 82%, DCMP: 18%) with ECG, SAECG, ECHO and 24 hours HOLTER. After 17 ± 16 months of follow up, pts were classified into the High risk [52pts, mean left ventricular ejection fraction (LVEF): 29 ± 10.2%] and the Low risk group (174 pts, mean LVEF: 33.7 ± 9.9%, p = 0.003) according to three SCD events/surrogates: 1. clinical VT/VF (17 pts) 2. ICD's appropriate activation (22 pts) 3. confirmed SCD (13 pts). LVEF, the filtered QRS (SAECG), NSVT episodes > 1 /24hours, VPBs > 240/24 hours, mean heart rate (HR), RMSSD and SDNN from heart rate variability (HRV) [24 hour HOLTER], were calculated and statistically analyzed for the two groups. Results: RMSSD was a statistically significant predictor of SCD (Long rank test p = 0.01). Furthermore after Cox regression analysis adjusted for LVEF, fQRS, NSVT>1/24 hours, VPBs > 240/24 hours, mean HR and SDNN, the RMSSD remained an important and independent SCD predictor with HR 0.974 (p = 0.01) 95% CI: 0.955–0.993. A cut off point of RMSSD < 46 (75th percentile) presented HR 2.491 for predicting SCD (p = 0.05) 95% CI: 0.969–6.405. Conclusions: In the present HF pts cohort with a short term follow up, RMSSD performed better (logrank p = 0.01) than the most commonly used SDNN (longrank p = 0.05) and it was an important and independent predictor of SCD. Further evaluation of the reduced RMSSD is guaranteed. P163 PREVALENCE OF RISK FACTORS OF SUDDEN CARDIAC DEATH IN TRYPANOSOME CRUZI SEROPOSITIVE PATIENTS Mora G Universidad Nacional de Colombia Chagasic patients with heart disease are at risk of sudden cardiac death (SCD) and sometimes it may be the first manifestation of the disease. The aim of this study was to assess the prevalence of some risk factors for MCS among carriers of antibodies to T. Cruzi with and without heart disease. Methods: 8 patients without heart disease taking (normal electrocardiogram and echocardiogram) were compared with 26 patients with heart disease. Echocardiogram was evaluated, number of premature ventricular contractions, heart rate variability determined by the SDNN, presence of ventricular extrasystoles and polymorphic duplet. Results: No significant differences were found in the different variables evaluated except for the number of extrasystoles in 24 hours (66 vs 369 p = 0.0084), being more common in patients with heart disease. Conclusions: factors commonly described as predictors of SCD are very common in patients with antibodies to T. Cruzi with or without heart disease. The only variable with a significant difference was the number of extrasystoles in 24 hours. P164 RISK STRATIFICATION USING MICROVOLT T‐WAVE ALTERNANS IS NOT FEASIBLE IN A LARGE PERCENTAGE OF POTENTIAL ICD RECIPIENTS Kraaier K; Wilde AAM; Scholten MF Medisch Spectrum Twente, Enschede, The Netherlands Purpose: Previous studies have demonstrated that microvolt T‐wave alternans (MTWA) screening in patients with ischemic and non‐ischemic cardiomyopathy is effective in identifying patients at high or low risk for sudden cardiac death. In this study we evaluated the feasibility of MTWA testing using an exercise protocol in the risk stratification of potential ICD recipients with ischemic or dilated cardiomyopathy. Methods: Medical charts of 180 primary prevention ICD recipients were reviewed to decide if patients were able to perform a MTWA exercise test or not. Contra‐indications for testing were: atrial fibrillation or flutter, pacemaker‐dependency, recent (cardiovascular) surgery (<1 month) and inability to exercise. Results: Fifty‐eight (35%) of the potential ICD recipients were not suitable for testing. Among which; 35 patients were excluded due to atrial fibrillation, 13 patients due to recent surgery, 6 patients due to co‐morbidity (NYHA class IV, paralysis or absence of lower extremities, balance problems, AVblock), and 3 patients due to pacemaker dependency. Conclusion: In several studies MTWA testing is a promising risk stratifier for predicting sudden cardiac death, however, 35% of the potential ICD candidates is not suitable for MTWA testing using an exercise protocol. Therefore alternative methods to estimate MTWA and their clinical value must be studied. P165 HOLTER DERIVED QTC INTERVAL RISK STRATIFIES HEART FAILURE PATIENTS FOR SUDDEN CARDIAC DEATH Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Sideris S; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To estimate the performance of current non invasive arrhythmia risk stratifiers in the prediction of sudden cardiac death (SCD) in heart failure (HF) patients (pts). Methods: We prospectively screened 230 pts (age: 64.5 ± 13.4 years, male: 83%, LVEF: 32.6 ± 10.1, NYHA class: 2.3 ± 0.5, CAD: 82%,DCMP: 18%) with ECG, SAECG, ECHO and 24‐hour HOLTER. After 17 ± 16 months of follow up, pts were classified into the High risk [52pts, mean left ventricular ejection fraction (LVEF): 29 ± 10.2%) and the Low risk (174 pts, mean LVEF:33.7 ± 9.9%, p = 0.003) groups according to three SCD events/surrogates: 1. clinical VT/VF (17 pts) 2. ICD's appropriate activation (22 pts) 3. Confirmed SCD (13 pts). LVEF, the filtered QRS (SAECG), the presence of NSVTepisodes> 1/24 hours, VPBs > 240/24 hours, mean Heart Rate (HR), SDNN from HRV and mean 24 hour QTc interval (24 hour HOLTER), were calculated and statistically analyzed for the two groups. Results: The Holter‐QTc was a statistically significant predictor of SCD (Long rank test p = 0.01). After Cox regression analysis adjusted for gender, LVEF, fQRS, NSVTepisodes > 1/24 hour, VPBs > 240/24 hour, mean Heart Rate and SDNN, Holter‐QTc remained an important and independent SCD predictor with HR 1.009 (p = 0.02) 95% CI: 1.001–1.017. A cut off point of QTc> 470ms (75th percentile) presented HR 1.825 for predicting SCD (p = 0.05) 95% CI: 0.993–3.335. Conclusions: In the present HF pts cohort with a short term follow up, Holter‐QTc was an important and independent predictor of SCD. Further evaluation of the Holter‐QTc in the prediction of SCD is guaranteed. P166 ARRHYTHMIAS IN NEUROMUSCULAR DISEASES: A Moroccan EXPERIENCE AND A LITERATURE REVIEW Bouhouch R*; Fellat I*; Zarzur J*; Oukerraj L*; Bennani R*; Birouk N**; Oudghiri FZ***; Cherti M* *Service de Cardiologie B, CHU Ibn Sina Rabat, MAROC Introduction: Neuromuscular Diseases are a heterogeneous molecular, clinical and prognosis group. Progress has been achieved in the understanding and classification of these diseases. Cardiac involvement in neuromuscular diseases, namely conduction disorders, ventricular arrhythmias and dilated cardiomyopathy with its impact on prognosis, is often dissociated from the peripheral myopathy. Therefore, close surveillance is mandatory in the affected patients. In this context, preventive therapy (beta‐blockers and angiotensin converting enzyme inhibitors) has been recently recommended in the most common Neuromuscular Diseases, Duchenne Muscular Dystrophy and Myotonic Dystrophy. Methods: We report a series of patients with neuromuscular diseases in whom we assessed cardiac involvement and initiated a therapy. From January 2007 to June 2011, 105 patients were referred to cardiology visit by a neurologist or pediatrician. Results: There were 49 female and 56 male with a mean age of 28 years old. Limb‐Girdle muscular dystrophies, Myotonic Dystrophy (MD), and Duchenne / Becker Muscular Dystrophy (DMD, BMD) are the major neuromuscular diseases in our series. Cardiac symptoms were found in 54 patients, ECG was often abnormal (96 patients): 41 patients had a conduction disorder, 42 patients had atrial or ventricular premature beats; Transthoracic Echocardiography found a left ventricular dysfunction in 10 patients. Therapy with beta‐blockers and angiotensin converting enzyme inhibitors was initiated in 37 patients and 5 patients required a Pace‐Maker or an Implantable Cardiovertor Defibrillator. Conclusion: A close collaboration between Cardiologists and referral physicians is mandatory for a better management of Cardiac involvement especially arrhythmias in patients with neuromuscular diseases. P167 MEAN HEART RATE FROM 24 HOUR HOLTER RECORDINGS PREDICTS TOTAL MORTALITY IN HEART FAILURE PATIENTS Arsenos P; Gatzoulis K; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Sideris S; Aggelis A; Stefanadis C; Apret First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To estimate Electrophysiological indices derived from non invasive Electrocardiographic and Echocardiographic screening as Total Mortality (TM) predictors for Heart Failure (HF) patients (pts). Methods: We screened 279 HF pts (age: 67 ± 13.0, male: 83%, NYHA: 2.4 ± 0.5, LVEF: 31.4 ± 10.1, CAD: 80%, DCMP: 20%) under optimum treatment and with ECG, SAECG, ECHO and 24 hour HOLTER (HM). After 14.8 ± 13.3 months of follow up 48 deaths occurred (Sudden Cardiac Deaths: 16, Pump Failure Deaths: 26, Non Cardiac Deaths: 6). Differences of non invasive markers between survivors and non‐survivors analyzed with Log rank test. The correlation of the non invasive markers with mortality was searched through survival analysis method utilizing Kaplan Meier – survival curves adjusted for possible confounders under building of appropriate Cox statistical models. Results: After Cox regression model analysis adjusted for gender, age, LVEF, VPBs/24 hour, NSVT episodes/24 hour, mean Heart Rate and QTc interval the only important and independent predictor of TM was mean Heart Rate(24 hour) presented HR: 1.044 (p = 0.007, 95% CI: 1.011–1.077). Conclusions: Mean Heart Rate predicted TM in HF patients importantly and independently of gender, age, LVEF, VPBs, NSVT and QTc. A cut off point of Heart Rate > 70.5 bpm (50th percentile) presented sensitivity 58% and specificity 51% for predicting TM. SUPRAVENTRICULAR TACHYCARDIAS P168 CASE OF A LATVIAN FAMILY'S ATRIOVENTRICULAR NODAL REENTRY TACHYCARDIA Kupics K; Jubele K; Kalinins A; Sipacovs P Paul Stradin's Clinical University Hospital We would like to describe a case of potentially hereditary AVNRT within one family. Only a very limited number of reports are available in the literature describing inherited cases of AVNRT. In Latvia such cases have not been reported yet. In this family a mother and her two sons suffered from arrhythmia episodes. All of these diagnoses of typical AVNRT were established using intracardiac electrophysiological study. The mother's father also had had an unspecified kind of arrhythmia. In both the son's father and his family members had never occurred any episodes of arrhythmia. The mother and both her sons had had no other comorbidities diagnosed. Only the mother had been on medication – metoprolol 50mg bid, but that therapy had not reduced the number of arrhythmia episodes. The first patient to be treated at out clinic was the younger son, aged 18 (patient no 1). In his case arrhythmias had been occurring for 2 – 3 years at that time. After the younger son's successful treatment, the mother also approached us. She was 51 years old (patient no 2) and has had arrhythmias for over 20 years. The symptoms had worsened after childbirths. The last patient from this family to be treated was the older son, aged 22 (patient no 3). He has had arrhythmias for approximately 2 months. The mother and both son's were treated using radiofrequency catheter ablation of the "slow pathway" of the atrioventricular junction. After one year of regular observation no arrhythmias have reoccurred. This case hints at the possibility that in some cases the reason for changes in the atrioventricular junction that are responsible for AVNRT could be inherited, possibly in the form of an autosomal dominant type. P169 3D NONINVASIVE MAPPING AND RESULTS OF CATHETER ABLATION OF TACHYARRHY‐
THMIAS Revishvili A; Sopov O; Dzhordzhikiya T; Simonyan G; Lyadzhina O; Fetisova E; Kalinin V Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia Introduction: We evaluated facilities of the novel 3D surface ECG based mapping technology in patients with different atrial and ventricular arrhythmias. Methods: Before procedure noninvasive mapping using 240‐lead ECG combined with CT scan based anatomy (Amycard, RUS) was performed in 102 patients. Among them 48 patients (mean age 36,3 ± 14,6 years) were with ectopic non‐ischemic ventricular arrhythmias (VT/PVC), 35 patients (mean age 32,8 ± 10,3 years) with WPW syndrome, 19 patients (mean age 39,4 ± 16,6 years) with ectopic atrial tachycardias. The findings were compared with invasive 3D mapping and successful radiofrequency ablation. Results: In 48 patients with ventricular arrhythmias (95,9%) a location of ectopic focus was similar to the invasive data and arrhythmia was successfully eliminated by single radiofrequency (RF) application. Two focal VT (4,1%) located in interventricular septum could not be accurately identified by noninvasive mapping. Clinical target coincided in 54 (100%) patients with WPW syndrome and atrial tachycardis and successfully terminated by RF ablation. Mean distance between noninvasive target and effective point of ablation was 3,8 ± 2,5 mm. Time of fluoroscopy in group of patients that underwent noninvasive mapping was significantly lower 4,1 ± 2,5 min in comparison with average 10,3 ± 4,9 min (P < 0,05). Conclusion: Initial experience with a novel noninvasive 3D mapping system shows its clinical utility in various arrhythmias, feasibility of accurately locating the target and significant reduction of fluoroscopy and procedure time. P170 DIFFERENCES IN ANATOMICAL LOCATION AND CONDUCTION PROPERTIES OF ACCESSORY PATHWAYS IN SYMPTOMATIC WPW PATIENTS WITH AND WITHOUT CLINICAL DOCUMENTED TACHYCARDIAS Pastor A; Leguizamón J; Zorita B; Panizo J; Jiménez S Hospital Universitario de Getafe (Madrid), Spain Radiofrequency ablation is the preferred treatment for symptomatic WPW syndrome. Clinicians have to face symptomatic WPW patients (P) but with non‐documented ECG clinical tachycardia (CTa), in whom some therapeutic doubts arise, especially in case of presumed high risk ECG appearance (midseptal/perihisian location). Purpose: Analyse the anatomical location and conduction capabilities of accessory pathways (AccP) in P with symptomatic WPW with and without documented ECG CTa before ablation. Methods: 100 consecutive symptomatic WPW P considered for ablation. Group A consisted of 56 P with documented ECG CTa and Group B, 44 P with symptoms of palpitations, dizziness or syncope, but without documented ECG CTa. Results: Left‐sided AccP was more frequent in group A compared to group B (60% vs 34%, P < 0.01). Septal location, was found more frequently in group B compared to group A (50% vs (28%, P < 0.05), being located close to AV conduction system (midseptal o perihisian) in 6 (14%) and 6 (11%) respectively. Only anterograde conductive AccP was found more frequently in group B than in group A (36% vs 5%, P < 0.02). Orthodromic tachycardia inducibility rate was similar in group A and in group B P with bidirectional conduction of AccP(92% vs 86%). Conclusion: 1. An important subset of symptomatic WPW P (44%) considered for ablation have not documented ECG CTa before the procedure, being septal location in half of these P. 2. Exclusive anterogradely conductive AccP were found more frequent in non‐documented ECG CTa group compared to documented ECG CTa group. 3. In non‐documented ECG CTa, bidirectional conductive AccP were present in 64% and had similar rate of inducible orthodromic tachycardia compared to documented ECG CTa group, maintaining indication for ablation in the majority of these P, although careful consideration if "high risk" WPW ECG profile (septal location near AV system) or anatomical difficulties are anticipated. P171 RESULTS OF ELECTROPHYSIOLOGIC TESTING IN CHILDREN WITH ASYMPTOMATIC WPW SYNDROME Ivanitskiy EA; Kropotkin EB; Tsaregorodtsev AP; Kasimtseva TA The Federal Centre of Cardiovascular Surgery The aim of this study was to find out the strategy of management of children with asymptomatic WPW syndrome. Methods: 20 consecutive patients were enrolled in the study, age 3 – 15 years. There were all typical features of preexitation on the surface ECG, and no registered paroxysms of tachycardia on surface ECG or symptoms of palpitation in past. 18 patients underwent catheter ablation of accessory pathway (AP) after previous electrophysiological study. All procedures were performed under the general anesthesia. Results: Anterograde conduction via accessory pathway more than 220 beats per minute (bpm) and effective refractory period (ERP) less than 250 ms were revealed in 15 patients. Anterograde conduction via AP less than 180 bpm and ERP more than 300 ms were seen in three patients. But retrograde conduction via AP in these three patients was more than 220 bpm, ERP was less than 250 ms. Atrioventricular reciprocating tachycardia was induced in 14 patients. Atrial flutter was induced in one patient with 1:1 conduction via AP. All these patients underwent catheter ablation of AP. No major complications were seen after catheter ablations. Conclusion: Indications for AP ablation were revealed in 90% of patients after previous electrophysiological study. Electophysiological study is a crucial moment for taking a decision to perform ablation of AP in children with asymptomatic WPW syndrome. P172 CARDIOMYOPATHY INDUCED BY PAROXYSMAL TACHYCARDIA – AN UNDERDIAGNOSED CLINICAL ENTITY Bogossian H; Ninios I; Karosiene Z; Pechlivanidou E; Mijic D; Kloppe A; Zarse M; Lemke B Klinikum Luedenscheid, Germany Introduction: Cardiomyopathy due to a sustained tachycardia is a common clinical entity. The detrimental effects of self‐terminating tachycardias, however, have been less thoroughly investigated. We examined the effects of interventional ablative therapy on the systolic left ventricular ejection fraction (EF) of otherwise healthy patients (P) with paroxysmal tachycardias. Methods: 241 consecutive P without structural heart disease(no coronary heart disease, no valve disease, no ICD or pacemaker) presenting for ablation therapy due to paroxysmal tachycardias were examined. EF was determined by echocardiography before and 1–3 months after ablation. Incidence of tachycardia was determined by repetitive Holter ECG and according to described symptoms. Results: 241 P with the following tachycardias were included: AVNRT (n = 99), atrial flutter (n = 57), paroxysmal AF (n = 51), EAT (n = 6), AVRT (n = 14), idiopathic VT (n = 14). 24% of P demonstrated with a slightly decreased EF (48 ± 6%): 22% of AVNRT‐P(EF 51 ± 5%), 28% of atrial flutter‐P (EF 47 ± 8%), 25% of paroxysmal AF‐P (EF 48 ± 9%), 17% of EAT‐P (EF 54 ± 4%), 21% of AVRT‐P (EF 46 ± 8%), 21% of VT‐P (EF 43 ± 7%). Ventricular tachycardias proved to be more detrimental to EF than supraventricular tachycardias. After successful ablation left ventricular function normalized in all patients (EF: 61 ± 5%). Conclusions: Not only sustained but also paroxysmal tachycardias may cause EF deteriorations which are fully reversible after ablation therapy. Supraventricular tachycardias worsen EF independent of its diagnosis but clearly correlated to its incidence. In P with undetermined cause of reduced EF a sinus rhythm ECG does not exclude the possibility of a tachycardiomyopathy. Therefore also paroxysmal tachycardias have to be excluded. In patients with frequent episodes of paroxysmal tachycardias ablation therapy should be planned on a short term basis to prevent tachycardiomyopathy. P173 TACHYCARDIOMYOPATHY INDUCED BY FOCAL ATRIAL TACHYCARDIA: THE INCIDENCE, ELECTROPHYSIOLOGICAL PREDICTORS AND THE LONG TERM OUTCOME Ju W; Chen M; Yang B; Chen H; Zhang F; Yu J; Cao K Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 2100 Objectives: To report the incidence, clinical and electrophysiological characteristics, and the long term outcomes of the patients with focal ATs induced cardiomyopathy. Methods: Totally 186 cases of patients with focal atrial tachycardias but without pre‐exiting structural heart disease underwent catheter ablation from Jan 2005 to Apr 2011 in our institution were enrolled in the study. The data were retrospectively analyzed to characterize the clinical and electrophysiological profiles of patients with tachycardia induced cardiomyopathy, which was defined as the left ventricle ejection fraction ≤50%. Results: Twelve patients (9 males, the mean age 23.4 ± 16.0 years) were identified to have tachycardiomyopathy, giving an incidence of 6.5%. The patients with tachycardiomyopathy were younger (23.4 ± 15.9 vs 45.7 ± 17.1, P < 0.05) and more frequently males (9/12 vs 64/174, P < 0.05). The tachycardias in the cardiomyopathy group were more frequently incessant (10/12 vs 32/174, P < 0.05).The prevalence of symptoms, including the palpitations, shortness, and syncope or pre‐syncope was not different between the two groups, as well as the tachycardia cycle length and heart rate. The appendage was the most preferential site for the tachycardia to develop cardiomyopathy (8/12). In a 36.3 ± 20.1 months follow up, all of the patients with cardiomyopathy had their left ventricle ejection fraction improved by either catheter ablation or rate control using drug therapy (43.9 ± 5.8 vs 61.1 ± 3.5, P < 0.05). However, one patient suffered sudden death due to unauthorized withdrawal, which leading to uncontrollable heart failure. Conclusions: About 6.5% patients with focal atrial tachycardia developed to tachycardiomyopathy. The incessant nature was associated with the development of the myopathy. The appendage was the most preferential site. Most patients had benign long term outcome using either catheter ablation or rate control by drug therapy. P174 NONINVASIVE BEAT‐TO‐BEAT CARDIAC MAPPING FOR TOPICAL DIAGNOSIS OF ATRIAL AND VENTRICULAR TACHYARRHY‐
THMIAS Shlyakhto E; Lebedev D; Treshkour T; Chmelevsky M; Zubarev S Almazov Federal Heart, Blood and Endocrinology Centre, St. Petersburg, Russia Topical diagnosis of atrial and ventricular ectopy is a relevant issue in electrocardiology. Non‐invasive beat‐to‐beat epi‐ and endocardial cardiac mapping (NCM) is a fundamentally new method of solving this problem. NCM is based of solving the so‐called inverse electrocardiographic (ECG) problem: digital reconstruction of electrograms on the epicardium and endocardium based on the multichannel ECGs recorded on the torso surface. Accurate individual heart and thorax anatomical images derived from tomography studies are used for the calculations. Objective: To determine localization of focal atrial and ventricular tachyarrhythmias (SVTA and VTA) and to explore nature of spread of excitation, using NCM. Materials and Methods: 35 patients were examined, 5 with SVTA and 30 with VTA, average age 43 ± 12 years. Men/women – 21/14. VTA were presented by monomorphic ventricular ectopic complexes (VEC) in 19 cases and nonsustained ventricular tachycardia (VT) in 11 cases. Among patients with SVTA: 3 were with atrial premature beats, 2 – with atrial tachycardia. All patients were identified with indications for radiofrequency catheter ablation (RFCA). For topical preoperative diagnosis NCM with AMYCARD 01 C SYSTEM for Noninvasive EP studies was performed. 15 patients underwent RFCA tachyarrhythmias: 12 patients with VTA and 3 patients with pulmonary veins (PV) ectopia. In 9 cases electroanatomic mapping CARTO was applied and in 3 cases – with software module CARTO Merge. Results: The areas of early activation were defined by construction of potential and isochrone maps on epi‐ and endocardium. The first results showed a complete coincidences of early activation areas obtained using intraoperative mapping and NCM. Conclusions: NCM can improve accuracy of preoperative topical VTA and SVTA diagnosis, reduce time of intraoperative mapping and duration of the cateter ablation procedures. P175 RELATIONSHIP BETWEEN LEFT VENTRICULAR DIASTOLIC FUNCTION AND ABNORMAL REPOLARIZATION AFTER RADIOFREQUENCY CATHETER ABLATION IN PATIENTS WITH WOLFF‐PARKINSON‐WHITE SYNDROME Weng K‐P; Lin C‐C; Hsieh K‐S Kaohsiung Veterans General Hospital, Taiwan Purpose: To assess the serial changes in LV function after RF ablation of a manifest accessory pathway and the relationship between T‐wave changes and LV diastolic function. Methods: The subjects consisted of three groups with tachyarrhythmias. Group A (n = 20): manifest WPW syndrome. Group B (n = 20): concealed WPW syndrome. Group C (n = 20): AVNRT. All patients underwent a series of EKG and echocardiographic examination before and after the catheter ablation procedure. With regard to LV diastolic function parameters, E/A ratio, DT, IVRT, Tei index and tissue Doppler parameters were assessed. Results: In group A (12 ± 3 years), 13 patients had T‐wave changes after ablation. In group B (13 ± 2 years) and C (11 ± 5 years), none had T‐wave changes after ablation. In three groups, there were no significant changes in LVDD, LVSD, and EF before and after the ablation procedure. The cE/A ratio decreased after the ablation and began to improve after 1 month. The cDT increased after the ablation and decreased after 1 month. Left ventricular cIVRT improved in the late period. No statistically significant change was observed in the E/Em ratio. The Em/Am ratio, Tei index, and tissue Doppler parameters obtained from the lateral side of the mitral annulus using tissue Doppler was statistically different before and after the ablation procedure. There was no correlation between the presence of T‐wave changes and postablation echocardiographic findings. Conclusions: T‐wave change after RF ablation of manifest accessory pathway may result from abrupt alteration of the sequence of ventricular repolarization and are not a direct result of RF ablation. This conclusion is supported by no correlation between the presence of T‐wave changes and postablation echocardiographic findings. Key words: Radiofrequency ablation, T‐wave, diastolic function P176 SLEEP APNEA DOES NOT PREDICT ATRIAL FLUTTER RECURRENCE AFTER ATRIAL FLUTTER ABLATION van Oosten EM; Furqan MA; Redfearn DP; Simpson CS; Michael KA; Fitzpatrick M; Hopman WM; Baranchuk A Kingston General Hospital, Queen's University, Kingston, Ontario, Canada Background: Sleep apnea (SA) has been associated with atrial fibrillation (AF) and has been found as a predictor of AF recurrence after successful pulmonary vein isolation (PVI). However, no investigations have been carried out to determine the prevalence of SA in patients with atrial flutter (AFL) and the impact of SA on AFL recurrence after AFL ablation. Aim: To determine if SA is a predictor of recurrence of AFL and/or atrial arrhythmias in patients who have undergone AFL ablation. Methods: Retrospective electronic chart review analysis of consecutive right sided isthmus dependent AFL referred for ablation over a two year period. Recurrent atrial arrhythmias were classified as AFL, AF, or other atrial arrhythmias. SA prevalence was determined. Results: We included 122 consecutive patients undergoing AFL ablation between Jan. 2008 – Dec. 2009. Mean follow‐up was 28.3 ± 6.4 months. 20 patients were excluded due to atypical flutter, procedure abandonment, misdiagnosis, or PVI being the primary procedure. Male 75.4%, mean age 68.3 ± 10.4 years, hypertension 65%, and structural heart disease 42%. Prevalence of SA was 27% (33 patients). Recurrence of AFL was observed in 9.8%, recurrence of AF was observed in 22%, and other arrhythmias in 5%. SA was not a predictor of AFL recurrence (6.1% vs. 11.2%, p = NS). SA was neither a predictor of AF nor of other arrhythmia recurrences. Variables associated with AFL recurrence were: no history of pre‐ablation antiarrhythmic drugs (18.8% vs. 6.7%, p = 0.04) and lower BMI (27.07 kg/m2 vs. 30.87 kg/m2, p = 0.04). Variables associated with AF recurrence included: paroxysmal atrial flutter (vs. persistent) (26.7% vs. 9.4%, p = 0.04), higher BMI (32.6 kg/m2 vs. 29.7 kg/m2, p = 0.039), and lower right atrial volume index (23.9 mL/m2 vs. 32.2 mL/m2, p = 0.002). Conclusions: In this cohort prevalence of SA in patients with AFL was increased (27%). SA was not found to be a predictor of AFL recurrence after successful AFL ablation. P177 INTRACARDIAC ULTRASOUND‐GUIDED ABLATION OF CAVOTRICUSPID ISTHMUS Bencsik G; Pap R; Makai A; Klausz G; Chadaide S; Traykov V; Sághy L 2nd Department of Internal Medicine and Cardiology Center, University of Szeged, Hungary Aims: Our aim was to compare intracardiac echocardiography (ICE) guided ablation of cavotricuspid isthmus (CTI) with conventional fluoroscopy‐guided ablation (FGA) focusing on procedure and fluoroscopy times, radiation exposure and delivered radiofrequency energy (RFE). Patients and Methods: In our single center, prospective, randomized study we included 72 patients (mean age 64.6 ± 11.06, 13 women) scheduled for CTI ablation with documented typical flutter. We randomized patients (1:1 fashion) in two groups: one with conventional FGA (36 patients with 3 femoral punctures for 2 multipolar and 1 ablation catheter) and a second ICE‐guided group (36 patients) with 4 femoral punctures (additional puncture for ICE catheter placed in right atrium). Procedure time was counted from starting the punctures until withdrawal of the last sheath. Fluoroscopy times and radiation data (cumulated radiation and dose‐area product (DAP)) were registered by radiology system and RFE data (sum of delivered RFE) by EP system. The endpoint for ablation was bidirectional block on the CTI after a waiting period of 30 minutes. Results: We found a significantly shorter procedure time (105.0 ± 30.3 min vs. 67.2 ± 16.0 min, p = 0.005) and a significantly lower fluoroscopy‐time (19.1 ± 10.7 min vs. 5.6 ± 4.3 min, p = 0.001) in the ICE‐guided group. DAP was found to be significantly higher in the FGA group (1493.6 ± 1263.3 cGycm2 vs. 433.3 ± 435.8 cGycm2, p = 0.001) and the sum of delivered RFE was significantly higher in the FGA group (14481.4 ± 11035.0 Ws vs.10339.5 ± 6917.7 Ws, p = 0.011). Four vascular complications (groin haematoma) and steam pops (3 in each group) were equally distributed. Conclusion: ICE‐guided ablation of CTI significantly shortens the procedure and fluoroscopy time and markedly decreases radiation exposure in comparison with FGA without a risk of increasing a complication rate. Using ICE‐guidance the sum of delivered RFE was found to be significantly lower. P178 ECHOCARDIAGRAPHIC DYNAMIC IN PATIENTS WITH PAROXYSMAL ATRIOVENTRICULAR NODAL REENTRY TACHYCARDIA BEFORE AND AFTER RADIOFREQUENCY CATHETER ABLATION Ardashev AV; Rybachenko MS; Konev AV; Zhelyakov EG; Belenkov YuN* 83 Clinical Hospital of FMBA, * Lomonosov State University, Moscow, Russia Purpose: To assess hemodynamic parameters in pts with atrioventricular nodal reentry tachycardia (AVNRT) before and after slow pathway radiofrequency catheter ablation (RFA). Methods and Material: Study included of 81 pts who were divided into 2 groups. Study group consistent of 61 AVNRT pts (17 female, mean age 45.3 ± 15.1 years) who underwent RFA of AV node slow pathway. Control group comprised of 20 healthy volunteers (5 female, mean age 41.9 ± 5.3 years) without structural heart pathology. Hemodynamic parameters were accessed by means of transthoracic echocardiography before and 2, 6, 12 months after intervention. We used M‐mode, 2D‐mode to determine end diastolic dimension of the left ventricle (LV), end systolic dimension of LV, end diastolic volume of LV, end systolic volume of LV, ejection fraction of LV. Results: There were no significant differences of hemodynamic parameters in studied and control groups before and 2, 6, 12 months after RFA. In AVNRT pts parameters of hemodynamics did not undergo substantial changes during 12 months of follow up after RFA comparing with initial values. Minor anomalies of development of cardiac connective tissue were diagnosed in 28 (45%) AVNRT pts (mitral valve prolapse – 21 pts, left ventricle accessory chords – 7 cases) vs 2 cases (mitral valve prolapse in both cases) of control group (10%) (P < 0.01). Conclusion: Hemodynamic parameters of AVNRT pts characterized by normal values and don't differ from healthy population before and after RFA of AV node slow pathway. AVNRT might be associated with minor anomalies of development of cardiac connective tissue. P179 ELECTROANATOMICAL MAPPING OF AV NODE AND CRYOABLATION OF PARAHISIAN ATRIAL TACHYCARDIA Katsouras GE; Grimaldi M; Petruzzellis A; Sgueglia M; Langialonga T Cardiology Clinic, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy Introduction: Focal atrial tachycardia originating from the parahisian region is relatively rare. Ablation of this form of tachycardia may carry a potential risk of atrioventricular (AV) block with consequent pacemaker implantation. Methods: N/A. Results: A 37 y female, without previous diseases of note, presented with nausea, asthenia, and sense of imminent death! ECG showed frequent and repetitive atrial extrasystoles. An electrophysiologic study was performed, demonstrating numerous repetitive parahisian extrasystoles. Beta‐blockers, flecainide or sotalol were not efficient and the patient after 6 months gave informed consent to proceed with ablation of the focus. We introduced a decapolar catheter into the coronary sinus as a reference catheter and used a Navistar catheter to map the arrhythmia (CARTO system). We first constructed the right atrium and AV ring anatomy while performing a detailed mapping of the AV node, creating a cluster of points of 2 mm diameter. Each point corresponded to a His signal on the catheter. We circumscribed such points with a yellow line (Fig.) and proceeded with activation mapping of the extrasystoles. The tachycardia was arising from the midseptal region between the AV node and the AV ring. We introduced a 7 F 4 mm tip Medtronic CryoCath quadripolar catheter which was also shown on our map after regulating the CARTO system. However, we performed cryoablation excluding the CryoCath catheter from the CARTO system for incompatibility reasons. After ablation, we noted junctional beats different from the original tachycardia which had disappeared by the first month control. At one‐year follow up, the patient presented only 1 atrial extrasystole during 24 h Holter. Conclusions: To our knowledge, this is the first report of AV node mapping with the technique described above, as well as the first report of combined use of cryoablation with the CARTO system. P180 THE OCCURRENCE OF AV BLOCK AFTER SLOW PATHWAY ABLATION AND 12 MONTHS FOLLOW UP: TWO‐CATHETER APPROACH Kocijancic A; Mrdja S; Mujovic N; Marinkovic M; Potpara T; Polovina M; Simic D; Ostojic MC Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia Background: Radiofrequency ablation of the slow pathway has been recommended as first‐line therapy for the treatment of AVNRT. The purpose of this study is to show that incidence of AV block follow the slow pathway ablation is not higher with two‐catheter approach than with multi‐catheter approach, as referred in the literature. Methods: A total of 92 consecutive patients (aged 19–76, mean 51.9 ± 13.3 years) underwent RFA of the slow pathway, 59 (64.1%) were female. Electrophysiologic method with only two electrode catheters, one diagnostic, (placed in the high right atrium) and one ablation cathether ("two‐catheter approach") was used. The patients were followed at the outpatient clinic for 1, 6 and 12 months during the first year after the procedure. Results: RF ablation was acutely successful in 91 patients (98.9%); slow pathway ablation was achieved in 38 patients (41.3%) and slow pathway modification in 54 (58.7%). Transient AV block occurred in 4 patients (4.3%) during the procedure. After 12 months follow‐up complete AV block occurred in 1 patient (1,1%) required pacemaker implantation. Conclusions: The use of a "two‐catheter approach" (one diagnostic and one ablation) was as effective and safe as a multi‐catheter approach. The incidence of acute and late AV block showed results similar to those of previous studies. P181 RIGHT ATRIAL TACHYCARDIA DESPITE SILENT RIGHT ATRIUM Bogossian H; Ninios I; Karosiene Z; Pechlivanidou E; Guenesdogan B; Kloppe A; Mijic D; Zarse M; Lemke B Klinikum Luedenscheid, Germany We saw a 62 year old male patient suffering from severe palpitations during his atrial driven tachycardia with a heart rate of 105 bpm with 1:1 ventricular pacemaker (PM) stimulation (Cycle length 575 ms) for 8 weeks. A DDDR PM has been implanted due to intermittent AV‐Block III°. CHD has been ruled out via coronary angiography. Echocardiographic examination showed only slightly reduced systolic left ventricular function (EF 48%) without any major valvular dysfunction. Cardiac risk factors were hypertonus, hyperlipidemia and diabetes. Additionally the patient suffered from obstructive sleep apnea. Paroxysmal atrial fibrillation has been described. Before EP‐study, PM modus was changed from DDDR to VVI 30/min which caused a decrease in heart rate down to 53 bpm due to 2:1 block in ventricular answer. During EP study we saw a totally silent right atrium (RA) which showed neither electrical activity nor response to stimulation even with high output. Exclusively in the coronary sinus (CS) and directly adjacent areas, a rapid centrifugal activity was demonstrated. 3‐D electroanatomical mapping was employed after pacing‐manoevers including entrainment and post‐pacing intervals were measured to closer define the area of interest. At the defined hot spot RF‐energy was applied. However, only after adding a line up to an electrically isolated anchor‐point at the tricuspid‐valve circumference tachy was terminated, followed by an atrial electrical standstill which required DDDR‐Pacing. Long AV‐interval allowed for intrinsic AV‐conduction which immediately decreased clinical symptoms. Atrial electrical standstill in one atrial chamber with the other one demonstrating rather normal electrical activity is quite unusual. In our case the underlying pathophysiological mechanism might be connected to increase right atrial pressure due to obstructive sleep apnea. This effect might be aggravated by the underlying hypertension and paroxysms of atrial fibrillation. P182 GENDER DIFFERENCES IN THE CLINICAL CHARACTERISTICS AND ATRIOVENTRI‐
CULAR NODAL CONDUCTION PROPERTIES IN PATIENTS WITH ATRIOVENTRICULAR NODAL REENTRANT TACHYCARDIA (AVNRT) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Atrial fibrillation and WPW syndrome have higher incidence in men while Atrial tachycardia and Atrioventricular nodal reentrant tachycardia (AVNRT) occurs frequently in women. The electrophysiological (EP) characteristics of gender differences in AVNRT is still not clear. This study investigated gender‐related EP differences in patients (pts) undergoing radiofrequency (RF) ablation. Objective: The aim of study was to investigate gender‐related EP differences in pts undergoing RF ablation of AVNRT. Methods & Results: 580 AVNRT pts (men/women 210/370; 1.8:1); mean age‐45.6 ± 18.6 years old, who underwent RF ablation were enrolled in study over three years (2007‐2010). We evaluated gender differences in EP characteristics. Women had younger age of onset, higher incidence of multiple jumps, shorter AH interval, atrial effective refractory period (ERP), anterograde (AG) fast pathway ERP, AG slow pathway ERP, retrograde (RG) slow pathway ERP, and longer ventricular ERP than men. Incidence of baseline VA dissociation was lower in women than men. No gender differences in tachycardia cycle length of AVNRT was noted. Women needed less isoproterenol/atropine to induce AVNRT. No gender differences in radiation exposure time, complication rate, acute success rate or second procedure rate were noted. Typical AVNRT was more predominant in women and atypical AVNRT was more in men. In patients with atypical AVNRT, there was no significant gender difference in incidence of baseline VA dissociation; however, the RG slow pathway ERP was significantly shortin women than in men. Women of premenopausal age ≤50 years old had higher incidence of AG multiple jumps and RG jump phenomenon, and short AG slow pathway ERP and RG slow pathway ERP than those of women ≥50 years old. Conclusion: Gender differences in AG and RG AV nodal EP were noted in pts with AVNRT, which may be related to cyclical changes in hormonal milieu in premenopausal women vs men and postmenopausal women. P183 OUTCOME ON ATRIAL FLUTTER PATIENT WITH POOR EJECTION FRACTION WHO UNDERWENT SUCCESSFUL RADIOFREQUENCY ABLATION AT ONE YEAR Tan VH (1,2); Imran SS (1,3); Liew R (1); Tan BY (1); Chong D (1); Teo WS (1); Ching CK (1) 1. National Heart Centre of Singapore, 2. Changi General Hospital, 3. Khoo Teck Puat Hospital Introduction: There were limited studies on the outcome of patients with atrial flutter and poor left ventricular ejection fraction (LVEF) who underwent successful radiofrequency catheter ablation (RFCA). We report the 12 month outcome of patients with atrial flutter and depressed LVEF who underwent successful RFCA. Methods: Patients with atrial flutter and depressed LVEF ≤ 40% were included over a 15 months period. Clinical demographics, recurrence of atrial flutter at 12 months and change in NYHA status and LVEF were collected and analyzed. Results: There were 15 patients with atrial flutter and LVEF ≤ 40% during the period. Majority were male (86.7%) and mean age was 66.7 ± 8.5 years. 80% of patients had ischemic heart disease and 20% had prior stroke. Distribution of NYHA status at baseline was as follow: class I: 6.7%, class II: 53.3%, class III: 33.3% and class IV: 6.7%. All underwent successful RFCA. One patient developed pseudoaneurysm at puncture site post procedure. Mean EF before ablation was 24 ± 6.3%. Post ablation mean LVEF increased significantly to 37.6 ± 17.6% (P < 0.01). Improved ejection fraction (>40%) after ablation was noted in 46.7% of patient. Mean duration of repeat EF post ablation was 9.1 ± 7.2 months. The recurrence rate was 14% at 12 months. Comparing those who had improved LVEF (>40%) with poor LVEF (≤40%), there was no significant different in baseline characteristic and recurrence rate at one year. However, there was significant difference in NYHA class post ablation in which 4 (57%) patients were at NYHA class 1 in EF>40% group as compare to none at NYHA class 1 in EF≤40% group, p = 0.03. Conclusions: Atrial flutter ablation in patients with LVEF ≤ 40% was safe with a recurrence rate of 14% at 12 months follow‐up. LVEF was significantly improved post ablation. Of note those who attained LVEF >40% had significantly improved NYHA status. P184 ONE YEAR OUTCOME ON ISCHEMIC VERSUS NON‐ISCHEMIC CARDIOMYOPATHY WITH POOR EJECTION FRACTION IN ATRIAL FLUTTER PATIENT WHO UNDERWENT SUCCESSFUL RADIOFREQUENCY ABLATION Tan VH (1,2); Imran SS (1,3); Liew R (1); Tan BY (1); Chong D (1); Teo WS (1); Ching CK (1) 1. National Heart Centre of Singapore, 2. Changi General Hospital, 3. Khoo Teck Puat Hospital Introduction: Studies have shown that patients with atrial flutter and poor left ventricular ejection fraction (LVEF) who underwent successful radiofrequency catheter ablation (RFCA) have significant improvement in LVEF and NYHA class. We sought to determine if there were differences in LVEF improvement and changes in NYHA status between patients with ischemic (ICMP) and non‐ischemic cardiomyopathy (NICMP) ≤ 40% LVEF who underwent successful RFCA for atrial flutter. Methods: Patients with atrial flutter and depressed LVEF ≤ 40% were included over a 15 months period. Clinical demographics, recurrence of atrial flutter at 12 months and change in NYHA status and LVEF were collected and analyzed. Results: 15 patients with atrial flutter and LVEF ≤ 40% during the period were recruited. 80% (12 patients) have ICMP versus 20% (3 patients) with NICMP. Clinical demographics between the two groups were similar. Distribution of NYHA status (ICMP vs. NICMP) at baseline was as follow: class 1: 0% vs. 33.3%, class 2: 66.7% vs. 0%, class 3: 25.0% vs. 66.7% and class 4: 8.3% vs. 0%. One patient in NICMP group developed pseudoaneurysm at puncture site post procedure. There was significant improved in mean LVEF post ablation within both groups (ICMP: 22.6% vs. 32.3%, p = 0.03; NICMP: 29.7% vs. 58.7%, p = 0.04). NICMP group had a significant increase in magnitude of LVEF post ablation compared to ICMP (+29.0% vs. +9.7%, p = 0.04). There was improvement in NYHA class post ablation in both groups (ICMP vs. NICMP) and as follow: class 16.7% vs. 66.7%, class 2: 58.3% vs. 33.3%, class 3: 25.0% vs. 0% and class 4: 0% vs. 0%. The recurrence rate was 25% at 12 months in the ICMP group whereas there was no recurrence in the NICMP group (p = 0.5). Conclusions: LVEF and NYHA status improved significantly in patients who underwent successful RFCA of atrial flutter. Of note, patients with NICMP seemed to have greater improvement in LVEF compared to those with ICMP. SYNCOPE P185 HEART RATE VARIABILITY IN CHILDREN IN DEPEND ON THE TYPE OF RESPONSE TO HEAD‐UP TILT‐TEST Pogodina AV; Dolgikh VV; Valyavskaya OV Scientific centre of family health and human reproduction problems of Siberian brunsh of RAMS Aim: To study the heart rate variability (HRV) during the daily life, before and following the passive 60° head‐up tilt test (HUT) in patients with different types of positive response to head‐up tilt. Methods: We evaluated 28 patients (8–17 y.o), 12 boys, with an inducible vasovagal response to the HUT. We analyzed HRV during the 5‐minute period just before tilt, during the 5‐minute period immediately after tilt in the 60° head‐up position and within 5 minutes preceding syncope while all subjects were asymptomatic. HRV also was calculated over a 24‐hour period. Results: Sixteen children had mixed response to HUT, 4 vasodepressor (VD) and 8 cardioinhibitory (CI). Over the 24‐hour period significant differences were obtained only for rMSSD, which in children with VD syncope was significantly lower than that in children with CI syncope (p = 0,03), and tended to a significant reduction compared with children with mixed syncope (p = 0,07). Values of all indices during the day had no significant differences between groups of children with different types of syncope. Values pNN50, rMSSD and SDNNi during a night's sleep had significantly lower in children with VD syncope, compared with a group of children with CI syncope (p = 0.03, p = 0.02, p = 0.03, respectively), as pNN50 in children with VD syncope was significantly lower than in children with a mixed type of syncope (p = 0.03). In the HUT all HRV parameters did not differ between groups in the supine positions. In the first 5 min of tilt there were significant differences between groups: the pNN50 in children with VD syncope became significantly lower than in children with CI (p = 0,038) and mixed (p = 0,037) types of syncope. Within 5 minutes preceding syncope significant differences between groups was again not shown for any of the indices of HRV. Conclusion: Children with VD syncope are characterized by lower vagal influences in the regulation of cardiac rhythm compared with patients having other types of syncope. P186 RISK STRATIFICATION OF SYNCOPE. MALIGNANT PRESENTATION OF SYNCOPE: DIFFERENCES BETWEEN EPISODES IN THE SAME PATIENT Ruiz GA; Chirife R; Aversa E; Tentori MC; Grancelli H; Nogues M; Perfetto JC Hospital Juan A Fernandez. Instituto Fleni In the diagnosis of syncope, the anamnesis provides important information related to risk stratification. The malignity of syncope is related to two different aspects: a) malignant presentation (MP), associated to risk of injury, b) malignant etiology (ME) related to mortality risk. However, we have observed in a previous study that when two or more episodes are reported, the patient's description is frequently different. Objective: To evaluate the degree of concordance of malignant presentation of syncope between different episodes in the same patient. Methods: An extensive questionnaire describing the last (up to) 4 episodes (ep.) was performed in 147 pts (49.2 ± 21 years, 65% women) with two or more syncopal episodes during the last 2 years. Definitions: MP: absence of prodroms, presence of injury, prolonged duration (> 5 minutes), and fecal/urine incontinence. ME: syncope during exercise, syncope during sleep, absence of prodroms or cardiological prodroms and cyanosis. A value of 1 was given to the presence of each variable, with a scale from 0 to 4. Last benign syncope (LBS)was defined as MP score = 0 in the last episode, last malignant syncope (LMS) was defined as MP score>0. The prevalence of each point score and the concordance of MP, ME scores, LBS and LMS between episodes were evaluated. Results: 440 episodes were evaluated in 147 pts. Of them, 252 (57%) had a MP score≥1 and 133 (30%) had an ME Score≥1. The prevalence of MP and ME scores (2 episodes) were respectively: 0 = 42% and 69%, 1 = 34% and 29%, 2 = 19% and 3%, 3 = 5% and 0%, 4 = 0% for both. The concordance between the last 2 ep. for MP, ME, LBS and LMS was 54%, 73%, 55% and 65%, respectively. Conclusion: The malignant quality of syncope is quite variable between episodes in the same patient. Almost half of patients whose last episode was benign had at least one criteria of malignity in previous episodes. These finding are important when considering the description of the episode for risk stratification. P187 ASYSTOLE DURING TILT TABLE TEST: WHO IS AT RISK? Zimerman A; Magalhães APA; Pimentel M; Zimerman LI Universidade Federal do Rio Grande do Sul Introduction: The tilt table test is a useful diagnostic method in the evaluation of syncope. Asystole is an important response which may occur during the test. Objectives: To evaluate the characteristics of patients with asystole during the tilt table test. Methods: A total of 640 tilt table tests were analyzed and patients who had a positive response were compared with the ones among them who had asystolic response. The protocol had a passive phase (20 minutes; 70 degrees inclination) and an active phase (1.25mg sublingual nitrate and inclination during 10 minutes). Asystole was defined as the presence of pause ≥3 seconds. Results: Patients were mostly females (63.8%) and mean age was 49.1 ± 22.2 years old. The tilt table test was considered positive in 334 patients (51.9%), from which 40 (12%) presented asystole, with an average duration of 9.1 ± 6.8 seconds. The patients with asystole had a lower age, 37.3 ± 18 vs. 48.7 ± 22 (p = 0.01). Asystole occurred in 9.3% of men and 9.9% of women (p = 0.86). It was present in 10.7% of the positive tests in the passive phase and in 12.8% after sensibilization (p = 0.7). The asystole duration during passive phase was 5.9 ± 3.6 vs. 10.6 ± 7.4 seconds after sensibilization (p = 0.03). Conclusions: Asystole during the tilt table test occurs more frequently in younger patients. The asystole duration was longer when the event took place after the pharmacological sensibilization with nitrate. P188 GENDER DIFFERENCES IN HEAD‐UP TILT TESTING (HUTT): 8 YEAR EXPERIENCE AT THE UNIVERSITY OF SANTO TOMAS HOSPITAL Yao RC; Reyes DRC; Ramirez MFL University of Santo Tomas Hospital Objectives: To determine if there is difference in response patterns to HUTT between males and females. Methods: Records of patients who underwent HUTT for the evaluation of syncope were reviewed. Results: 328 out of 332 records were included in the study. 58.5% were females with mean age of 43 years for females and 48 for males. 48.2% of the female population tested positive compared to 30.4% among the male population. 23 patients developed a positive response without nitroglycerin (NTG) provocation. 78% were females. 111 patients developed a positive response with NTG provocation. 70% were females. Female patients who tested positive were significantly younger than males (38 vs 52 P = 0.0001). Mean baseline SBP and DBP were significantly lower in females who had positive result. Responses to HUTT among males in decreasing frequency are Type 1, followed by Type 3, POTS, Type 2a, Type 2b, and dysautonomic responses while in females, Type 1, followed by POTS, Type 3, 2b, 2a and dysautonomic response. Mixed type of response is more common in females than in males (74% VS 26%). POTS, Type 2b and dysautonomic responses were also more common in females. Frequency of type 2a and Type 3 responses were not significantly different between genders. When divided into 0–30, 31–60, and >60 years age group, significantly more females had a positive response in the 0–30 (59% vs 18% P = 0.0001) and 30–60 age group (49.5% vs 28.1% P = 0.006). In the >60 years age group, more males had positive response to HUTT, however this was not statistically significant. (44.7% vs 27.5% P = 0.09). Conclusion: In our institution, more females than males had positive response to HUTT both with and without provocation. Female patients with a positive response were significantly younger, had lower baseline SBP and DBP. Type 1 response is the most common type of response in both genders. In the >60 years age group, more males tested positive but this was not statistically significant. TELEMONITORING FOR CARDIAC RHYTHM MANAGEMENT DEVICES P189 PERSONALIZED REMOTE MONITORING OF ATRIAL FIBRILLATION IN PATIENTS WITH ELECTRONIC IMPLANT DEVICES Trucco E; Arbelo E; Laleci GB; Yang M; Kabak Y; Chronaki C; Hinterbuchner L; Guillén A; Dogac A; Brugada J; iCARDEA Hospital Clinic, Thorax Institute, Cardiology Department, Barcelona, Spain Introduction: Care management systems are used to support and manage the care of patients (pt) with chronic diseases. Although adopting evidence‐based clinical guidelines provide numerous benefits, till now they are underutilized in clinical practice due to interoperability problems of different healthcare data sources. The iCARDEA architecture is an intelligent platform for personalized remote monitoring of pts with cardiovascular implantable electronic devices (CIED). The aim is to introduce the iCARDEA care management system for Atrial Fibrillation (AF) in CIED pts, with emphasis on prevention of cardioembolic events and rate and rhythm management. Methods: The care plan engine executes the clinical guideline for management of patients with AF by accessing the Electronic Health Record (EHR) systems, the patient maintained personal health records (PHR) and the CIED data through standard interfaces. Results: The AF care plan is initiated whenever an AF event is detected and the physician is notified automatically by the iCARDEA system. Information about care plan execution steps are provided, and a link is given to a graphical monitoring tool which shows the care plan workflow graphically, allowing seeing the results of each decision step, such as the retrieved EHRs. For every decision, the care plan engine accesses the EHR and PHR. After a recommendation is presented to the physician, different options are provided, such as guidance on possible doses and major side effects, updating the hospital information system for storing this prescription, or continuing with the rest of the care plan. Conclusion: Through iCARDEA, early detection of AF events will be facilitated. This will facilitate the timely introduction of protective interventions against thromboembolic events, and will enable the anticipation of adverse hemodynamic effects. After completing all the system components including the security and privacy measures, a clinical trial is planned. P190 DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF THE POPULATION ENROLLED IN "CLINICAL EVALUATION OF REMOTE MONITORING WITH DIRECT ALERTS TO REDUCE TIME FROM EVENT TO CLINICAL DECISION (REACT)" STUDY McComb J; Fernandez‐Lozano I; Kacet S; Jung W; Landolina M; Mortensen P; Raatikainen P; Mullens W; Speca GC; Gazzola C; REACT Freeman Hospital, Newcastle (UK) The number of patients with Implantable Cardioverter Defibrillators (ICD) or Cardiac Resynchronization Therapy Defibrillators (CRT‐D) is increasing significantly. They need regular follow up (FU); guidelines require FU 2–4 times per year and additional FUs if necessary. The latest generation of devices allows remote interrogation, monitoring and automatic detection and alerting of potentially silent but dangerous events. The REACT study was designed to investigate if the detection of clinically relevant events with daily alerts notification by St Jude Medical (SJM) Merlin.net remote care leads to faster clinical decision and action. Methods: The REACT study is a prospective, randomized parallel open trial. 220 patients (219 analyzable) were enrolled between March 2010 and February 2011 by 28 centres in 11 European countries. Eligible patients must meet guidelines for ICD or CRT‐D implant and have a SJM device compatible with the Merlin.net Remote Care system. Results: The characteristics of Control Group (C) (n = 107, alerts off) and Treatment Group (T) (n = 112, alerts on) are as below: ControlTreatmentTotalGender (Male):86%86%86%Age (years):  62 ± 11  64 ± 12  63 ± 12Height (cm):173 ± 7173 ± 7173 ± 7Ischemic heart disease:62%62%62% Ejection Fraction was significantly lower in the control group: 30 ± 13 vs 32 ± 12, p = 0.04 (overall 31 ± 13). Hypertension (n = 104, 47%), Hypercholesterolemia (n = 87, 39%) and Diabetes (n = 54, 34%) are the commonest co‐morbidities. The indication for device implantation is primary prevention in 140 (64%) and secondary in 79 p (36%), 134 (61%) patients received an ICD (single or dual chamber) and 85 (38%) a CRT‐D device. Conclusion: The population enrolled in the REACT study is similar to the real‐world ICD and CRT‐D population. P191 REMOTE MONITORING SERVICE FOR CARDIAC DEVICE (ICD'S) PATIENTS. INITIAL EXPERIENCE FROM A GREEK HOSPITAL Rassias I; Tzeis S; Andrikopoulos G; Theodorakis G Henry Dunant Hospital Introduction: The application of remote monitoring (ICD's patients), consists of regular follow up of various parameters, concerning the normal operation of an ICD device, the recording of arrhythmic events and the number of delivered therapies. (appropriate or not). In this particular study we are describing the initial experience of our center, using the remote monitoring system Care Link by Medtronic. Method: 19 ICD patients were included in this study (7 with ischemic‐12 with non ischemic cardiomyopathy), consisting of remote monitoring follow up. 10 patients have BV ICD, 8 patients have DDD ICD and 1 patient has VVI ICD. On a regular weekly basis, we are checking the usual parameters, concerning the normal function of an ICD such as impedance, sense and threshold, as well as the arrhythmic events (ventricular tachycardia‐fibrillation episodes, atrial fibrillation episodes), the parameters concerning heart failure deterioration (optivol), the percentage of pacing (atrial, ventricular, biventricular) and the delivered therapies (appropriate, inappropriate therapies). Results: The mean follow up time, of our study is two months. We have recorded two episodes of sustained ventricular tachycardia, terminated appropriately with antitachycardia pacing and delivered shock correspondingly. In one patient we recorded an unusual increase of the impedance of the ventricular electrode. (> 3000 Ω). We also have recorded 7 episodes of atrial fibrillation and 11 episodes of ventricular tachycardia. Conclusion: The remote monitoring system of ICD patients offers many advantages concerning the safety and the quality of life, especially of those who live in rural areas. P192 INTEGRATION OF LATITUDE REMOTELY TRANSMITTED DATA INTO AN EMR SYSTEM USING FILEMAKER PRO SOFTWARE: PROCEDURE AND ALGORHYTMS Pupita G; Molini S; Matassini MV; Mazzanti I; Brambatti M; Capucci A Clinica di Cardiologia, Ospedali Riuniti di Ancona The LATITUDE® Patient Management system allows to remotely follow Boston Scientific ICD and CRT‐D devices, accessing a website where the device info (transmitted using Bluetooth technology) is displayed. Boston Scientific has developed a software to download available transmissions into a local directory: it creates HL7 files structured according to the HL7 2.3.1 Observation Result Unsolicited message type, sending the information in the form of a lab report document. Each file contains a Message Header, a Patient Identification segment, and four Observation Reports sections (last interrogation, implant, lead test, lead information), each one having several Observation Results segments containing the parameters, that include lead status, device set up, arrhythmic events and stimulation statistics details. We developed a procedure to retrieve data from the HL7 files to put them into an EMR system; both are built in FileMaker Pro. The integration procedure is fully automated: it imports each files' segments in an ad hoc table, reconstructs the original message and grabs each parameter by parsing the reconstructed text, using specifically built custom functions developed in Filemaker Pro; finally the parameters are stored into the EMR system. We've tested the above mentioned procedure with our Center's data, processing a total of 163 transmissions belonging to 52 patients. We've encountered some minor issues: data import must be set to Unicode, date fields calculations need to be adjusted for the presence of the datum, the threshold measure units are always passed even if no measurement has been recorded; several numeric parameters can contain text instead of numbers; decimal separator must be adjusted to local standards. LATITUDE® remotely transmitted data can be integrated into an EMR system effortlessly, thus allowing full availability of patients' data and providing a way to closely monitor several clinically relevant parameters. P193 ICARDEA: PERSONALIZED REMOTE MONITORING OF PATIENTS WITH ELECTRONIC IMPLANTED DEVICES Arbelo E; Trucco E; Dogac A; Luepkes C; Chronaki C; Hinterbuchner L; Ploessnig M; Yang M; Guillen A; Brugada J; iCARDEA European Community's Seventh Framework Programme (FP7/2007–2013) – Grant Agreement n.o.: ICT‐248240 Introduction: Cardiac implanted electronic devices (CIEDs) have become part of the standard therapy in patients (p) who are at risk of life‐threatening arrhythmias. CIEDs require regular scheduled hospital visits to monitor the device parametres and any adverse event. Additionally, many p require extra visits due to arrhythmic events or system‐related complications. This calls for new methods of long‐term surveillance to optimize patient safety, alleviating the burden of caregivers, and lowering costs through IT support. The iCARDEA project aims at developing an intelligent platform to semi‐automate the follow‐up of CIED p using adaptable computer interpretable clinical guideline models. Methods: Data from hospitals' electronic health records (EHR), from p‐maintained personal health records (PHR) and the CIED device readouts, provided by the remote monitoring services, are collected and correlated. This abstract describes the system architecture of iCARDEA. Results: In order to provide the Adaptive Care Planner, the CIED data is converted into a vendor independent standard format, and EHR and PHR data are converted to HL7 Clinical Document Architecture format, in order to be connected to the iCARDEA system. The data presented is enriched by automatically generated specific warnings and suggestions based on statistically valid patterns extracted using data analysis techniques applied to reference case knowledge bases. An adaptive care planner employing clinical guidelines automates risk assessment generating alarms as appropriate. Patients are empowered with integrated PHRs that enable informed and responsible participation in their health care and education. Conclusion: Leveraging the remote management capabilities of CIEDs heightens awareness of device status and disease progression, allowing more timely and effective treatment, while reducing the burden of in‐office visits. iCARDEA monitoring will reduce the time from an event to a clinical decision. VENTRICULAR TACHYARRHYTHMIAS P194 VENTRICULAR ARRHYTHMIAS: LOOKING FOR THE REASON Tatarski RB; Lebedev DS; Gureev SV; Michailov GV Federal centre of heart, blood and endocrinology Everybody knows for today about a large number of patients with ventricular arrhythmias (VA). But high technology methods as a 3D electroanatomical mapping usage cannot show the myocardial and endocardial structural changes, and, as a result, modification of it's electrophysiology, that is a cause of VA presence. Goals: To identify the presence of heart structural changes using endocardial biopsy (EB) in patients with idiopathic VAs. Materials and Methods: 77 patients (27 male, age 42 ± 18 years) with idiopathic VAs were treated by radiofrequency ablation and they passed EB during operation. It' proved, that EB doesn't increase risk of intervention, it's duration and radiation obligation for patient and personnel. Different types of biopsy instruments were used during EB. 4 –7 bits extraction from each patient was considered as sufficient. Results: EB showed chronic myocarditis in 16 (22%), cardiosclerosis –10 (13%), acute myocarditis –9 (12), arrhythmogenic right ventricle dysplasia –18 (23%), lypoma –5 (6%), toxic myocardiopathy –3 (4%), amyloidosis –5 (6%), hypertrophy and protein dystrophy –11 (14%) patients respectively. In no case any of such disease was suspected. Total effectiveness of RF ablation in these patients during 10‐year observation period assembled 85%. No fatal event, associated with EB, was presented. Conclusion: The endocardial biopsy usage opens new horizons in diagnostics, pathogenetic foundations of VA and prognosis evaluation in patients with VA; it makes RF ablation more predictable. But it needs in large number of investigations for full data evaluation and determination of treatment strategy in these patients. P195 ABLATION OF VENTRICULAR ARRHYTHMIAS ORIGINATING FROM VENTRICULAR OUTFLOW TRACT USING REMOTE MAGNETIC FIELD NAVIGATION: FEASIBILITY AND SAFETY STUDY Pajitnev D; Zaltsberg S; Greiss H; Lehinant S; Neumann T; Kuniss M Kerckhoff Heart Center, Bad Nauheim, Germany Background: Radiofrequency (RF) ablation is an effective and generally accepted treatment of symptomatic premature ventricular contractions (PVCs) originating from ventricular outflow tract (VOT). Catheter navigation using an external magnetic field may allow accurate mapping and ablation with reduced fluoroscopy time. The purpose of this study was to assess the feasibility of VOT PVCs ablation using remote magnetic navigation. Methods: 12 consecutive patients (pts) with symptomatic outflow tract ventricular arrhythmias and no underlying structural heart disease were included (2 female, age 59 ± 8 years). For mapping and ablation a 3.5 mm cooled tip magnetic catheter (Celsius RMT Thermocool® Biosense Webster) were used. Remote magnetic navigation was performed with Niobe System (Stereotaxis Inc.). After positioning of the catheter in the VOT activation‐ and pace‐mapping was performed by using the automated bull's eye mapping function of the Niobe system. Ablation was performed at the site of earliest activation (at least −30 ms) and/or best pace‐mapping. Cessation of spontaneous PVC activity was considered as ablation endpoint. Results: Successful ablation site was localized in the septal RVOT in 4 pts (33%), in the posterior RVOT in 6 pts (50%) and in 2 pts in the left and non‐coronary aortic cusp respectively. Mean procedural time was 74 ± 27 minutes with fluoroscopy time of 2.8 ± 1.5 minutes. Successful ablation was achieved in all patients utilizing 8.5 ± 7 RF‐applications at 40 Watts. No complications were observed. Conclusion: Arrhythmias originating from the right and left ventricular outflow tracts can be treated safely and successfully using remote magnetic navigation. The use of automated navigation function of the system allows precise mapping with reduced fluoroscopy times for both, the patient and the investigator. P196 IS CATHETER ABLATION OF VENTRICULAR TACHYCARDIA WORTHWHILE IN PATIENTS WITH ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY? Segetova M; Peichl P; Cihak R; Lefflerova K; Bytesník J; Kautzner J Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Objectives: Radiofrequency catheter ablation (RFA) is often considered of limited value in management of ventricular tachycardia (VT) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). The aim of this study was to review long term results of substrate‐based RFA in ARVC. Methods: The study population comprised 14 patients (age 49.3 ± 18.4 years, 5 female) who underwent 1 or more RFA procedures for VT. Ten of them had implantable cardioverter defibrillator. Eleven primary procedures were followed by recurrence of VT during follow up that necessitated re‐do procedure or heart transplant in one patient with recurrent electrical storm. Only 3 patients had no recurrence after the first RFA. A total of 35 RFA procedures were performed using 3‐dimensional substrate mapping (n = 34) or conventional entrainment (n = 1) mapping (2,5 ± 1.5 procedures per patient). Epicardial approach was needed 4 times in 3 subjects (all younger than 30 years). During 31 ± 18.1 months after the last ablation procedure, patients had no recurrences of VT. Conclusions: Despite a high rate of earlier recurrences after first RFA, repeated procedures can abolish VTs in ARVC in long‐term horizon. Epicardial ablation seems to be necessary in all younger subjects (below 30 years of age). P197 RELATIONSHIP BETWEEN ECHOCARDIOGRAPHIC MARKERS AND INDUCIBILITY OF VENTRICULAR ARRHYTHMIAS IN ISCHAE‐
MIC CARDIOMYOPATHY PATIENTS Kanoupakis EM; Koutalas EP; Kallergis EM; Mavrakis HE; Saloustros IG; Solidakis G; Psathakis E; Goudis CA; Vardas PE Cardiology Dpt, University Hospital of Heraklion Crete Introduction: Research on prognostic factors of ventricular arrhythmias inducibility in patients with severe reduced LV systolic function being ICD candidates for primary prevention of sudden cardiac death has given limited results so far. Aim of our study was to examine the relationship of specific echocardiographic markers, beyond LV ejection fraction, particularly left ventricular hypertrophy and left ventricular end‐diastolic diameter, with ventricular arrhythmias inducibility during electrophysiological study in patients with ischemic cardiomyopathy. Methods and Results: Data were acquired from patients with ischemic cardiomyopathy and severe reduced LV systolic function who underwent electrophysiological in the context of primary prevention of sudden cardiac death. Electrophysiological study protocol included programmed electrical stimulation from right ventricular apex. Of 119 patients included, ventricular arrhythmias were induced in 76 (63.9%). Prior echocardiographic study revealed 26 (21%) patients with ventricular hypertrophy (defined as interventricular septum and posterior wall diastolic thickness >11 mm) and 90 patients (76.3%) with dilated left ventricle (defined as LV end‐diastolic diameter >55 mm). 80% of patients with left ventricular hypertrophy had ventricular arrhythmias induced compared to 59% of patients without ventricular hypertrophy (P < 0.05). However, as regards LV end‐diastolic diameter, difference between groups was not statistically significant (p = 0.92). Conclusion: In populations at high risk for sudden cardiac death, such as ischemic cardiomyopathy patients, ventricular hypertrophy is correlated to ventricular arrhythmias inducibility and possibly is a risk factor for spontaneous malignant arrhythmias. P198 SPATIAL QRS‐T ANGLE IS SIGNIFICANTLY INCREASED IN ASYMPTOMATIC SARCOID PATIENTS WITH VENTRICULAR ARRHYTHMIAS Giallafos I; Kouranos V; Stampola S; Kalianos A; Peros I; Rapti A; Tryposkiadis F; Giallafos J Department of Cardiology of University of Athens & University of Larissa Although arrhythmia is a common in patients with sarcoidosis (Sar), it is often underdiagnosed. Electrocardiographic (ECG) derived spatial QRS‐T angle (QRS‐T‐a) is a novel marker of ventricular repolarization which have predictive value for sudden cardiac death in general and in diseased populations. The present study was carried out to evaluate the QRS‐T‐a in asymptomatic patients with Sar and to investigate the relationship between QRS‐T‐a and the occurrence of potentially serious ventricular arrhythmias. ECG derived QRS‐T angle of 112 Sar patients was calculated from the surface electrocardiogram (ECG) while MRI and 24 hour ambulatory ECG (Holter) was performed. Risk for arrhythmias was estimated for each patient by using Lown classification criteria for ventricular arrhythmias based on Holter results. Four subgroups were formed according to the combination of the arrhythmic risk (Lown >3 was high and Lown ≤3 was low) and the possible cardiac involvement (yes–no). The angle of the patients was compared with that of 65 healthy subjects. Results: 36 patients (32%) fulfilled the criteria of cardiac involvement while 12 patients were classified as Lown 4A (Couplets of Premature Ventricular Beats) with 3 as 4B (Non sustained Ventricular Tachycardia). The spatial QRS‐T angle of the Sar patient's were increased compared to the control's one, while the subgroup analysis showed that the cardiac positive & Lown >3 group had significantly elevated angle compared to the other disease groups. Bivariate correlation showed that spatial QRS‐T angle is positively associated with the age (p = 0.031, r = 0.204) and the Lown classification (p = 0.011, r = 0.240). Spatial QRS‐T angle seems to be increased in Sar patients compared to healthy subjects especially those with increased arrhythmic risk and with cardiac involvement. Determination of this angle can be useful in the risk assessment of however needs further studies for evaluation of this finding. OTHER P199 EVALUATION OF P WAVE DISPERSION AND QRS DURATION BEFORE AND AFTER THROMBOLYTIC THERAPY Rafla S; Elbadawy T; Helmy T; Ahmad E Alexandria Faculty of Medicine, Egypt The effect of thrombolytic therapy on P wave dispersion (PWD) and QRS duration were studied in 30 patients (pts) with acute STEMI. PWD is defined as the difference between the longest and shortest P wave duration recorded from surface ECG. Pts received thrombolytic therapy (Streptokinase) in addition to standard medical therapy. Pts were divided into 2 groups; group A: Pts with successful thrombolytic therapy (23) and group B: Pts with failed thrombolytic therapy (7). P wave duration and dispersion were measured. The normal PWD is 28 ms ± 10. QRS duration was measured and pts were divided into 3 groups; Duration <90 ms, duration 90–110, and duration >110 ms. The incidence of arrhythmia was recorded. Results: PWD was higher in pts with STEMI than normal range. PWD on admission was positively related to age, ST deviation score, CK‐MB, Troponin, left atrial size, ejection fraction, and inversely related to beta blocker use before admission and not related to heart rate. After thrombolytic therapy; PWD and P max were higher in group B than group A: (Gr A 34 ± 6 vs Gr B 47 ± 10 ms, P < 0.006). Arrhythmias during the duration of stay in the ICU were atrial fibrillation in one, ventricular fibrillation in one and V tachycardia in three. Three pts died. As regards QRS duration; there was a significant change in QRS duration (shortening) in pts with successful thrombolysis. There was a significant negative correlation between the QRS duration and EF, and there was a significant positive correlation between QRS duration and the end diastolic and end systolic diameters. The incidence of complications (arrhythmias, heart failure, shock, pulmonary edema, mortality) increased with the increase in QRS duration. Conclusions: PWD is correlated with success of thrombolytic therapy and with other parameters as LA size and EF, In pts with STEMI the QRS duration is a useful indicator of LV systolic function, dimensions and is a predictor of outcome. P200 SLEEP DISORDERED BREATHING IN PATIENTS WITH ACUTE CORONARY SYNDROMES Kallergis E; Chrysostomakis S; Goudis C; Bouloukaki I; Mermigkis C; Schiza S; Simantirakis E; Siafakas N; Vardas P Department of Cardiology, University Hospital, Heraklion, Crete, Greece Aims: Although the prevalence of Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) is high in patients with acute coronary syndromes (ACS), there is little knowledge about the persistence of OSAHS in ACS patients after the acute event. The aim of this study was to assess the prevalence and time course of OSAHS in patients with ACS, during and after the stabilization of the acute cardiac event. Methods and Results: Fifty two patients with first ever ACS and with preserved left ventricular function, who were not on sedation or inotropes, underwent attended overnight polysomnography (PSG) in our sleep center, away from the CCU environment, on the third day after the acute event. In patients with an apnea hypopnea index (AHI) >10/h, we performed a follow up PSG one and six months later. Twenty eight patients (54%) had an AHI >10/h. There was a significant decrease in AHI 1 month after the acute event (13.9 ± 5.9 vs. 19.7 ± 6.7, p = 0.001), confirming the diagnosis of OSAHS in 22 of 28 patients (79%). At 6‐month follow up the AHI had decreased further (7.5 ± 4.6 vs. 19.7 ± 6.7, P < 0.05), and at that time only 6 of the 28 patients (21%) were diagnosed as having OSAHS. Conclusion: We have demonstrated a high prevalence of sleep apnea in the acute myocardial ischemia setting, which did not persist 6 months later, indicating that, to some degree, SDB abnormalities may be transient and related with the acute phase of the underlying disease. P201 COMPARISON OF INDIVIDUALS WITH DIASTOLIC DYSFUNCTION AND NORMAL DIASTOLIC FUNCTION IN TERMS OF HEART RATE RECOVERY AS A PREDICTOR OF MORTALITY Aksoy MN; Kilic H; Sari M; Ertem AG; Yeter E; Balci MM S.B. Health Ministry, Ankara Diskapi YB Training and Research Hospital Dept. Of Cardiology Heart rate recovery which is measured in recovery period of the exercise ECG test is a function of vagal tonus. It can be used as a predictor of mortality independent from other cardiovascular risk factors. In this study we compared asymptomatic diastolic dysfunction patients with healthy controls in terms of HRR which was already documented to be abnormal in patients with diastolic heart failure. We enrolled 71 patients in total which was divided into 3 groups consisted of Grade 1 DDF, Grade 2 DDF and Normal DF groups. Diastolic function assessments were made by TTE and all the patients achieved age predicted submaximal heart rate during exercise stress test. Heart rate recovery measured at 1st (HRR1) and 2nd (HRR2) minutes after cessation of exercise without a cool down period. HRR1 values in the Grade 1 DDF group were significantly lower than control group. Although mean HRR1 of Grade 2 DDF showed a trend towards lower than controls, it did not reach any statistical significance comparing with Grade 1 DDF and control group. (Normal, Grade 1 and Grade 2 HRR1 values were 36,6 ± 9,7 25,1 ± 11,1 and 29,0 ± 10,2 p:0,003). There were no significant difference in HRR2 between groups. In regression analysis, the difference of HRR1 values between Grade 1 DDF and Normal DF seemed to be independent from other variables (age, sex, DM, HT, smoking). These findings suggest that autonomic functions begins to deteriorate much before the onset of symptoms in diastolic dysfunction patients and this deterioration could be a sign of an increase in overall mortality risk in this subgroup of patients. Keywords: Heart rate recovery, Diastolic dysfunction, Echocardiography P202 RESULTS OF HOLTER MONITORING AND DAILY MONITORING OF BLOOD PRESSURE AT YOUNG ATHLETES Skuratova NA; Belyaeva LM; Gomel Regional Children hospital, Gomel, Belarus Belarusian Medical Academy of Post‐Graduate Education, Minsk, Belarus There are literary data about revealing of an arterial hypotension at young athletes which is frequently treated as physiological and testifies to the raised tone of parasympathetic nervous system. Aim: To estimate results of the Holter monitoring and daily monitoring of blood pressure (DMBP) at young athletes. Materials and methods: At 80 young sportsmen of 8–18 years (middle age 13, 0 ± 2, 2 years) it has been spent Holter monitoring and DMBP. Results: The group of young athletes with arterial hypotension (5 to 50 percentile) has been presented by 38 children (47, 5%). Normal values DMBP (from 50 to 90 percentile) had 22 (27, 5%) young athletes, normal values DMBP (from 50 to 90 percentile) had 22 (27, 5%) young athletes, "high normal" blood pressure or arterial hypertension had 16 (20%) children. Among surveyed children 4 (5%) the person had an arterial hypotension less than 5 percentile. At the analysis of occurrence various arrhythmias at athletes it is revealed, that at young sportsmen with an arterial hypotension less than 50 percentiles during DMBP considerable ECG‐changes (Sa‐block, sinus tachycardia, bradycardia and others) were registered authentically often (p = 0,01, × 2). Conclusions: 1The majority of young sportsmen have an arterial hypotension less than 50 percentile during DMBP that can be a sign of physiological sports heart, however demands additional inspection.2Young athletes with an arterial hypotension less than 50 percentile during DMBP have considerable ECG‐changes at Holter monitoring more often, that dictates necessity of differential diagnostics between physiological and pathological athletes heart. P203 A1 EXPONENT FROM DETRENDED FLUCTUATION ANALYSIS (DFA) OF HEARTBEAT TIME SERIES PREDICTS TOTAL MORTALITY IN HEART FAILURE PATIENTS Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Tsiachris D; Archontakis S; Aggelis A; Pietri G; Kartsagoulis E; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To estimate the DFA method analysis of heartbeat time series as compared to other conventional non invasive electrophysiological indices for their ability to predict total mortality (TM) in Heart Failure (HF) patients (pts). Methods: We screened 191 HF pts (age: 64.7 ± 13.5 years, male: 84%, NYHA class: 2.3 ± 0.5, LVEF: 32.5 ± 10.4, CAD: 80%, DCMP: 20%) under optimum treatment with ECG, SAECG, ECHO and 24 hours HOLTER. After 18 ± 16.8 months of follow up 34 deaths occurred (Sudden Cardiac: 13, Pump Failure: 17, Non Cardiac: 4). Differences between survivors and non‐survivors for electrophysiological TM predictors were analyzed with Log rank test. The correlation of the electrophysiological predictors with TM was evaluated through survival analysis method utilizing Kaplan Meier curves adjusted for possible confounders under building of appropriate Cox statistical models. Results: In univariate analysis, DFA a1 was a statistically significant predictor of TM. (Logrank p = 0.002). This finding was verified after Cox regression analysis adjusted for gender, left ventricular ejection fraction (ECHO), fQRS (SAECG), Ventricular Premature Beats >10/hour, Non Sustained Ventricular Tachycardia≥1 episode, mean Heart Rate, SDNN/HRV and 24 hour mean QTc (HOLTER). The most important and independent predictor of TM was DFA a1 with hazard ratio (HR): 0.144, (p = 0.008, 95%CI:0.346–0.606). A cut off point of a1< 0.697 (25th percentile) presented HR 3.299 (p = 0.006) 95% C.I. 1.401–7.767. Conclusions: DFA a1 exponent was an important and independent predictor of TM in HF patients. P204 STRUCTURE AND CHOICE OF TREATMENT METHODS OF TACHYARRHYTHMIAS STARTING IN ANTENATAL PERIOD Svintsova L; Kovalev I; Child's Heart Center Institute of Cardiology Materials: We observed 17 children whose tachycardia was firstly disclosed in the perinatal period and was confirmed by fetal echocardiography (Echo). All patients were performed reschedule abdominal delivery at 33–38 weeks of gestation. They were admitted to our clinic with arrhythmogenic cardiopathy and HF by 1 month of life. Tachyarrhythmias were idiopathic in all children with anatomically normal heart. Results: Permanent form of atrial flutter (AF) was in 8 patients with fetal tachycardia in anamnesis, in 5 children – persistent paroxysmal atrial tachycardia, in 4 child – also persistent paroxysmal tachycardia involving accessory pathways. Patients with permanent form of AF (n = 8) were successfully performed electric cardioversion. Here tachycardia relapses were not arisen. Most of patients with persistent paroxysmal tachycardia were refractive to AAT. Seven of them were performed radiofrequency ablation (RFA) of tachycardia. RFA of tachycardia was performed to two children weighing 3800 g and 4200 g during their first two months of life. RFA ablation was performed to them in the second half‐year period of their life. The postoperative period was without complications in all patients. Follow‐up was from one month to five years. Tachycardia relapses were not observed. AAT appeared effective in two children having concealed WPW syndrome. In both cases tachycardia was stopped by amiodarone. Treatment course in both cases was 4 months. Recurrent tachycardia was not revealed after drug withdrawal. Follow‐up was 3 and 6 months respectively. Conclusion: Cardioversion is effective for treatment of permanent atrial flatter in infants and newborns. Persistent paroxysmal tachycardias have progressive course, are accompanied by HF rising and are refractory to AAT. RFA is the most effective method of treatment in such patients. P205 WHAT IS BEHIND "IDIOPATHIC ARRHYTHMIA": ENDOMYOCARDIAL BIOPSY AS A CLUE TO THE PRECISE DIAGNOSIS Blagova OV; Nedostup AV; Kogan EA; Sulimov VA; Abugov SA; Kupryanova AG; Zaidenov VA; Donnikov AE I.M.Sechenov I Moscow State Medical University Objective: To estimate the role of endomyocardial biopsy (EMB) of right ventricle in precise nosology diagnosis ascertainment and therapy specification in patients with «idiopathic» arrhythmias. Methods: We observed seventeen patients (8 females, 42.6 11.9 y.o.) with «idiopathic» arrhythmias resistant to therapy (atrial fibrillation (AF) in 88%). Investigation concluded EMB with following histological examination; PCR detection of virus infections; detection of anti‐heart antibodies (AB). Results: Perfusion defects were found in 56% of patients, moderate enlargement of the left atrium in 41%; AB against endothelium in 65%, conduction system in 76%, cardiomyocytes in 53%, and specific antinuclear AB in 65%. Virus genomes in EMB samples were detected by PCR in 4 patients: parvovirus B19 – in 2 EMB samples, herpes virus 6 type – in 1 EMB sample and in blood only – EBV in 1 patient; 11 patients had myocarditis, one of parvovirus B19 carriers had endomyocarditis; productive vasculitis was in 2 patients prevailed. Four 3 virus‐negative samples had signs of immune cytolysi, and one with mytosis. Primary cardiomyopathy, ARVD, and Fabry disease were also found. The follow up is 32.7 7.3 months. Therapy of antiarrhythmic drugs, corticosteroids (n = 12, 28.8 ± 10.9 mg/day), azatioprine 150 mg/day (n = 2), hydroxychloroquine 200 mg/day (n = 10), meloxicam 15 mg/day (n = 7), gancyclovir/acyclovir (n = 4), iv immunoglobulin (n = 2) was prescribed for 14 patients. Reduction of AF episode frequency (from several times per week up to several times per month) was noted in 69,2% of patients. None of those receiving immunosuppressive therapy had a transformation AF to the chronic form. Aggravations of arrhythmia due to an infection or a cancelling of therapy are noted at 47%; two patients required RFA. Conclusions: By means of EMB at 88,2% of patients it is revealed the immune‐inflammatory nature of «idiopathic» arrhythmias (AF), the effect from specific therapy is received. [ABSTRACT FROM AUTHOR]

This article lists international meetings published in the November 1, 1968 issue of "International Social Science Journal." The list includes Fifth European Symposium of European Committee for Rural Law to be held in the Netherlands, session of Institute of International Law to be held in Great Britain on matters of international law, public and private, conference of Inter-Parliamentary Union to be held in India, and Eleventh General Conference of International Association for Research in Income and Wealth to be held in India. The list also includes Second International Congress of Balkan and Southeast European Studies to be held in Athens, Greece, Tenth International Congress of Criminal Law of International Association of Penal Law to be held in Europe, International Conference on the International Transfer of Management Skills to be held in Europe, Thirteenth Triennial Conference of War Register's International to be held in the U.S., Nineteenth Congress of International Union of Local Authorities to be held in Athens, Greece.

ANTIARRHYTHMICS O001 EFFECTIVENESS AND SAFETY OF NEW CLASS III ANTIARRHYTHMIC AGENT NIFERIDILE IN PHARMACOLOGICAL CONVERSION OF PERSISTENT ATRIAL FIBRILLATION AND FLUTTER Yuricheva Y; Maykov E; Sokolov S; Golitsyn S; Mironov N; Beloshapko G; Yushmanova A; Rosenshtraukh L; Chazov E
 Russian Research Cardiology Centre The aim of our study was to evaluate the efficacy and safety of i.v. administered new class III antiarrhythmic agent niferidile in doses up to 30 mkg/kg in conversion of persistent atrial fibrillation (AF) and flutter (AFL) to sinus rhythm. 50 patients (33 male) without structural heart diseases, age 55 ± 12 years, with arrhythmia lasting 4,4 ± 4,2 months (2 weeks‐ 24 months) were included. Niferidile was administered as 3 bolus injections (10 mkg/kg each) performed with the 15‐min interval. Conversion to sinus rhythm within 24 hours was achieved in 44 of the 50 patients: success rate of niferidile in dose of 10 mkg/kg was 54%, in dose of 20 mkg/ kg – 70%, and in dose of 30 mkg/ kg reached 88%. Niferidile was effective in all 11 patients with AFL and in 33 of 39 patients (85%) with AF. None of patients developed proarrhythmic effects such as «torsade de pointes». Conclusion: i.v. niferidile in doses up to 30 mkg/kg seems to be very effective (up to 88%) and safe for sinus rhythm restoration in patients with persistent AF and AFL. O002 ELECTROPHYSIOLOGIC AND ANTIARRHYTHMIC EFFECTS OF NEW CLASS III AGENT NIFERIDILE IN PATIENTS WITH PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIAS Mironov NYu; Golitsyn SP; Sokolov SF; Yuricheva YuA; Maikov EB; Shlevkov NB; Rosetstraukh LV; Chazov EI
 Russian cardiology research complex Background: According to preclinical studies Niferidile (Nf) is a novel potassium channel blocker that inhibits transient outward and delayed rectifier currents and increases effective refractory periods (ERP) more in atria, less in ventricles. High affinity of Nf to atrial myocardium predispose to high efficacy in patients with supraventricular arrhythmias and to low risk of ventricular arrhythmogenic action. Objectives: To evaluate electrophysiologic and antiarrhythmic effects of Nf in patients with paroxysmal supraventricular tachycardia (PSVT). Materials and Methods: Effects of Nf (20micrograms/kg intravenously) were studied in 22 patients (14 males) with PSVT (11 orthodromic tachycardia in WPW syndrome, 8 atrioventricular nodal reentrant tachycardia, 3 orthodromic tachycardia due to concealed bypass tract) during endocardial electrophysiological study (EPS). Termination of PSVT by Nf could be investigated in 16 patients and prevention of reinduction of PSVT by this drug – in 19 patients. Results: Nf terminated PSVT in 81.25% and prevented reinduction of PSVT in 75.95% of patients. Nf increased the ERP of right atrium (by 22.61%, p < 0.001), left atrium (by 21.55%, p < 0.001), right ventricle (by 14.02%, p < 0.05) and accessory pathways (anterogradely by 30.16%, p < 0.001; retrogradely by 33.6%, p < 0.001). Nf did not alter sinus node recovery time and atrioventricular conduction. Nf prolonged QT (by 21.3%, p < 0.01) and QTc (by 16.01%, p < 0.05) intervals without the evidence of proarrhythmic effect. Conclusions: Prolongation of ERP in cardiac tissues (mostly in atrials) is the main electrophysiologic effect of Nf. New drug demonstrated high antiarrhythmic efficacy and good safety profile in patients with PSVT. O003 PHARMACOLOGICAL TREATMENT OF PATIENTS WITH INAPPROPRIATE SINUS NODE TACHYCARDIA: BETA‐BLOCKER OR IF‐CHANNEL INHIBITOR? Borbola J; Abraham P; Foldesi Cs; Kardos A
 Hungarian Institute of Cardiology Inappropriate sinus‐node tachycardia (IST) is a rare disease defined as increased heart rate at rest, and/or inadequate response to physical or emotional stress. In the last years 25 patients (23 women, 2 men, age: 18–57 (33) years) were treated with IST due to palpitations. Patients had no structural heart disease (LVEF: 65 ± 2%), TSH values were within normal limits, but resting heart rate were repeatedly high: 106 ± 3/min. The results of Holter recording (expressed as minimal‐maximal and average heart rate/min) without medication showed high heart rate values: 58 ± 2 – 163 ± 3 – (96 ± 2)/min. The bicycle ergometry showed an average loading capacity of 120 ± 5 W (heart rate: control (C): 104 ± 4/min, top (T): 170 ± 6/min. The aim of the study was to compare the beta‐blocker and ivabradine treatment in IST patients. The beta‐blocker treatment (bisoprolol 5 mg/day) improved the high sinus node frequency spectrum both during Holter monitoring (54 ± 2 – 135 ± 4 – 81 ± 2/min, p < 0.0001) and during ergometry (120 ± 8 W; C: 86 ± 3; T: 145 ± 4/min; p < 0.05). The ivabradine therapy decreased the heart rate significantly and dose‐dependently compared to the control values: ivabradine 5 mg b.i.d: 50 ± 2 – 131 ± 5 – 76 ± 2/min (p < 0.0001), ivabradine: (7.5 mg b.i.d.): 48 ± 1 – 130 ± 6 – 72 ± 2/min; p < 0.0001), and decreased the heart rate frequency during ergometry: ivabradine (2×5 mg/day: C: 83 ± 3; T: 137 ± 4/min (p < 0.05)), (2×7.5 mg/day: C: 77 ± 4; T: 137 ± 8/min (p < 0.05)). There was no change in the loading capacity. The ivabradine treatment was well tolerated, there was no sinus bradycardiac episode leading to treatment discontinuation. On the other hand, several side effects were noticed during beta‐blocker therapy. Based on our clinical experiences, IST can be treated with the sinoatrial node modulator drug ivabradine successfully and safely. The ivabradine treatment might be considered as an alternative to the ablation of the sinoatrial node with the inherent risk of pacemaker implantation. ATRIAL FIBRILLATION ABLATION O004 ABLATION OF PAROXYSMAL AND PERSISTENT ATRIAL FIBRILLATION: 1‐YEAR FOLLOW‐UP THROUGH IMPLANTABLE ECG RECORDER Romanov A; Pokushalov E; Corbucci G; Shabanov V; Elesin D; Stenin I; Losik D
 State Research Institute of Circulation Pathology Introduction: The aim of this prospective observational study was to identify Responders to ablation through continuous subcutaneous monitoring for 1 year after ablation in patients with paroxysmal atrial fibrillation (PAF) or persistent AF (PersAF). Method: Patients with symptomatic drug refractory AF were enrolled. Real‐time three‐dimensional (3D) left atrium maps were reconstructed by using a nonfluoroscopic navigation system (CARTO, Biosense‐Webster, USA). The ipsilateral left and right pulmonary veins (PVs) were encircled in 1 lesion line by circumferential PV isolation. All patients were implanted with Reveal XT (Medtronic Inc.) for continuous AF monitoring and data collected every month during the 12‐month follow‐up. Results: We enrolled 129 patients (56 ± 9 years, 102 males), all of whom were followed‐up for 12 months after the last ablation procedure: 58 (45%) had a history of PersAF. After only 1 ablation procedure, 76 (59%) of the 129 patients were AF‐free at 12‐month: 48 out of 71 (68%) in the PAF group and 28 out of 58 (48%) in the PersAF group. After 1 or more ablation procedures, 94 (73%) of the 129 patients were AF‐free 12 months after the last procedure: 57 out of 71 (80%) in the PAF group and 37 out of 58 (64%) in the PersAF group. Conclusion: Ablation is highly effective in treating AF, as assessed through detailed 1‐year continuous monitoring: success rate is higher in PAF than in PersAF patients. The use of subcutaneous monitors is a valuable means of identifying responders and nonresponders, and can potentially guide antiarrhythmic and antithrombotic therapies. O005 FUNCTIONAL IMPROVEMENT IN ADVANCED HEART FAILURE AFTER MITRAL SURGERY IN PATIENTS UNDERGOING RADIOFREQUENCY ABLATION OF ATRIAL FIBRILLATION IS RELATED TO LONG TERM MANTAINANCE OF SINUS RHYTHM Rostagno C; Blanzola C; Sclafani G; Montesi GF; Braconi L; Stefano PL; Cardiologia Generale1, §Cardiochirurgia – AOU Careggi – Firenze Objective: Atrial fibrillation is associated with a higher mortality in patients with advanced heart failure, Persistence of AF after mitral valve (MV) surgery is associated with poorer hemodynamic improvement in comparison to resumption of sinus rhythm (SR). RF‐maze associated with MV surgery is associated with a 60–70% long term persistence of SR. The aim of this prospective investigation was to evaluate the relation between persistence of SR and change of functional status in patients in patients with advanced NYHA class. Methods: 301 consecutive patients were treated by RF‐maze with Medtronic CardioBlate® system associated with MV surgery between November 2001 and December 2007 and were followed up for an average period of 1450 days. 234 /301 were in advanced NYHA functional class (III‐IV). Clinical examination, ECG and echocardiogram were evaluated at baseline and during follow‐up (3 to 96 months). Results: At an average follow‐up of 1450 days, 180/234 (77%) patients in preoperative NHYA class III‐IV were alive. One hundred and twenty were in SR, while 60 remained in stable AF. In the two groups age was similar (mean 64.7 years in SR, 66.7 in AF) as mean AF duration (36 vs 39 months). Baseline LA diameter, left and right atrium area were greater in patients in whom AF persisted in comparison to those in SR. These last patients showed a more relevant remodelling of atrial chambers after surgery. Baseline mean NYHA class was 2.96 in SR and 3.13 in AF patients. At follow‐up a significant functional improvement was found in SR patients (average NYHA class 1.31 vs 2.33, p < 0.003), associated with a significant decrease of calculated systolic pulmonary pressure. Conclusions: persistence of SR after AF ablation is associated with a significant functional improvement in comparison to patients who remain in AF. Persistent pulmonary hypertension after surgery may limit clinical improvement and contribute to maintenance of AF. O006 TRANSSEPTAL ACCESS AND ATRIAL FIBRILLATION ABLATION GUIDED BY INTRACARDIAC ECHO IN PATIENTS WITH ATRIAL SEPTAL CLOSURE DEVICES Santangeli P; Di Biase L; Burkhardt JD; Horton R; Sanchez J; Lakkireddy D; Bai R; Beheiry S; Hongo R; Natale A
 Texas Cardiac Arrhythmia Institute – St. David's Medical Center, Austin, TX Background: Percutaneous positioning of closure devices is a well‐established treatment of atrial septal defects (ASD). These patients are at increased risk of developing atrial fibrillation (AF), and treatment by catheter ablation is underutilized due to the perceived difficulty of obtaining transseptal access in the presence of the closure device. We report the acute and long‐term results of radiofrequency catheter ablation of AF in patients with ASD closure devices. Methods: Thirty‐nine patients (age 54 ± 6 years, 72% males) with drug‐refractory AF (33% paroxysmal, 51% persistent, 16% long‐standing persistent) and ASD closure devices (82% Amplatzer®, 18% Cardioseal®) underwent radiofrequency catheter ablation. A double transseptal access guided by intracardiac echocardiography (ICE) was obtained in all patients. Results: In 35/39 (90%) patients the transseptal access was obtained in a portion of the native septum, while in 4/39 (10%) a direct access through the device was required. The latter group had a significantly longer time for achieving the double transseptal access (73.6 ± 1.1 min vs. 4.3 ± 0.4 min, p < 0.001), longer fluoroscopy time (122 ± 5 min vs. 80 ± 8 min, p < 0.001), and total procedure time (4.1 ± 0.2 hours vs. 3.1 ± 0.3 hours, p < 0.001). At a follow‐up of 14 ± 4 months the overall success rate was 77% (85% in paroxysmal AF, 73% in non‐paroxysmal AF). Transthoracic contrast‐enhanced echocardiography with the Valsalva maneuver, performed between 3 and 6 months after the procedure, failed to detect shunt in all patients. Conclusions: Radiofrequency catheter ablation of AF is feasible, safe and effective in patients with ASD closure devices. Transseptal access can be obtained in portions of the native septum in the majority of the cases. Direct transseptal puncture of the device is feasible and safe, but it requires longer time for each transseptal access. O007 IMPACT OF RADIO‐FREQUENCY CHARACTERISTICS ON ACUTE PULMONARY VEIN RECONNECTION AND CLINICAL OUTCOME AFTER PVAC ABLATION De Greef Y; Tavernier R; Schwagten B; De Keulenaer G; Stockman D; Duytschaever M
 Department of Cardiology, Antwerp Cardiovascular Institute Middelheim, Belgium Aim: To study the impact of radio‐frequency (RF) characteristics on acute pulmonary vein reconnection (PVR) and outcome after PVAC ablation. A strategy of PV isolation with additional ablation of PVR (PVI + PVR) was compared to PVI‐only. Methods: Eighty patients underwent PVAC‐ablation: in 40 patients, PVI‐only was performed; in another 40 patients adenosine and 1‐hour waiting time were used to unmask and ablate PVR (PVI+PVR) after baseline PVI. Freedom of AF was compared at 12months. RF‐characteristics of PVAC applications needed for baseline PVI were assessed. Results: There was no difference in clinical characteristics or baseline RF‐profile between the 2 groups. In the PVI+PVR group, PVR was observed and ablated in 38 out of 160 veins (24%). Freedom of AF after PVI+PVR was higher compared to PVI‐only (85% vs 65%, p < 0,05). Within the PVI group, when comparing patients with and without AF recurrence, percentage of PVAC applications with high T° but low power (>48°, <3W) was higher (28 ± 18% vs 11 ± 11%, p < 0,0001). When comparing PVs with and without PVR, the percentage of PVAC applications with high T° but low power was also higher (27 ± 13% vs 13 ± 15%, p < 0,0001). Conclusions: After PVAC‐guided PVI, 24% of PVs exhibit acute PVR. Additional ablation of PVR is associated with improved clinical outcome. Acute PVR and recurrence of AF are characterised by a prior PVAC ablation with a considerable number of applications with high temperature but low power. If PVI is obtained with low power PVAC applications, a consistent use of adenosine and waiting time is required. O008 THE ROOF LINE DOES NOT INFLUENCE THE 12‐MONTH SUCCESS OF CIRCUMFERENTIAL ABLATION OF THE PULMONARY VEINS: RESULTS OF A PROSPECTIVE RANDOMIZED STUDY. Arbelo E; Guiú E; Andreu D; Borras R; Berruezo A; Tolosana JM; Brugada J; Mont L
 Hospital Universitari Clínic, Thorax Institute, Barcelona, Spain Introduction: The isolation of the pulmonary veins (PV) for the treatment of atrial fibrillation (AF) is often associated to linear radiofrequency lesions within the left atrium (LA) in an effort to improve results. The aim of the study was to evaluate the contribution of the roof line in the mid‐term success of AF ablation. Methods: We prospectively included patients (p) undergoing catheter ablation for AF. The PV isolation was performed by continuous circular lesions around ipsilateral PV, checking for conduction block with a circular multipolar catheter within the veins. Subsequently, p were randomized to no further ablation (CPVA‐NoRL) versus an additional linear ablation at the roof of the LA (CPVA‐RL) between the superior aspect of the circular lesions at the left and right PV). Follow‐up was performed at 1, 3, 6 months after the procedure and every 6 months thereafter. After a 3 month blanking period, recurrence was defined as the occurrence of any arrhythmia of ≥30 seconds. Results: 140 patients (55 ± 11 years, 69% male, 35% hypertension, LA diametre 42 ± 6 mm, LVEF 62 ± 8%, 20% structural cardiomyopathy) undergoing AF ablation, were randomized. No significant differences were observed between the CPVA‐NoRL vs. CPVA‐RL groups in terms of LA diametre, presence of hypertension, structural cardiomyopathy nor any other arrhythmia predictor. After a first procedure of AF ablation, there was no significant difference in the arrhythmia‐free survival curve between the two groups (72% in CPVA‐RL vs. 78% in CPVA‐NoRL at 12‐months, log‐rank p = 0,29). The incidence of LA macroreentrant tachycardias after a first procedure was 4,8% in the CPVA‐RL group versus a 5,5% in the CPVA‐NoRL one. Conclusion: The left atrial roof line does not improve mid‐term results of the isolation of the pulmonary veins for the ablation of atrial fibrillation. O009 COMPLEXITY OF ATRIAL FIBRILLATION IN CHINESE IN ROUTINE DAILY PRACTICE: INSIGHTS FROM THE REALISEAF‐TAIWAN REGISTRY Chiang CE; Wang KL; Naditch‐Brule L; O'Neill J; Steg PG; RealiseAF registry
 General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan Purpose: Patients with atrial fibrillation (AF) have multiple co‐morbidities and high cardiovascular risk. Most studies were carried out in Western countries, and there is a paucity of data from Chinese patients. The aim of this analysis was to describe clinical characteristics, risk factors, co‐morbidities, and management strategies in Taiwanese patients in the RealiseAF registry. Methods: RealiseAF was a cross‐sectional survey of 10,523 patients from 831 sites in 26 countries on 4 continents, with at least one AF episode documented by standard electrocardiogram or by Holter monitoring in the last 12 months. Participating physicians were randomly selected in 2009 from lists of office‐/hospital‐based cardiologists and internists. Results: Among 742 patients in Taiwan who were eligible for analysis, the mean (SD) age was 70.2 (11.8) years. More men (59.8%) than women were enrolled. Permanent AF was most common (51.7%), followed by paroxysmal (33.3%) and persistent (11.1%) AF. Cardiovascular risk factors and co‐morbidities were very common: 72.9% had hypertension, 27.0% had diabetes, 40.7% had heart failure, 34.5% had coronary artery disease, 21.9% had cerebrovascular disease, and 38.8% had valvular heart disease. A rate‐control strategy (67.8%) was more frequently undertaken than rhythm‐control (24.5%). The majority of patients (85.2%) received at least one anti‐arrhythmic drug, but 81.5% of patients had an EHRA AF classification ≥2. The mean (SD) CHADS2 score was 2.2 (1.4), and 65.1% had a CHADS2 score ≥2. However, only 31.8% of patients were receiving an oral anti‐coagulant. Conclusions: AF patients in daily practice in Taiwan had multiple risk factors and co‐morbidities, similar to those in Western countries. Patients were highly symptomatic despite the widespread use of anti‐arrhythmic drugs. The risk of stroke was generally high, but the use of anti‐coagulants was extremely inadequate. There is an apparent unmet need in AF treatment in Chinese patients. O010 IMPACT OF RADIOFREQUENCY CATHETER PULMONARY VEIN ISOLATION (PVI) ON TOTAL ATRIAL FIBRILLATION (AF) BURDEN IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION Urban L; Hlivak P; De Melis M; Garutti C; Corbucci G; Hatala R
 National Cardiovascular Institute, Slovak Medical University, Bratislava, Slovakia Background: Evaluation of success of radiofrequency catheter ablation (RFCA) in AF patients (pts) is largely based on symptoms reduction / abolition and on intermittent ECG recordings. Evaluation of the occurrence of AF by means of continuous ECG monitoring was rarely used until now. Aim: To quantify the total AF burden (AF%) in pts undergoing catheter PVI in the pre‐ and post‐ablation period. AF% was defined as the percentage of the total monitoring time during which the patient was in AF. To this aim, continuous ECG monitoring was performed by means of implantable loop recorder (ILR, Reveal XT, Medtronic Inc., USA) in pts undergoing radiofrequency catheter ablation for paroxysmal AF. Patients and Methods: 52 pts (56 ± 9 years, 79% males) were prospectively enrolled in this study. All patients had the ILR implanted in stable sinus rhythm before RFCA (3 ± 2 months) and were followed‐up for 9 months after RFCA. The initial 3 months were blanked and were not comprised in the analysis. All pts had paroxysmal AF for a mean of 6.4 ± 4.8 years, 47% of them had a history of >1 episode of persistent AF prior to ILR implantation, mean left atrial diameter was 44 ± 4 mm, LVEF% was 59 ± 6%. Their mean CHADS2 score was 1 ± 0.7. RFCA comprised point‐by‐point electroanatomically guided PVI only in 31 pts (60%), linear lesions were added in 21 (41%). Results: 1The median pre‐ versus post‐RFCA AF% was 19.5% and 0.4%, respectively (p < 0.00001)2The maximum daily AF burden decreased from 21 ± 6 h to 7 ± 8 h (p < 0.0001)3Post RFCA, 90% of pts did not have episodes lasting >24h. Conclusions: This pilot study on the role of continuous ecg monitoring by ILR in assessing RFCA outcome demonstrates a dramatic reduction in paroxysmal AF burden and episode duration after PVI based RFCA. Pre and post‐RFCA ecg data derived from ILR allow for comprehensive AF characterization which is important for quantifying RFCA success and for further clinical arrhythmia management. O011 INDUCIBILITY OF ATRIAL FIBRILLATION DOES NOT INFLUENCE THE OUTCOME AFTER PULMONARY VEIN ISOLATION Arbelo E; Guiú E; Andreu D; Borras R; Berruezo A; Tolosana JM; Brugada J; Mont L
 Hospital Universitari Clínic, Thorax Institute, Barcelona, Spain Introduction: Some conflicting results of the efficacy of the inducibility test used in the catheter ablation of atrial fibrillation (AF) have been reported. The aim of this study was to investigate the value of inducibility in the outcome of circumferential pulmonary vein isolation in patients with paroxysmal AF. Methods: In this prospective study, 114 consecutive patients (p) undergoing ablation of atrial fibrillation were included. The ablation set included antral encircling of the pulmonary veins (PV) in all p (checking for conduction block with a multipolar circular catheter placed within the veins), with additional lines at the LA roof in 55 p and the mitral isthmus line in 8 p. At the end of the procedure, inducibility was evaluated with trains of 10 impulses with an initial cycle length of 350 ms, reduced by 10 ms until 250 ms or until 1:1 atrial capture was lost. AF was considered inducible when sustained for at least 30 seconds. Patients were followed up at 1, 3 and 6 months after the procedure and every 6 months thereafter. Results: 130 patients (55 ± 11 years, 74% male, 40% hypertension, LA diametre 42 ± 5 mm, LVEF 60 ± 10%, 16% structural cardiomyopathy) undergoing AF ablation (99 p Paroxysmal AF, 31 p Persistent AF in sinus rhythm during the procedure) were evaluated. AF was inducible in 25 p (22%) after antral PV isolation. No significant differences were observed between the inducible vs. non‐inducible groups in terms of LA diametre, presence of hypertension, structural cardiomyopathy nor any other arrhythmia predictor. After a first procedure of AF ablation, there was no significant difference in the arrhythmia‐free survival curve between the two groups (68% vs 86% at 12‐months, p = 0,584) (figure). Conclusion: The absence of inducibility of arrhythmias after circumferential pulmonary vein isolation does not predict a better mid‐term result after catheter ablation of atrial fibrillation. O012 THE ABLATION OF COMPLEX FRAGMENTED ATRIAL ELECTROGRAMS DOES NOT INFLUENCE 12‐MONTH SUCCESS OF PULMONARY VEIN ISOLATION FOR THE ABLATION OF ATRIAL FIBRILLATION: A PROSPECTIVE RANDOMIZED STUDY Arbelo E; Guiú E; Andreu D; Borras R; Berruezo A; Tolosana JM; Brugada J; Mont L
 Hospital Universitari Clínic, Thorax Institute, Barcelona, Spain Introduction: The ablation of continuous and fragmented potentials has been proposed as an adjuvant therapy to the isolation of the pulmonary veins (PV) in an effort to improve results. The aim of this study was to evaluate the impact of the ablation of fragmented potentials in the ablation of persistent/permanent atrial fibrillation (AF). Methods: We prospectively included patients (p) undergoing catheter ablation for persistent / permanent AF. The PV isolation was performed by continuous circular lesions around ipsilateral PV, checking for conduction block with a circular multipolar catheter within the veins. Subsequently, p were randomized to no further ablation (CPVA‐NoF) versus additional ablation of fragmented potentials (CPVA‐F). These fragmented potentials were defined as any continuous and fractionated activity of low voltage, sustained over >10 seconds over time. Follow‐up was performed at 1, 3, 6 months after the procedure and every 6 months thereafter. After a 3 month blanking period, recurrence was defined as the occurrence of any arrhythmia of ≥30 seconds. Results: 110 patients (53 ± 10 years, 81% male, 36% hypertension, LA diametre 45 ± 6 mm, LVEF 54 ± 12%, 26% structural cardiomyopathy) undergoing AF ablation, were randomized (82% persistent AF, 18% permanent AF). No significant differences were observed between the CPVA‐NoF vs. CPVA‐F groups in terms of LA diametre, presence of hypertension, structural cardiomyopathy nor any other arrhythmia predictor. After a first procedure of AF ablation, there was no significant difference in the arrhythmia‐free survival curve between the two groups (58% en CPVA‐F vs. 65% en CPVA‐NoF at 12‐months, log‐rank p = 0,434). Conclusion: The ablation of complex fragmented atrial electrograms in addition to PV isolation does not improve the mid‐term results of pulmonary vein isolation for the ablation of persistent and permanent atrial fibrillation. O013 SINGLE CENTER EXPERIENCE OF CATHETER ABLATION FOR ATRIAL FIBRILLATION USING MULTI‐ELECTRODE MAPPING AND ABLATION CATHETERS Zeb M; Scott A Paul; Yue A; Roberts P; Morgan J
 Southampton University Hospital Purpose: Radiofrequency Ablation (RFA) is an established therapy for the treatment of paroxysmal and persistent atrial fibrillation (AF). Many techniques have been reported to achieve RFA. We report a single center experience of RFA using three multielectrode catheters. Method: We collected data of the patients who had radiofrequency ablation for AF using custom designed multielectrode mapping and ablation catheters between May 2007 and November 2009 at this center. Results: 105 pts aged 56 ± 9.6 yrs underwent radiofrequency ablation using three multielectrode catheters. Eighty seven patients were new and 18 patients had redo AF ablation using the multielectrode mapping and ablation catheters. In the new patients the mean duration of procedure was 141 + 38 minutes and fluoroscopy time was 38 + 14 minutes. The mean duration of follow up was 15.8 + 6.4 months. Symptomatic improvement was achieved in 75 (86%) patients, 48 (55%) patients remained in sinus rhythm (SR) after first procedure while 7 (8%) had multiple procedures and remained in SR without Antiarrhythmic drugs (AADs). Fourteen (16%) patients required AADs following single procedure and one (1.1%) patient after multiple procedures to remain in sinus rhythm. Seven (8%) patients had reduced burden of AF. No improvement occurred in 12 (13.7%) patients. In the 18 redo patients, 15 (83.3%) patients had symptoms improvement. Four (22.2%) patients remained in SR after single procedure and 4 (22.2%) patients required multiple procedures to remain in sinus rhythm without AADs. one (5.5%) patient remained in sinus rhythm on AADs following single procedure one (5.5%) patient remained in sinus rhythm on AADs following multiple procedures. Five (27%) patients had reduced burden of AF and 3 (16.6%) patients had no improvement. Conclusion: PVI using multielectrode mapping and ablation catheters is an effective treatment of paroxysmal and persistent AF with a complication rate equivalent to published data. O014 CHARACTERIZATION OF FRACTIONATED ATRIAL ELECTROGRAMS CRITICAL FOR MAINTENANCE OF AF: A RANDOMIZED CONTROLLED TRIAL OF ABLATION STRATEGIES (THE CFAE AF TRIAL) Hunter RJ; Diab I; Tayebjee M; Richmond L; Sporton S; Earley M; Schilling RJ
 Cardiology Research Department, St Bartholomew's Hospital Introduction: Whether ablation of complex fractionated atrial electrograms (CFAE) modifies AF by eliminating drivers or atrial de‐bulking remains unknown. This randomised study aimed to determine the effect of ablating different CFAE morphologies compared to normal electrograms (i.e. de‐bulking normal tissue) on the cycle length of persistent AF (AFCL). Methods: After pulmonary vein isolation CFAE were targeted until termination of AF or abolition of CFAE prior to DC cardioversion. 10s electrograms were classified according to a validated scale, with Grade 1 being most fractionated and grade 5 normal. Patients were randomised to have CFAE grades eliminated sequentially, from grade 1 to 5 (group 1) or grade 5 to 1 (group 2). Because grade 5 electrograms were considered normal, only 5 were ablated. An increase in AFCL (mean of left and right atrial appendage) ≥ 5 ms was regarded as significant. Results: 968 CFAE were targeted in 20 patients. CFAE grade determined by rapid visual inspection agreed with that at off‐line manual measurement in 93% (k= 0.91). AFCL increased after targeting 51 ± 35% of grade 1 CFAE, 30 ± 15% grade 2, 12 ± 5% grade 3, 33 ± 12% grade 4, and 8 ± 15% grade 5 CFAE (p < 0.01 for grades 1, 2, and 4 versus 5, 3 versus 5 not significant). Binary logistic regression confirmed the impact of CFAE grade, but showed no effect of electrogram amplitude, location in the left or right atrium, or the order in which CFAE were targeted on the proportion of lesions causing AFCL prolongation. Elimination of the most fractionated electrograms first reduced the number of grade 3 and 4 CFAE encountered (group 1 versus group 2 both p < 0.01), translating to fewer CFAE targeted per patient in group 1 compared to group 2 (37 ± 14 and 58 ± 18 respectively; p = 0.015). Conclusion: Targeting CFAE is not simply atrial de‐bulking. Ablating certain grades of CFAE increases AFCL, suggesting they are more important in maintaining AF. O015 COMPARISON OF LEFT MITRAL AND INFERIO‐SEPTAL ISTHMUS ABLATION FOR CURE POSTABLATIVE PERIMITRAL FLUTTER Ardashev AV; Zhelyakov EG; Konev AV; Rybachenko AV; Belenkov YuN*
 83 Clinical Hospital of FMBA, * Lomonosov State University, Moscow, Russia Aim: to compare mitral isthmus vs. inferio‐septal isthmus ablation to cure perimitral atypical atrial flutter (PAAF) after radiofrequency ablation (RFA) of atrial fibrillation (AFib). Methods: Study consisted of 22 pts (8 women, 54.3 ± 13.6 years of age) with PAAF who underwent RFA because of paroxysmal (4 pts), persistent (11 pts) and permanent (7 pts) AFib. All studied pts underwent redo because of drug‐refractory PAAF in the period of 6 ± 3 months after primary RFA. Activation mapping and entrainment technique demonstrated PAAF in all studied pts. Mitral isthmus RF‐lesions in the left atrium were a first step (endocardial approach to mitral isthmus). Then distal CS‐roof RFA was performed (epicardial approach to mitral isthmus). As a third step linear RFA of the inferio‐septal isthmus (from right inferior pulmonary vein ostium to mitral annulus) was performed (endocardial approach to inferioseptal isthmus). Additional RF‐applications delivered inside the proximal CS roof (epicardial approach to inferioseptal isthmus). Results: Left mitral isthmus endocardial RF‐pulses terminated AAF in 4 cases, increased CL of PAAF without changes of atrial hierarchy activation in 2 cases (from 200 to 310 ms), and transformed PAAF to AFib in 2 cases. Distal CS‐roof RF‐isolation terminated PAAF in 2 pts. Endocardial inferio‐septal isthmus ablation was associated with SR restoration in 2 cases and increasing of PAAF CL in 5 cases. RFA applied into the proximal CS terminated PAAF in 10 pts. Follow up was 26.7 ± 12.4 mos. Endocardial and epicardial mitral isthmus approach terminated perimitral PAAF in 6 pts (36%). RF‐ablation of endocardial and epicardial aspects of the inferioseptal isthmus restored SR in 12 pts (64%) (p < 0.05). There were neither AFib nor PAAF during follow up period. Conclusion: Endocardial and epicardial aspects of the inferio‐septal isthmus seem to be more critical comparing to mitral isthmus to cure PAAF after RFA of AFib. O016 TWO DIFFERENT ABLATION STRATEGIES IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION: A PROSPECTIVE RANDOMIZED COMPARISON Romanov A; Pokushalov E; Shabanov V; Elesin D; Artemenko S; Stenin I; Yakubov A; Losik D
 State Research Institute of Circulation Pathology Introduction: The aim of this study was to compare PVI isolation plus LL with PVI plus ablation of ganglionated plexi (GP) in patients with paroxysmal AF. Methods: One hundred forty six consecutive patients with paroxysmal AF were randomly assigned to 2 different ablation schemes: PVI plus LL (n = 72) and PVI plus GP (n = 74). Primary end point was to assess the maintenance of sinus rhythm (SR) after procedures. Anti‐arrhythmic drugs were discontinued within 2–4 weeks after ablation in both groups. PVI was successful in all targeted veins in both groups. Results: PVI plus GP – after single procedure at the 12‐month follow‐up, 51 of 74 patients (68.9%) were in SR without AAD. AF recurrence was the reason of a redo procedure in 11 patients, atypical atrial flutter in 2 patients, and typical atrial flutter in 3 patients. In the 2 patients with atypical atrial flutter, a reentry circuit involving the right PVs was the mechanism. Among the remaining 11 patients with AF recurrence a recovery of veno‐atrial conduction in at least 1 or more PVs was found in all the patients. With the addition of a second procedure, the overall success rate without AAD was 79.7% (59 of 74 patients). PVI plus LL – 38 of 72 patients (52.7%) were in SR without AAD (p = 0.006). Repeat ablation was performed for recurrent AF in 21 patients, and for atypical atrial flutter in 9 patients. The mechanism of the atypical atrial flutter was a conduction gap in the lesion line of the left isthmus in 7 cases and a conduction gap in the roof line in 2 patient. Among the 21 patients with AF recurrence, a recovery of veno‐atrial conduction in at least one or more PVs was found in all the patients. After second procedure, the overall success rate without AAD was 73.6% (53 of 72 patients; p = 0.03). Conclusions: PVI isolation plus GP is superior to the PVI plus LL strategy in maintaining SR without antiarrhythmic drugs after first and second procedures in paroxysmal AF. O017 PULMONARY VEIN ISOLATION: A COMPARISON OF THE ABLATION PROCEDURAL OUTCOMES BETWEEN POINT BY POINT AND MULTIPOLAR CIRCULAR ABLATION CATHETER (PVAC) IN PATIENTS WITH ATRIAL FIBRILLATION Lim SH; Lewis A; Affolter J; Broadhurst P
 Aberdeen Royal Infirmary Background: Catheter ablation is widely used in the treatment of atrial fibrillation. The aim of this study is to compare the procedural outcomes between point by point ablation and multipolar circular ablation catheter (PVAC) for pulmonary vein isolation (PVI) in patients with atrial fibrillation. Methods: This was a retrospective cohort analysis of adults undergoing PVI in a tertiary care center. Procedural outcomes were compared between PVAC and point to point ablation group using student's t‐test and the chi‐square as appropriate. A p < 0.05 was considered statistically significant. Outcomes: Among 85 patients (mean age 56years, 54men) undergoing PVI ablation, 57 patients had point to point ablation and 28 had PVAC ablation. NAVX geometry mapping of the left atrium was used in both ablations. Screening time (46 vs 66mins; p = 0.000), radiation dose from fluoroscopy (5553 vs 8282cGy.cm2; p = 0.010) and duration of procedure (3 vs 4 hours; p = 0.000) were significantly shorter in the PVAC group. There was also higher success of complete electrical isolation of targeted pulmonary veins using PVAC (93 vs 76%; p = 0.064). In addition, there was less additional ablations (roof lines and cavo tricuspid isthmus ablation) and pre procedural cardiac CT/MRI performed in patients undergoing PVAC ablation and this were statistically significant. Ablation duration, day 1 post ablation rhythm, procedure complications and days of admission were comparable between both groups. Conclusion: Patients undergoing PVI ablation using PVAC had higher success in electrically isolating the targeted pulmonary veins and lower screening time, procedure duration and radiation dose. The results suggest PVAC may prove to be a practical option to point by point ablation. O018 EFFECTS OF PULMONARY VEIN ISOLATION ON THE CARDIOPULMONARY EXERCISE PARAMETERS IN PATIENTS WITH SYMPTOMATIC ATRIAL FIBRILLATION Kriatselis C; Brala D; Nedios S; Gerds‐Li JH; Fleck E
 Deutsches Herzzentrum Berlin Introduction: Pulmonary vein isolation (PVI) is an effective procedure for symptomatic atrial fibrillation refractory to treatment. Following successful PVI, most patients experience an improvement in subjective symptoms. However, the effect on objective cardiopulmonary exertion parameters is not yet known. We studied the influence of PVI on these parameters, as tested by cardiopulmonary exercise testing with maximal exertion. Methods: Twenty‐eight patients (8 women, age 58 ± 11 years) with paroxysmal (n = 15) or persistent (n = 13) atrial fibrillation and indication for PVI were studied. Spiroergometric testing was performed before and 3 and 6 months after PVI (ergometer bicycling in semi‐supine position, stress increase of 10 Watts/min until symptom‐limited maximal exertion reached). Antiarrhythmic medication was terminated after 4 weeks in patients with paroxysmal and after 3 months in those with persistent atrial fibrillation. Cardiopulmonary parameters measured or calculated were: maximal oxygen uptake (VO2max, ml/min), functional capacity (FC,% VO2max/VO2 pred.) und anaerobic threshold (AT, calculated by the V‐slope method). Results: FC before PVI was 92 ± 16% (range 65–125%). Six months after PVI 24 patients had sinus rhythm. VO2max and FC were significantly increased in comparison with the baseline values (2114 ± 750 vs 1954 ± 635 ml/min, p: 0.021 and 101 ± 24 vs 93 ± 17%, p: 0.04). The AT was also significantly improved (1224 ± 330 vs 1080 ± 338%, p: 0.003). Summary: Following primarily successful isolation of the pulmonary veins the maximal oxygen uptake, functional capacity and anaerobic threshold of patients show a significant increase through a follow‐up period of six months. O019 EFFICACY, SAFETY, AND OUTCOME OF ATRIAL FIBRILLATION ABLATION IN THE ELDERLY Arbelo E; Guiú E; Andreu D; Borras R; Berruezo A; Tolosana JM; Brugada J; Mont L
 Hospital Universitari Clínic, Thorax Institute, Barcelona, Spain Introduction: Catheter ablation of atrial fibrillation (AF) has become a treatment option for patients with drug refractory AF. With improved safety, the therapy has been offered to older populations. However, the outcome of AF ablation in the elderly is not clear. The aim was to compare success rate, outcome, and complication rate of AF ablation in the elderly (>70 years old) versus the younger population. Methods: We retrospectively analyzed 785 consecutive patients that had undergone a catheter ablation for drug‐refractory symptomatic AF from 2003 to 2011. Patients were divided into two groups: (Gr1) ≥70 years (n = 41) and (Gr2) <70 years (n = 744). AF ablation consisted of pulmonary vein antral isolation with or without additional linear lesions of complex fractionated electrogram ablation. Follow‐up was performed at 1, 3, 6 months after the procedure and every 6 months thereafter. After a 3 month blanking period, recurrence was defined as any arrhythmia of ≥30 seconds. Results: Baseline characteristics among the two groups only differed in gender (78% Gr1 vS 42% Gr2), presence of hypertension (40% Gr1 and 59% Gr2) and the duration of AF (57,5 ± 58,1 Gr1 and 59,1 ± 59,2 Gr2). No differences were observed in terms of LA diametre, structural cardiomyopathy, nor other arrhythmia predictor. After a follow‐up 14,5 ± 14,9 months, there was no difference in the arrhythmia‐free survival curve after a 1st procedure (60% G1 vs. 56% Gr 2 at 12‐months, log‐rank p = 0,66). The complication rate was similar (8,1% in group 1 versus 7,3% in Gr2). However, there were 2 strokes and 2 other cardioembolic events in the group ≥70 yo, and this was significantly different (1,5% group 1 versus 9,8% group 2,). There were no deaths. Conclusion: AF ablation is a safe and effective treatment for AF in the older patients. However, special care must be taken with the anticoagulation management, for there seems to be a higher risk of periprocedural thromboembolic events. O020 CATHETER ABLATION WITHOUT FLUOROSCOPY: A SINGLE INSTITUTION EXPERIENCE Clark JM; Smith GL; Lane J
 Akron Children's Hospital, Akron OH Introduction: Catheter ablation without the use of fluoroscopy is becoming more widely used. We review our experience over the last three years utilizing the Ensite system. Methods: Chart review was performed for all ablations either completed or attempted without fluoroscopy between January 2008 and May 2011. Information gathered included patient age, height, weight, tachycardia mechanism, ablation energy used, procedure time, fluoroscopy time, success or failure of procedure, and complications. For patients undergoing transseptal puncture, transesophageal echocardiography (TEE) was used instead of fluoroscopy. Results: There were 224 procedures performed or attempted without fluoroscopy. In 221 procedures fluoroscopy was not used. Mean patient age was 14 years (range 6 months to 65 years). Mean weight was 57.2 kg (range 7.2 – 142kg). Mean procedure time was 142 minutes (range 42 – 402 minutes, median 127). The mechanisms of tachycardia were as follows: AVNRT in 80 patients; WPW in 80 patients; concealed accessory pathway in 46 patients; AET in 5 patients; VT in 4 patients; flutter in 2 patients; and 7 patients had more than one tachycardia mechanism. Radiofrequency energy was used in 123 procedures, cryoenergy in 99, and both in 2. Acute success was achieved in 219/224 (98%). There were no complications. Fluoroscopy was needed in three procedures. One patient with a left‐sided pathway was ablated under conscious sedation, and therefore could not undergo TEE. One patient required fluoroscopy due to technical problems with TEE. And one patient with flutter had a transvenous atrial pacing lead. Fluoroscopy was used to localize the tip of the pacing lead. Conclusion: Catheter ablation can be routinely performed without the use of fluoroscopy. Utilizing newer three‐dimensional mapping systems, fluoroscopy is rarely necessary. This has long‐term benefits to both patients and staff. O021 TRANSCRANIAL MEASUREMENT OF CEREBRAL MICROEMBOLIC SIGNALS DURING PULMONARY VEIN ISOLATION: A COMPARISON OF TWO DIFFERENT ABLATION TECHNIQUES Nagy‐Baló E; Tint D; Beke I; Clemens M; Kovács R*; Csiba L*; Édes I; Csanádi Z
 Institution of Cardiology and Department of Neurology*, University of Debrecen, Hungary Backround: Pulmonary vein isolation (PVI) have been increasingly used to cure atrial fibrillation. Recently, concerns have been raised that subclinical brain damage may occur due to microembolisation during these procedures. We compared the occurrence of bubble formation seen on intracardiac echocardiography (ICE) and microembolic signals (MES) detected by transcranial Doppler using different ablation techniques and anticoagulation strategies. Methods and Results: 26 procedures in 25 consecutive patients (age: 51 ± 13 years; female:male 5:20) were included in this prospective study. PVI was performed using cryoballoon and conventional anticoagulation protocol (ACT>250 sec) during 7 procedures (Group1), multipolar duty‐cycled radiofrequency catheter (PVAC) and conventional anticoagulation protocol in 12 procedures (Group 2) and PVAC with an aggressive anticoagulation regime (ACT>350 sec) during 7 procedures (Group 3). The total number of MES detected during the procedures were 1494 ± 1136 in group 1, 5631 ± 3317 in group 2 and 5419 ± 2064 in group 3 (p = 0,01). A significant difference was also demonstrated in the number of solid microemboli in the 3 groups (220 ± 97, 915 ± 240 and 963 ± 385, respectively, p = 0,01). MES were detected mostly during energy delivery in all 3 groups (425 ± 405, 30903 ± 3076 and 3619 ± 1636, respectively, p = 0,01). Strong correlation (r = 0.89) was found between the degree of bubble formation on ICE and the number of MES in all groups. Conclusion: Duty‐cycled RF ablation is associated with significantly more MES even when a more aggressive anticoagulation is applied. Most of MES are gaseous in nature and occur during energy delivery. ATRIAL FIBRILLATION: EPIDEMIOLOGY, AETIOLOGY AND MANAGEMENT O022 PREDICTORS OF CLINICAL EFFICACY OF "ABLATE AND PACE" THERAPY IN PATIENTS WITH PERMANENT ATRIAL FIBRILLATION Brignole M; Botto GL; Mont L; Oddone D; Iacopino S; De Marchi G; Campoli M; Sebastiani V; Vincenti A; Garcia Medina D; APAF
 Ospedali del Tigullio Aim: To evaluate the 2‐year clinical improvement after "Ablate and pace" therapy and to identify the variables able to influence its efficacy in patients with severely symptomatic permanent atrial fibrillation (AF). Methods and results: In the Ablate and Pace in Atrial Fibrillation (APAF) trial, 171 patients, in whom AV junction ablation had been successfully performed, were randomly assigned to right ventricle (RV) pacing or echo‐guided cardiac resynchronization (CRT) pacing and had valuable follow‐up data. During a median follow‐up of 20 months (interquartile range 11 – 24), 125 (73%) patients had clinical improvement after "Ablate and pace" therapy (Responders group); responders were 63% of RV paced patients and 83% of CRT paced patients (p = 0.003). Other 46 (27%) patients did not have clinical improvement (7%) or worsened (20%) (Non‐responders group). At univariate analysis, non‐responders were more likely to be males, to have lower systolic blood pressure, larger LV end‐systolic diameter and to have RV pacing. At multivariable Cox regression analysis, CRT mode and echo‐optimized CRT remained the only independent protective factors against non‐responsive conditions (HR = 0.24 [95% CI 0.10–0.58, p = 0.001 and 0.22 [95% CI 0.07–0.77, p = 0.018 respectively). When comparing freedom from non‐responsive conditions, there was a trend in favor of echo‐optimized CRT versus simultaneous biventricular pacing (p = 0.077). Conclusion: In patients affected by severely symptomatic permanent AF, clinical benefit from Ablate and Pace therapy was observed in 63% of RV pacing group and 83% of CRT pacing group. CRT pacing and echo‐optimized CRT were the only independent predictor of clinical benefit. O023 DOES THE LEFT ATRIAL APPENDAGE MORPHOLOGY CORRELATES WITH THE RISK OF STROKE IN PATIENTS WITH ATRIAL FIBRILLATION? RESULT FROM A MULTICENTER STUDY Di Biase L; Gaita F; Anselmino M; Horton R; Santangeli P; Salvetti I; Gilli S; Sanchez J; Burkhardt JD; Natale A
 Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA Introduction: The left atrial appendage (LAA) represents one of the major cause of TIA/stroke in pts with atrial fibrillation (AF). We quantitatively studied various morphology of the LAA by computed tomography (CT) and by magnetic resonance (MRI) and correlated the LAA morphology with the history of stroke/TIA. Methods: 932 pts with drug refractory AF planning to undergo AF ablation. All pts underwent cardiac CT or MRI and care was taken to obtain LAA frames. All pts were screened for history of TIA/stroke. LAAs were categorized into different morphologies which included Chicken Wing, Windsock, Cauliflower and Cactus. Results: CT images of 499 patients and MRI images of 433 pts were analyzed (59 ± 10 yrs, 79% male, BMI 27 ± 4, EF 60 ± 7, 14% CHADS2 ≥2). The LAA was categorized into four morphologies: 278(30%) pts were classified as Cactus, 451(48%) as Chicken Wing, 179(19%) as Windsock and 24(3%) as Cauliflower. Out of the 932 pts, 73(8%) pts had prior history of ischemic stroke or transient ischemic attack. The prevalence of pre‐procedure stroke/TIA in Cactus, Chicken Wing, Windsock, and Cauliflower morphologies were 12%, 4%, 10%, and 18% respectively (p = 0.003). After controlling for CHADS2 score, gender, and AF types in a multivariable logistic model, Chicken Wing morphology was found to be more likely to remain stroke‐free (odds ratio 19, p = 0.043). In separate multivariate model we entered chicken wing as reference group and assessed the likelihood of stroke in other groups in relation to reference. Compared to chicken wing, Cactus had 4.08 times (p = 0.046), Windsock‐ 4.5 times (p = 0.038), and Cauliflower 8.0 times (p = 0.056) more likely to have an ischemic event. Conclusion: This study suggests that pts with chicken wing morphology are less likely to have an embolic event even after controlling for comorbidities. If confirmed, these results could have a relevant impact on the anticoagulation management of pts with an intermediate risk for stroke. O024 A GLOBAL COMPARISON OF THE APPROPRIATENESS OF THROMBOPROPHYLAXIS AT TIME OF ACUTE CARDIOVERSION: PRELIMINARY DATA FROM THE RHYTHM‐AF STUDY Lip GYH; Crijns HJGM; Bash LD; for the RHYTHM‐AF Study Scientific Committee
 University of Birmingham, Birmingham, England Purpose: Explore type of antithrombotic therapy (ATT) in atrial fibrillation (AF) patients (pts), and appropriateness at cardioversion (CV), in terms of stroke risk and AF duration. Methods: RHYTHM‐AF is a prospective observational study in 10 countries (8 in EU, Brazil, Australia). Pts considered for CV were enrolled from acute care settings between May 2010 and July 2011. Data collected at time of AF; descriptive statistics compared type of ATT administered at time of CV and discharge, related to both stroke risk ('high risk' defined by CHA2DS2‐VASc score ≥ 2) and duration of AF (< or ≥ 48 hrs) of each patient. Pts with unknown AF duration were included in the group with AF ≥ 48 hrs. Results: Of 2381 pts who were cardioverted (35% via pharmacologic (PCV), 65% via direct current (DCV) cardioversion), 63% were at high risk of stroke and 24% presented with AF ≥ 48 hrs. Among all pts undergoing PCV and DCV, 64% (n = 540) and 74% (n = 1141), respectively, had either a high stroke risk or AF>48hrs. Among these high risk pts, 35% (n = 191), and 85% (n = 971) were on vitamin K antagonists (VKA) or heparin at time of PCV and DCV, respectively. At discharge, these rates had risen to 60% and 93%, respectively. Among all low stroke risk pts with a short AF duration undergoing PCV (n = 300) and DCV (n = 400), 14% and 71% were overtreated with VKA or heparin at the time of CV, respectively. At discharge, these rates even rose further to 27% and 79%, respectively. Conclusions: In the majority of high risk AF pts PCV is performed without appropriate ATT. PCV does not seem to trigger correct ATT although between conversion and discharge the numbers of appropriately treated PCV pts increased significantly. In contrast, DCV is most frequently performed under appropriate ATT. Overtreatment with ATT occurs mainly in pts undergoing DCV. To enhance pericardioversion stroke prevention, CV algorithms should focus less on type of conversion and more on stroke risk factors and AF duration. O025 AF AS A CONSEQUENCE OF TUBERCULOUS PERICARDITIS: SOUTH AFRICAN EXPERIENCE Syed FF; Ntsekhe M; Wiysonge C; Badri M; Oh JK; Mayosi B; IMPI Africa
 Cardiac Clinic, Univ. of Cape Town, S.Africa and Div. of Cardiology, Mayo Clinic, Rochester, USA Background: There is no study regarding the prevalence, correlates, and natural history of atrial fibrillation (AF) associated with tuberculous (TB) pericarditis to guide the management of affected patients. Methods: Consecutive patients presenting with TB pericardial effusion of at least 1 cm width anteriorly recruited between January 2006 and September 2008 for a study of HIV‐associated cardiomyopathy were reviewed. AF was diagnosed on 12‐lead electrocardiography taken at presentation and repeated at follow‐up intervals of 2 weeks, 2 months and 6 months. Logistic regression analysis was used to determine factors associated with AF at presentation. No anti‐arrhythmic interventions were administered to patients with AF. Results: Eighty patients with TB pericardial effusion were enrolled. The median [IQR] age was 33 [28–43] years, 53 (66%) were male and 71% were HIV‐infected. The prevalence of AF at presentation was 25% (20/80). All underwent pericardiocentesis, with no change in numbers with AF. Anti‐tuberculosis chemotherapy was associated with a rapid resolution of AF, with 80% recovery of sinus rhythm at 2 weeks, 90% at 2 months, and 100% at 6 months. In multivariate logistic regression analysis, left ventricular systolic dysfunction (odds ratio [OR]= 10.395, 95% CI 2.504–43.157, p = 0.001) and raised N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) (OR per ng/L increase = 1.001, 95% CI 1.000–1.002, p = 0.003) were independently associated with AF. There was no significant difference in the prevalence of AF in survivors compared to those who died at 6 months of follow‐up, and no case of stroke was observed among the survivors. Conclusions: AF is common in patients with TB pericardial effusion, but resolves completely over six months of anti‐tuberculosis treatment without anti‐arrhythmic interventions. Left ventricular systolic dysfunction and raised NT‐proBNP are independently associated with AF in TB pericarditis. O026 AV NODE ELECTRIC BYPASS IN PATIENTS WITH REFRACTORY SYMPTOMATIC PERMANENT ATRIAL FIBRILLATION: SINGLE CENTRE PROSPECTIVE STUDY De Filippo P; Ferrero P; Ferrari P; Brambilla R; Cantù F
 Electrophysiology and Cardiac Pacing Unit, Cardiovascular Department, OORR Bergamo, Italy Background: Ablate and pace provide optimal rate control in patient with refractory symptomatic atrial fibrillation. Main drawback of this strategy is life‐long nonphysiologic ventricular activation. An appealing solution is to set up a AV node electric bypass (AVNEB) combining pure His bundle stimulation with compact node ablation. We sought to investigate the feasibility and the long term clinical and technical outcome of this strategy. Methods: This intention‐to‐treat study enrolled patients with long lasting symptomatic atrial fibrillation refractory or not further amenable of rhythm control with heart rate not controlled. Preliminary workup included: echo, six minute walking test, quality of life assessment (SF 36). All patients underwent an attempt of AVNEB; if it failed, a conventional ablate and pace procedure was delivered. In patients undergoing AVNEB a second back up lead was implanted. Pre procedural assessment and device control were repeated at 3, 6 and 12 months. Results: 12 patients (67 ± 6 years) were enrolled: in 10/12 AVNEB was achieved, in 2/12 a conventional ablate and pace procedure was performed. Out of the 10 patients with AVNEB, we observed a transient loss of capture during RF application in 5/10 not impairing procedural success, a late loss of His capture in 2/10 and a recovery of AV conduction in 2 patients that required a redo AV node ablation. His capture threshold progressively increased over time (2,5 times at 1 year vs baseline). In all 12 patients, we observed a significant improvement of quality of life and 6 minute walking distance, while the trend in EF increase was not significant. Conclusions: Although AVNEB is an attractive therapeutic strategy, we observed important technical drawbacks that may limit its clinical routine applicability. The main challenge appears to be the capability of delivering a stable pure His pacing together with an efficacious ablation of the AV node. O027 DIASTOLIC FUNCTION IS AN IMPORTANT FACTOR FOR BOTH SUCCESSFUL AND FASTER PHARMACOLOGIC CONVERSION TO SINUS RATE IN PATIENTS WITH FIRST EPISODE OF NON‐VALVULAR ATRIAL FIBRILLATION Nikas D; Theodorou S; Karanasios A; Antonopoulos E; Papazoglou G; Kyriazos I; Latsoudas S; Kefalas K; Antonoulas A
 Cardiology Department, Lamia General Hospital, Lamia, Greece Introduction: To evaluate patterns of diastolic dysfunction associated with successful pharmacological cardioversion (PCV) in patients with atrial fibrillation of recent onset (Afib). Methods: Prospective study included 164 patients [82 males (50.0%), mean age 67.6 ± 14.6] with first episode of Afib for PCV. NT‐proBNP at admission (aNT‐proBNP) and discharge (dNT‐proBNP), absolute and relative (%) NT‐proBNP difference (dfNT‐proBNP,%dfNT‐proBNP) and E/e' ratio were used as patterns of diastolic dysfunction. Patients were categorized in group A for successful PCV and Group B for unsuccessful PCV, within 72 hours. Statistical analysis was performed using t‐test for comparisons and linear regression analysis for correlations. Results: Patient in Group A had significantly lower values of E/e' ratio (mean 7.0 ± 3.4 for Group A and mean 8.6 ± 3.7, p = 0.04). There was no difference in aNT‐proBNP, dNT‐proBNP or dfNT‐proBNP between the two groups. Lower levels of aNT‐proBNP and the lower values for E/e' were significantly correlated with shorter days for PCV (r = 0.41, p < 0.03 and r = 0.44, p = 0.05, respectively) (Figures 1 and 2). Conclusions: Lower values of E/e' ratio in admission are associated with better rates and shorter time for PCV. Lower levels for aNT‐proBNP is associated with shorter time for PCV but no better rates of PCV. O028 SIX MONTH OUTCOMES IN PATIENTS ENROLLED IN A CONTEMPORARY MIDDLE EASTERN ATRIAL FIBRILLATION REGISTRY (GULF SAFE) Zubaid M; Rashed W; Alsheikh‐Ali AA; AlMahmeed W; Shehab A; Sulaiman K; Al‐Zakwani I; Al Qudaimi A; Asaad N; Amin H; Gulf SAFE Registry
 Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait Purpose: To study the clinical characteristics and six month outcomes of atrial fibrillation (AF) patients in the Middle East. Methods: We used data from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE), a prospective multinational registry of consecutive AF patients presenting to emergency rooms (ER) of 23 hospitals in the Gulf region of the Middle East between October 2009 and June 2010. Results: We enrolled 2043 patients (age 57 ± 16, age ≥75 (14%), 48% female, 30% with diabetes, 53% with hypertension, 28% with history of heart failure, 13% with prior stroke/transient ischemic attack (TIA), 24% with history of significant valvular disease). Types of AF were: first attack 37%, paroxysmal 17%, persistent 10%, permanent 33% and not known 3%. Of patients with non‐valvular disease, 25% had CHADS2 score of 0, 27% had CHADS2 score of 1 and 48% had a CHADS2 score of 2 or more. AF was the primary reason for ER visit in 45% of patients, of whom 75% presented within 48 hours of symptom onset. Six month follow up was completed for 1772. Six month mortality was (7%). [3.2% for patients with primary reason for ER visit AF, 17% for patients with primary reason for ER visit other cardiac, 24.2% for patients with primary reason for ER visit other non‐cardiac]. At six month follow up the following outcomes were recorded: TIA in 21 patients (1.2%), stroke in 26 (1.5%), peripheral embolization in 2 (0.1%), any bleeding in 114 (6.4%), major bleeding in 21 (1.2%), admission for heart failure in 142 (8%) and admission for atrial fibrillation in 109 patients (6.2%). Conclusions: Middle Eastern patients with AF are relatively young with high risk profile. They have relatively low incidence of adverse outcomes at six months. O029 PREDICTIVE FACTORS OF ATRIAL FIBRILLATION RECURRENCE AFTER CARDIOVERSION Masar G; Ejup P; Blerim B; Dardan K; Xhevdet K
 UCC of Kosova Introduction: Cardioversion to sinus rhythm should be considered for all patients in atrial fibrillation (AF). Our aim was to determine the immediate and long‐term outcome of cardioversion in patients with atrial fibrillation, and to determine factors predicting AF recurrence after cardioversion. Materials and Methods: A prospective twenty‐years follow‐up study of 1220 patients with atrial fibrillation (coronary artery disease, 24.5%; arterial hypertension 65%; lone AF 10.5%) undergoing cardioversion between 1990 and 2010 was done. Transthoracic (98%) and transoesophageal (12%) echocardiograph examination were performed before rhythm–control cardioversion treatment algorithm strategy was involved. Results: Electrical cardioversion was successful in 94% of the patients. Female gender was associated with successful cardioversion (p = 0.02). Only 46% remained in sinus rhythm after the one‐year follow‐up. Patients with a structural myocardial disease were at a higher risk of recurrence of AF (54% of patients had one and 22%, more than one AF episode during one year follow‐up). Maintenance of sinus rhythm was associated with anti‐arrhythmic drug treatment (p = 0.033). Relapse of atrial fibrillation was associated with reduced left ventricular ejection fraction (p = 0.003). Complications occurred in 1.2% of the electrical cardioversions; of these, 0.4% were thromboembolic events. Discussion: Less than one half of the patients remained in sinus rhythm after the one year follow‐up despite the use of anti‐arrhythmic drugs and upstream therapies on AF. Electrical cardioversion is not without risk. Patients with a history of AF of >12 months, mitral valve disease, left ventricular dysfunction, enlarged left atrium and a history of recurrence of AF were at a higher risk of recurrence of AF. Conclusion: Cardioversion should be considered primarily when symptoms of AF are unacceptable despite optimal frequency regulation or in patients with AF detected for the first time. O030 THE FIRST EPISODE OF ATRIAL FIBRILLATION (AF): PAROXYSMAL, PERSISTENT OR UNCERTAIN? Panizo JG; Perea J; Galán L; Jiménez S; Romero R; Ruiz M; Villanueva A; Hinojar R; Ruiz JG; Cosío FG
 Cardiology Service. Hospital Universitario de Getafe, Madrid. Spain. Background: The classification of AF in paroxysmal or persistent has advanced our understanding of the clinical course and improved treatment indications. However, at the time of the first episode AF can not be classified and the clinical course is uncertain. Objectives: To study clinical presentation and course of a first documented episode of AF in a public hospital serving a Spanish industrial town of 250,000 people. Methods: From January 2008 to December 2010 we registered all patients with a first episode of AF admitted to the emergency room (ER). We excluded patients with poor clinical tolerance or structural heart disease, as cardioversion (CV) is generally applied in these, altering the natural course. Patients were followed up 15 ± 4 days after discharge. Findings: 168 patients admitted for AF were discharged (50.6% men, age 63.9 ± 13.9 y). The symptoms were palpitations in 35.5%, dyspnea in 13%, chest pain in 7.1%, syncope/presyncope in 14.3%, other in 7.1%, and 23.1% were asymptomatic. In 27 CV was attempted with antiarrhythmic drugs (AAD) followed in 1 by electrical CV and 25 of these were discharged in sinus rhythm (SR). The remaining 141 patients were managed with rate control drugs (digoxin, beta‐blocker, calcium antagonists) or no drugs, and after an observation time ≤ 48 h, 58 (41%) were discharged in SR and 83 (59%) in AF. Two patients each in the SR and AF groups received AAD on discharge. At follow‐up 15 patients discharged in AF had recovered SR. Conclusions: In patients without severe structural heart disease or arrhythmia intolerance, in the absence of AAD 41% recover SR in ≤48 h and another 11% at 15 day follow‐up. This high trend to persistence of AF after the first episode underlines the importance of early consideration of CV, either in the ER or soon after short‐term follow‐up, in order to prevent structural remodeling. Only long‐term follow‐up will allow the diagnosis of paroxysmal AF in cases with recurrent self‐limited episodes. BASIC SCIENCE: FROM BENCH TO BEDSIDE O031 AUTOANTIBODY AGAINST THE BETA1‐ADRENERGIC RECEPTOR PREDICT INCREASED MORTALITY FOR SUDDEN CARDIAC DEATH WITH CHRONIC HEART FAILURE Pei J‐H; Chen J‐Z; Zhang Y‐H; Cao K‐J; Zhang P; Pu J‐L
 Fu Wai Cardiovascular Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences Background: Clinical studies and in vitro animal experiments suggested that β1‐ adrenergic receptor autoantibody (β1‐AAB) played an important rule in the pathophysiological process of chronic heart failure (CHF). Removal of β1‐AAB with immunoabsorption reduced mortality in those patients. Therefore, we set to evaluate whether β1‐AAB may predict the prognosis and sudden cardiac death (SCD) in patients with CHF. Methods: In total of 2062 patients of CHF including 824 cases of dilated cardiomyopathy(DCM) and 1238 cases of ischemic cardiomyopathy(ICM) and control group(824 cases) were collected and followed‐up in this study. β1‐AAB was detected by ELISA method and compared the results in different groups. The correlation between β1‐AAB and the prognosis of CHF was analyzed. Results: The successful follow up rate was 85.26%(1758 cases) including 704(85.44%) cases of DCM and 1054(85.14%) cases of ICM with the median of 36 months(0.40□65 months), 379 (21.56%) cases composed of 164 cases of DCM and 215 cases of ICM died in total, 153(40.37%) cases including 69 cases of DCM and 84 cases of ICM had SCD. The positive rate β1‐AAB between CHF group and control group were 8.19% and 2.2% (p < 0.01). Cox regression analysis revealed that the positive β1‐AAB was associated with all‐cause mortality and SCD but not with Non‐SCD(NSCD) both in DCM(HR were 2.420 [95% CI:1.605–3.649] for all‐cause mortality, 4.514 [95% CI:2.405–8.471] for SCD and 1.691 [95% CI:0.969–2.951] for NSCD) and in ICM (HR were 2.339 [95% CI:1.673–3.271] for all‐cause mortality,3.749 [95% CI:2.389–5.884] for SCD and 1.475 [95% CI:0.877–2.480] for NSCD). Conclusions: The positive rate of β1‐AAB was higher in patient group than in the control group. It indicated 4 to 5‐fold of risk for SCD. It may serve as an independent predictor for the prognosis of the patients with CHF. Keywords: Autoantibody; β1‐adrenoceptor; biological marker; chronic heart failure; sudden cardiac death O032 FEASIBILITY OF LASER DOPPLER PERFUSION SENSOR FOR HEMODYNAMIC DIFFERENTIATION OF CARDIAC ARRHYTHMIAS Rajan V; Lee M; Schauerte P; Marx N; Stegemann B; Stegemann E
 Medtronic Bakken Research Center, Endepolsdomein 5, 6229GW, Maastricht, the Netherlands Introduction: Arrhythmia detection in cardiac implantable devices is solely based on rate and rhythm obtained from intracardiac electrogram signals. There is no proven, reliable and sensitive, hemodynamic sensor which can work in a closed loop with these devices. We are exploring the feasibility of using a tissue perfusion sensor based on laser Doppler flowmetry (LDF) technique to monitor the hemodynamic status of cardiac arrhythmias. Methods: Fifteen patients with an indication for an electrophysiological study were enrolled. Tissue perfusion was measured using a commercial laser Doppler perfusion monitor (LDPM). Fiber optic perfusion probes were placed epicutaneous on the left arm or high chest skin where a stable perfusion signal was observed. Arterial blood pressure was used as hemodynamic reference. High rate atrial and ventricular pacing at 120, 140, 160 and 180 beats per minute simulated supra ventricular and ventricular tachycardias. Results: Patients were mostly male (10 male, 5 female), the mean age was 47 ± 20 years, and the mean left ventricular ejection fraction was 52 ± 9.1%. Patients were evaluated for ventricular arrhythmia (7), AVNRT (4), WPW (1) and SVT (4). A significant linear relationship was observed (p < 0.01, r = 0.7) between change in mean arterial pressure and perfusion at 5 seconds after the simulated cardiac arrhythmias. High rate ventricular pacing (180BPM) resulted in 43.25 ± 13% drop in perfusion from baseline at 5 seconds reflecting the drop in pressure (35.5 ± 10%). Whereas the change in perfusion and pressure during high rate atrial pacing (180BPM) was relatively low (0.03 ± 19% vs 0.77 ± 15%) showing that LDPM has the potential for discriminating hemodynamically stable and unstable arrhythmias. Conclusion: Laser Doppler perfusion sensor is a potential tool for cardiac arrhythmia monitoring and therapy optimization. We are currently exploring the feasibility of miniaturizing the technique to realize a closed loop system. O033 CARDIAC RESYNCHRONIZATION THERAPY AND BONE MARROW CELL TRANSPLANTATION IN PATIENTS WITH ISCHEMIC HEART FAILURE AND ELECTRO‐MECHANICAL DYSSYNCHRONY. A RANDOMIZED PILOT STUDY Romanov A; Pokushalov E; Corbucci G; Prokhorova D; Shabanov V; Artemenko S; Stenin I; Elesin D; Losik D; Yakubov A
 State Research Institute of Circulation Pathology Introduction: The aim of this study was to evaluate the benefit of combining BMMC transplantation with CRT in patients with severe ischemic HF, left bundle branch block (LBBB) and mechanical dyssynchrony. Methods: Patients with ischemic HF, LVEF < 35%, LBBB and mechanical dyssynchrony underwent intramyocardial transplantation of BMMC and CRTD system implantation. This randomized, single‐blind, cross‐over study compared clinical and echocardiographic parameters during two follow‐up periods: 6 months of active CRT (BMMC+CRTact) and 6 months of inactive CRT (BMMC+CRTinact). Physical performance was assessed by means of a 6‐minute walking test. Myocardial perfusion was evaluated by SPECT. Quality of Life (QoL) was assessed through the Minnesota Living with HF Questionnaire (MLwHFQ). Results: Twenty‐six patients (64 ± 7 years) were enrolled in the study. The distance covered by the patients during the 6‐minute walking test significantly increased in the BMMC+CRTinact phase (BMMC therapy only) in comparison with the baseline (269 ± 68 vs 206 ± 51; p = 0.007) and in the BMMC+CRTact phase (BMMC therapy + CRT) in comparison with the BMMC+CRTinact (378 ± 59 vs 269 ± 68; p < 0.001). The summed rest and stress score (SPECT) decreased significantly in the BMMC+CRTact and BMMC+CRTinact phases in comparison with the baseline (P ≤ 0.03). Both phases showed equivalent myocardial perfusion in the segments into which BMMC had been injected. QoL score was significantly lower in the BMMC+CRTinact phase than at the baseline (44.1 ± 14 vs 64.8 ± 19; p < 0.001), and in the BMMC+CRTact phase than in the BMMC+CRTinact phase (26.4 ± 12 vs 44.1 ± 14; p = 0.004). Conclusion: BMMC and CRT seem to act independently on myocardial perfusion and electro‐mechanical dyssynchrony, respectively. Combining these two complementary therapies can significantly improve LV performance in patients with severe HF and electro‐mechanical dyssynchrony. O034 EFFECTS OF WENXIN GRANULE ON L‐TYPE CALCIUM AND TRANSIENT OUTWARD POTASSIUM CURRENT IN ADULT RAT MYOCARDIUM Wang X; Wang X; Wang T; Gu Y‐W; Tang Y‐H; Huang C‐X
 Department of Cardiology, Renmin Hospital of Wuhan University Arrhythmia is the leading cause of death of heart disease. The class I anti‐arrhythmic drugs showed that these drugs increased sudden death and total mortality compared with the placebo group. Wenxin Granule is developed by The China Academy of Traditional Chinese Medicine (TCM). From clinical application, it can effectively control the arrhythmia, and is safe and reliable. We used ventricular myocytes isolated from the heart of male rat. The whole patch‐clamp technique was performed to record current in ventricular myocardial cells of adult rats. Upon the application of Wenxin Granules, the amplitude of calcium current was decrease, The peak amplitude of ICa‐L was decreased 29.3%± 4.8%, 45.8%± 5.3%, 72.6%± 4.1% (n = 6, P < 0.05) by WenXin Granules derivatives at 1g/L, 5g/L, 10g/L, respectively. Wenxin Granules made current‐voltage (IV) curves upwards, shifted the curve to the right, and prolonged the recovery time of Ca2+ channel from inactivation. WenXin particle inhibited the current density of Ito and the decreased rates of the peak Ito were (15.31 ± 7.21)%, (32.86 ± 5.08)%, (53.25 ± 4.74)%, (73.23%± 4.11)%. at 1g/L, 5g/L, 10g/L, 20g/L group, respectively. The current‐voltage curve was shifted downward, and steady‐state inactivation curve shift to right. The results of the present work suggested that Wenxin Granule modulate L‐type calcium channels and transient outward potassium channel in rat cardiac myocytes. Our study suggested that Wenxin Granule might play a cardioprotective role, and suppress arrhythmias by altering Electrophysiological properties of ilon channel. O035 ASSOCIATION BETWEEN MYOCARDIAL HYPOXIA AND ATRIAL STRUCTURAL REMODELING IN THE RAPID ATRIAL PACING CANINE MODE Tianyi G; GuoJun X; Xianhui Z; Baopeng T; Xia G; Yaodong L
 Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, Chi Introduction: Atrial structural remodeling is important for the occurrence and maintenance of atrial fibrillation(AF). The high rate of atrial excitation would lead to tissue hypoxia during AF. However, the relation of myocardial hypoxia and atrial structural remodeling has not been clarified. Methods:"J"‐type electrodes were placed in the right atrial appendage under the guidance of X‐ray in 16 dogs, Animals in model group (n = 8) received fast pacing (400 beats/min) for 10 weeks while animals in control group (n = 8) maintained at sinus rhythm. Burst stimulation was applied to induce atrial fibrillation in all animals after 10 weeks, animals were sacrificed thereafter and the left atrial tissues were taken for myocardial collagen measurement (Masson staining) and myocardial ultrastructure examination. Western blot and real‐time polymerase chain reaction analyses of the expression of Matrix metalloproteinase 9(MMP‐9), vascular endothelial growth factor (VEGF), VEGF receptors, and hypoxia‐induced transcription factor‐1α (HIF‐1α) were performed. Results: Atrial myocardial collagen volume fraction was significantly increased in model group compared with the control group. Ultrastructure examination in atrial tissue evidenced disorder, fracture, collagen fiber proliferation, mitochondrial swelling, blurred cristae, and intercalated disc distortion, expansion. Compared with the control group, the MMP9, the VEGF, HIF‐1α of mRNA and protein levels increased significantly in the AF group. VEGF receptor‐1 mRNA, a high affinity receptor for VEGF, but not VEGF receptor‐2, was upregulated in the atria of the AF group. Conclusions: Upregulation of HIF‐1/VEGF is involved in the enhancement of MMP‐9 expression under hypoxic conditions.This may lead to atrial structural remodeling. Atrial fibrillation; Atrial structural remodeling; Hypoxia; Matrix metalloproteinase O036 SEVOFLURANE PRECONDITIONING PROTECTS ISOLATED RAT HEARTS AGAINST ISCHEMIA/REPERFUSION INJURY VIA ATTENUATION OF L‐TYPE CA2+ CURRENT SUPPRESSION Gong J; Yao Y; Fang N; Li L
 Department of Anesthesiology, Fuwai Hospital, and Peking Union Medical College Background: To investigated the effects of sevoflurane preconditioning on action potential duration (APD) and L‐type Ca2+ current (ICa, L) characteristics. Methods: Langendorff perfused SD rat hearts were randomly assigned to one of the 3 groups: time control group (TC group), ischemic‐reperfusion group (I/R group, 25 mins of ischemia followed by 30 mins of reperfusion), and sevoflurane preconditioning group (SpreC group, preconditioned with 3% sevoflurane for 15 mins). The hemodynamics, cardiac troponin I (cTnI) levels and arrhythmia data were measured. At the end of reperfusion, single left ventricle myocytes of epicardium were dissociated enzymatically, then the APD and ICa, L characteristics were determined by a whole‐cell patch clamp technique. Statistical significance was assigned as P < 0.05. Results: Sevoflurane preconditioning improved LVDP, ± dp/dt, and HR recovery, decreased cTnI release, and decreased the incidence of ventricular tachycardia or ventricular fibrillation upon reperfusion (SpreC vs I/R, P < 0.05). Compared with the TC group, ischemia‐reperfusion injury could shorten the APD90 (from 37.65 ± 3.05 s to 31.44 ± 2.93 s), reduce the peak ICa, L densities (from 9.68 ± 0.47 to 4.79 ± 0.25 pA/pF) and elevate the current‐voltage curves (P < 0.05). Compared with the I/R group, sevoflurane preconditioning could prolong the APD90, increase the peak ICa, L densities, and lower the current‐voltage curves (P < 0.05). The ICa, L steady‐state activation, inactivation, and recovery from inactivation curves were not significantly different between the I/R and SpreC groups. Conclusions: Sevoflurane preconditioning could protect isolated rat hearts against ischemia/reperfusion insults and improve reperfusion ventricular arrhythmias, which may be related to the attenuation of ICa, L current suppression induced by ischemia/reperfusion injury. Key words: reperfusion arrhythmia, sevoflurane, ischemia/reperfusion injury, preconditioning, L‐type Ca2+ current O037 DIFFERENTIAL DENSITIES OF CHOLINERGIC NERVES IN CANINE SUPRAVENTRICULAR REGIONS OF HEARTS Li Z; Zhao QY; Huang H; Yang B; Huang CX
 Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China Introduction: Cholinergic nerve plays an important role in the induction and maintenance of atrial fibrillation (AF). Cholinergic innervation at supraventricular tissues is considered to be the histological basis and ablation associated target site for the arrhythmia, however, the distribution of cholinergic nerve in supraventricular tissues is not studied. Methods: We performed histological and immunohistochemistrical staining on canine tissues of left atrial appendage (LAA), right atrial appendage (RAA), left atrium (LA), right atrium (RA), atrial septum (AS), crista terminalis (CT), pulmonary vein (PV) and superior vena cava (SVC) using hematoxylin and eosin (H&E) and antibodies to choline acetyltransferase (ChAT). Results: Normal canine cardiovascular histological structures were shown from H&E staining. Cholinergic nerve densities at LAA and RAA were significantly higher than LA, which was higher than RA, but no significant difference was observed between LAA and RAA. Furthermore, RA was significantly higher than AS, CT, PV and SVC while there were no significant differences among the latter four. Conclusions: The different densities of cholinergic nerve at canine supraventricular regions indicate that the heterogeneity property establishes the histological basis of cholinergic nerve mediated pathological conditions. Structures with higher cholinergic innervation at supraventricular tissues are considered to be ablation associated target site for AF. O038 DIFFERENT ELECTROPHYSIOLOGY EFFECTS BETWEEN SEVOFLURANE AND SEVOFLURANE POSTCONDITIONING ON CARDIOMYOCYTES DISPERSED FROM RAT HEARTS Gong J; Yao Y; Fang N; Li L
 Department of Anesthesiology, Fuwai Hospital, and Peking Union Medical College Objectives: To observe the effects of sevoflurane or sevoflurane postconditioning on action potential (AP) and L‐type calcium currents (ICa,L) of cardiomyocytes dispersed from Langendorff perfused rat hearts. Methods: Part I: The effects of 3% sevoflurane on AP and ICa,L of single left ventricle myocytes were tested. Part II: Langendorff perfused isolated SD rat hearts were randomly assigned to one of the 2 groups: ischemic/reperfusion group (I/R group), and sevoflurane postconditioning group (SpostC group, postconditioned with 3% sevoflurane at the first 15 minutes of reperfusion), then the AP and ICa,L characteristics of single left ventricle myocytes were determined by a whole‐cell patch clamp technique. Statistical significance was assigned as P < 0.05. Results: Part I: The amplitude of membrane potential (AMP) and resting membrane potential (RMP) were not changed by 3% sevoflurane (P < 0.05), but the APD90 was significantly prolonged from 37.56 ± 3.09 ms to 48.39 ± 3.13 ms (P < 0.05). Peak ICa,L densities were reduced at about 37% of the control group by 3% sevoflurane (P < 0.05). The data between the control group and the recovery group were not significantly changed. Part II: Compared with the I/R group, sevoflurane postconditioning increase peak ICa, L densities (from 4.79 ± 0.25 pA/pF to 6.94 ± 0.20 pA/pF, P < 0.05), but the time to peak was not changed (P < 0.05). There were no significant differences in the ICa,L steady‐state activation, inactivation, and reactivation curves between the I/R and SpostC groups. Conclusions: 3% Sevoflurane directly suppresses ICa,L peak densities and prolongs APD90 of cardiomyocytes, while 3% sevoflurane postconditioning attenuates the suppression of ICa,L peak densities induced by ischemia/reperfusion injury, which may extenuate calcium overload and may improve reperfusion ventricular arrhythmias. Key Words: ischemia/reperfusion injury, sevoflurane, L‐type Ca2+ current, action potential duration, postconditioning CARDIAC IMAGING O039 ESOPHAGYC MULTI SLICE 64 COMPUTED TOMOGRAPHY (MSTC‐64) 3D RECONSTRUCTION AND PASSIVE FUSION WITH ESOPHAGUS SHELL. A NOVEL APPROACH DURING PULMONARY VEIN ISOLATION. Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A; Kamlofsky M; Banega R
 Instituto Cardiovascular de Buenos Aires (ICBA) Purpose: Catheter ablation(CA) has proven as standard procedure for drug‐refractory atrial fibrillation (AF). Atrio esophagic fistula has been described as an infrequent but lethal complication of this procedure. Differents techniques were described to avoid this tremendous complication. Objective: Describe a new technique to determinate the accuracy of tridimensional esophagic reconstruction from MSTC‐64 to. Determine its feasibility and reproducibility as a methodological approach to avoid atrio esophagic fistula complication in a huge cohort of patients. Methods: Single‐center prospective analysis of consecutive patients who underwent ablation of atrial fibrillation and received a MSCT‐64 prior to ablation in the Center between May 2009 and May 2011. A MSTC‐64 computed tomography was optimized for imaging of pulmonary veins. We performed the tridimensional reconstruction of the esophagus as described previously to determinate the relation with the PVO. We designed simultaneously with the left atrium shell another one for the esophagus positioning a quadripolar catheter inside the esophagus. We performed the fusion of the left atrium with the MSTC using Verismo® tool. Results: 153 patients were included with a mean age 61 ± 9.7 yrs, 90% male and a mean BMI of 26.5 ± 6.4 kg/m2. 78 (93.97%) patients were in sinus rhythm at time of MSCT‐64. We determine the esophagus tract in 146 patients (95.18%). The accuracy obtained was of 62.02% when MSTC was performed more than 48hs prior PVI. When we discriminate studies performed less than 48 h we have obtained 83.82% of accuracy (p < 0.05). The range of mismatch between each structure after fusion was 6 mm ± 10 mm. Conclusions: Passive Fusion of the esophagus has a high accuracy to determinate the esophagus position if the MSCT is performed during the last 48h before the procedure. This allows avoid this critical structure during AF ablation and lets us modify the strategy during ablation procedure. O040 PREDICTIVE VALUE OF LEFT ATRIAL VOLUME AS DETERMINED BY MAGNETIC RESONANCE IMAGING FOR PULMONARY VEIN ISOLATION AS SINGLE ABLATION APPROACH FOR PERSISTENT ATRIAL FIBRILLATION Kriatselis C; Nedios S; Gebker R; Jahnke C; Paesch I; Gerds‐Li JH; Fleck E
 Deutsches Herzzentrum Berlin Background: Pulmonary vein isolation (PVI) is an effective interventional treatment for paroxysmal atrial fibrillation (AF). The role of PVI as single interventional treatment of persistent AF remains unclear. The purpose of this study was to test the predictive value of left atrial volume (LAV) as determined by cardiac magnetic resonance (CMR) imaging in patients with persistent atrial fibrillation undergoing PVI without any additional left or right atrial ablation lesions. Methods and Results: Sixty‐three consecutive patients (44 men, mean age: 63 ± 10 years) with drug‐refractory persistent AF were included. A CMR examination was performed one day before the scheduled PVI and the different LAVs were determined: maximal LAV (LAVmax), minimal LAV (LAVmin), LAVmax and LAVmin per m2 of body surface area, LA ejection fraction. The ablation procedure included isolation of all pulmonary veins without additional ablation lesions. If a second procedure was needed this included only reisolation of the reconnected PVs. During a mean follow‐up of 25 ± 7 months AF recurred in 25 out of 63 (40%) patients. A cut‐off value of 110 ml for LAVmin was the strongest predictor of outcome. 32 out of 34 patients (94%) of patients with an LAVmin ≤110 ml remained in sinus rhythm during follow‐up while this was the case in only 6 out of 29 patients (21%) with an LAVmin >110. The number of second ablation procedure was lower in patients with LAVmin ≤110 compared to those with LAVmin >110 (1.3 vs 1.7, p:0.01). Conclusions: LA volume as measured by preinterventional CMR is a significant predictor of long‐term outcome after pulmonary vein isolation in patients with persistent atrial fibrillation. As a minimal LAV of 110 ml or less predicts long‐term freedom from AF after pulmonary vein isolation, a strategy of extensive left atrial ablation in these patients does not seem to be justified. CARDIAC RESYNCHRONISATION THERAPY O041 CARDIAC RESYNCHRONIZATION THERAPY IN ROUTINE CLINICAL PRACTICE: RESULTS FROM A EUROPEAN SURVEY Nagamori J; Braunschweig F; Ståhlberg M
 Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Background: Current guidelines give detailed advice with regard to the selection of appropriate patients for cardiac resynchronization therapy (CRT). However, strategies for patient follow‐up and device optimization have not been subject to systematic research and may differ largely between institutions. This survey aimed to describe current follow‐up and device optimization strategies in European centers. Methods: A survey containing 35 questions regarding methods for post implantation follow‐up routines and optimization methods was sent out by email to centers implanting CRT‐devices in Sweden, Finland, Denmark, Spain, France and Germany. Results: A total of 52 centers, following‐up approximately 10.050 patients, responded to the survey (participation rate 15%). For CRT‐P patients the median time‐interval between follow‐up visits was 6 months (IQR: 3–6) while it was 1 month shorter for patients with CRT‐D. In 69% of the responding centers CRT‐optimization was routinely performed in all patients while 29% optimized selected patients only (non‐responders, NYHA IV, lowest EF). When device optimization was considered, the atrioventricular‐ and interventricular delay was individualized in 98% and 82% respectively. In a subset of centers, pacing mode (55%) and basic heart rate (32%) was also modified to maximize treatment efficacy. Echocardiography was the most commonly used method to optimize devices (92% of the centers) while only 6% routinely used invasive methods. Conclusions: The clinical routine concerning follow‐up of CRT‐patients varies between European centers but generally includes device optimization, at least for selected patients. Echocardiography is the most widely used method for device tuning. The differences in follow‐up strategies probably reflect the lack of evidence for optimal CRT‐patient follow‐up and device programming. O042 HIGH‐SPEED ROTATIONAL ANGIOGRAPHY FOLLOWED BY 3‐D RECONSTRUCTION OF CORONARY SINUS IN CRT DEVICE IMPLANTATION Zubarev E; Lebedev D
 Almazov Federal Heart, Blood and Endocrinology Centre, Saint‐Petersbug, Russian Federation Aim: To assess the capability of rotational angiography in CRT device implantation. Methods: We implanted CRT devices in 109 patients from 2009 till 2011 years. After coronary sinus (CS) cannulation standard occlusive retrograde angiography was performed in all patients. Besides, 17 patients underwent high‐speed rotational angiography followed by 3‐D reconstruction of coronary venous tree. Rotational isocentric scan was obtained by rapid rotation of C‐arm, left anterior oblique (LAO) 45° to right anterior oblique (RAO) 45° with speed of 60° per second (Allura Exper FD 10, Philips). Received images were analyzed using special software with assessment of full range of angles, diameters of target veins and 3‐D model of coronary venous tree was created, providing an operator with significantly more information about CS anatomy. According by received data we chose angulation and instrument for each patient. Results: Performing single rotational scanning was enough to evaluate venous anatomy in 82%, while additional standard angiography was required in 18% of cases. Optimal angulation for left ventricle lead implantation was found to vary significantly both for each vein and patient. The mean volume of contrast dye was 11.2 ± 3.3 ml for rotational angiography compared to 48.6 ± 29.9 ml for standard angiography (p < 0.0001). Conclusion: Rotational angiography followed by 3‐D reconstruction of CS anatomy allows minimizing the dose of contrast dye. Using this method enables an operator to evaluate parameters of target vein and choose LV lead and its delivery system more accurately. O043 CORONARY SINUS LEAD EXTRACTION: SAFETY, TECHNIQUES, AND COMPLICATIONS Taborsky M; Fedorco M; Heinc P
 Ist Internal Clinic, Universtity Hospital Olomouc, Czech Republic Introduction: The implantation of coronary sinus (CS) pacemaker leads has dramatically increased over the past few year. Extraction of CS leads remains limited. Methods: We analysed all percutaneous extractions of transvenous CS leads performed at our institution. Extractions occurring within 1 month of implantation were excluded. Results: Between 2000 and 2010, 117 CS leads were percutaneously extracted from 99 patients(8 infections and 91 lead dysfunction). In 1 patient the endovasal CS lead extraction was unsuccessful. The average duration in situ for the CS Leads was 2.41 ± 1.77 years. The majority of the leads were removed by simple traction (n = 97, 82.8%). The rest of the LV electrodes were removed by advanced extraction techniques including locking stylet with sheath support (n = 14,11.9%), locking stylet and laser (n = 6, 5.1%). The majority of CS leads implanted longer than four years required advanced extraction techniques (20/37, 54.3%). There were complications with extraction of 11 leads (9.4%). It was difficult to determine whether complications were attributable to CS lead extraction, another lead extraction, or reimplantation. Complications included CS or vein thrombosis (n = 4/99 pts, 4.4%), CS dissection (n = 2/99 pts, 2.2%), bleeding (n = 3/99, 3.3%), and pneumothorax (n = 2/99, 2.2%). Endovascular reimplantation of a new CS lead was successful in 87 of 99 attempts (87%). A longer duration after the implant was associated with increased use of an advanced extraction technique (p <.001). Duration of implantation and method of extraction were not associated with complications, fluoroscopy time, or re – implantation success. Conclusions: CS leads in situ greater than four years often require advanced techniques. Advanced extraction techniques can be implemented when simple traction is unsuccessful without an appreciable increase in complications. O044 THE STRUCTURAL CHANGES OF THE RIGHT HEART DURING CARDIAC RESYNCHRONIZATION THERAPY Bucyte S; Sedlickaite D; Silkute A; Brukstute S; Puodziukynas A; Jurkevicius R; Kazakevicius T; Zabiela V; Sileikis V
 Department of Cardiology, Lithuanian University of Health Sciences, Medical Academy Purpose: To estimate the structural changes of the right heart during cardiac resynchronization therapy (CRT). Methods: 37 patients meeting ESC recommended CRT implantation indications were included into this study. The size of the right ventricle (RV), the volume of the right atrium (RA), right ventricle myocardial performance index (RV MPI), tricuspid annular plane systolic excursion (TAPSE) and the highest tricuspid annular systolic velocity (TASV) were evaluated before starting CRT and after 3 and 6 months of treatment. Statistical analysis was performed using SPSS version 15.0. Results: Mean initial RV size was 34.95 ± 8.6 mm., after 3 months of CRT in responders' and non – responders' group it was 34.02 ± 8.45 mm and 35.67 ± 8.88 mm, respectively, after 6 months – 34.82 ± 7.9 mm and 34.45 ± 10.23 mm, respectively. Mean initial RA volume was 82.31 ± 39.3 ml., after 3 months of CRT in responders' and non – responders' group it was 48.9 ± 10.46 ml and 89.75 ± 35.12 ml, respectively, after 6 months – 65.62 ± 25.23 ml and 70.0 ± 24.2 ml, respectively. Mean initial RA and mean RA after 3 months appeared to differ significantly (p < 0.05) between the responders' and non – responders' groups. Mean initial RA correlated with mean initial RV and highest TASV. We found a high positive correlation (r > 0.5) between the reduction of mean RA and the increase of LV EF and TASV in responders' group after 3 months. Conclusions: 1During CRT the structure of the right heart does change.2The difference of the mean initial RA volume and mean RA volume after 3 months of CRT between responders' and non – responders' was statistically significant.3Severe dilation of the RA might be the prognostic sign of the absence of the response to CRT. O045 THE FUNCTIONAL CHANGES OF THE RIGHT HEART DURING CARDIAC RESYNCHRONIZATION THERAPY Bucyte S; Sedlickaite D; Silkute A; Brukstute S; Puodziukynas A; Jurkevicius R; Kazakevicius T; Zabiela V; Sileikis V
 Department of Cardiology, Lithuanian University of Health Sciences, Medical Academy Purpose: To estimate the functional changes of the right heart during cardiac resynchronization therapy (CRT). Methods: 37 patients meeting ESC recommended CRT implantation indications were included into this study. The size of the right ventricle (RV), the volume of the right atrium (RA), tricuspid annular plane systolic excursion (TAPSE) and the highest tricuspid annular systolic velocity (TASV) were evaluated before CRT and after 3 and 6 months. Statistical analysis was performed using SPSS version 15.0. Results: Mean initial RV size was 34.95 ± 8.6 mm., after 3 months of CRT in responders' and non – responders' group it was 34.02 ± 8.45 mm and 35.67 ± 8.88 mm, respectively, after 6 months – 34.82 ± 7.9 mm and 34.45 ± 10.23 mm, respectively. Mean initial RA volume was 82.31 ± 39.3 ml., after 3 months of CRT in responders' and non – responders' group it was 48.9 ± 10.46 ml and 89.75 ± 35.12 ml, respectively, after 6 months – 65.62 ± 25.23 ml and 70.0 ± 24.2 ml, respectively. Mean initial TAPSE was 12.92 ± 5.62 mm., after 3 months of CRT in responders' and non – responders' group it was 14.5 ± 3.1 mm and 11.9 ± 5.7 mm, respectively, after 6 months – 14.52 ± 3.9 mm and 14.5 ± 3.15 mm, respectively. Mean highest initial TASV was 11.03 ± 3.37 cm/s., after 3 months of CRT in responders' and non – responders' group it was 13.0 ± 4.0 cm/s and 10.56 ± 3.94 cm/s, respectively, after 6 months – 13.15 ± 3.77 cm/s and 12.0 ± 3.0 cm/s, respectively. Mean initial RA correlated with mean initial RV and highest TASV. We found a high positive correlation (r > 0.5) between the reduction of mean RA and the increase of LV EF and TASV in responders' group after 3 months. Conclusions: 1During CRT the structure and function of the right heart does change.2Even in non – responders' group the function of RV does improve.3Severe dilation of the RA might be the prognostic sign of the absence of the response to CRT. O046 WHY WE STILL CALL THEM NON‐RESPONDERS? Papavasileiou L; Forleo GB; Vecchio F; Cioè R; Minni V; Della Rocca DG; Topa A; Magliano G; Santini L; Romeo F
 Division of Cardiology, Department of Internal Medicine, University of Rome "Tor Vergata" Introduction: The objective of cardiac resynchronization therapy (CRT) is the improvement of objective parameters and the amelioration of the quality of life of patients with heart failure. We have different measures to evaluate the percent of patients who could be considered CRT responders. The aim of our study was to evaluate if there is a concordance between left ventricular ejection fraction (LVEF) changes and changes in subjective (patients view) parameters. Methods: We analyzed 61 consecutive patients underwent CRT implantation at our institution between May 2009 and December 2010. Patients were divided in two groups based on the presence (responders) or absence (non responders) of an improvement (≥15%) of LVEF. Patients view was assessed by: the six minute walk test (6MWT) and the Minnesota Living With Heart Failure Questionnaire (MLHFQ). Results: The two groups were homogeneous regarding age, sex, EF prior implantation and underlining heart disease. After a mean follow up of 8.4 ± 4.8 months, 34 patients were responders (Δ EF = 19 ± 13) while 27 patients (non responders) did not fulfill LVEF criteria (ΔEF =−3 ± 13). Regarding patients view, no significant differences were found between two groups about Δ 6MWT distance (209 ± 119 in non responders group vs 221 ± 105 in responders group, p = ns), Δ MLHFQ (−13 ± 16 vs −7 ± 22, p = ns). Of note, acute decompensation with necessity of hospitalization was observed in similar mode in both groups (4 events in non responders group vs 3 in responders group). Conclusions: Objective parameters routinely used in order to evaluate the response of patients in CRT are valid, nevertheless a vast majority of patients report improvement of clinical status in absence of the classic measurable parameters. New tools are necessary in order to assess benefits of cardiac resynchronization therapy. O047 DIRECT ENDOCARDIAL LEFT VENTRICLE: A SAFE AND EFFECTIVE ALTERNATIVE TO TRADITIONAL RESYNCHRONIZATION VIA CORONARY SINUS Roa‐Garrido J; Moriña‐Vazquez P; Barba‐Pichardo R; Fernandez‐Gomez Juan M; Venegas‐Gamero J; Arrhythmias Department
 "Juan Ramón Jiménez" Hospital, Huelva, Spain. Introduction: Biventricular pacing through the Coronary Sinus (CS) is effective for the treatment of patients with heart failure and left bundle branch block. However, this approach is sometimes not feasible (lack of response, anatomical considerations of CS, etc). Although surgical epicardial lead implantation is the alternative, this technique may be deleterious in patients with low ejection fraction (EF) and high anaesthetic risk. Thus, direct endocardial Left Ventricle (LV) stimulation performed under local anaesthesia may be an alternative. We describe the results of direct endocardial LV pacing. Method: Prospective study (n = 12) with failed resynchronization via CS (April 2006‐January 2011) all except one with width QRS. Technique: Femoral approach, transeptal puncture and LV mapping; active fixation of the lead at the point where the longer electrical delayed was observed, peeled away from the introducer and connection to generator. Parameters: previous device implanted through the upper veins, inferior generator was programmed VVT (n = 8); n = 3 with an exclusive femoral approach was accomplished and connected to a tricameral generator. Follow‐up: 6 to 48 months. An echocardiogram was performed before implantation and 6 months later. Results: The LV lead was implanted successfully in all the cases (thresholds under 1.5 V). 4 Pocket haemathoma were observed, 3 cured spontaneously, the other suffered from infection so the system was explanted. A patient with narrow QRS died due to cardiogenic shock, another died due to a hemorrhagic stroke after implantation. The rest of the patients had improved at least a step in the NYHA status at 3 months. All of them improved EF. A patient with recurrent episodes of ventricular fibrillation and shocks is now asymptomatic. Conclusion: Direct endocardial LV pacing through the transeptal approach is safe and may be a less risky and more efficient alternative than surgical epicardial lead implantation to resynchronization via CS. O048 INCREASE IN TPEAK‐END INTERVAL INDUCED BY BIVENTRICULAR PACING PREDICTS VENTRICULAR TACHYARRHYTHMIA FOLLOWING CARDIAC RESYNCHRONIZATION THERAPY Miyoshi F; Onuma Y; Watanabe N; Kikuchi M; Ito H; Adachi T; Kawamura M; Asano T; Tanno K; Kobayashi Y
 Division of Cardiology, Department of Medicine, Showa University School of Medicine Background: The relationship between induction of arrhythmias and dispersion of repolarization after CRT is controversial. Objective: This study aimed to determine whether cardiac resynchronization therapy (CRT) alters QT interval, QT dispersion, and Tpeak–Tend interval (Tpeak–end) and whether such changes relate to the risk of developing major arrhythmic events (MAE). Methods: Data from 67 patients (49 male, age 71 ± 10 years) who underwent CRT device placement were analyzed retrospectively. Patients had NYHA class III (n = 62) or IV (n = 5) heart failure, as a result of ischemic heart disease (n = 28), cardiomyopathy (n = 35) or valvular heart disease (n = 4). Mean left ventricular ejection fraction was 25 ± 9%. The electrocardiogram was recorded at baseline and during follow‐up after implantation (3 days, 7 days, 1 month, and 2 months). For each electrocardiogram, the following parameters were measured: QRS duration, QT interval, QTc, QT dispersion, and Tpeak–end. Results: After 29‐month follow‐up, 11 patients experienced MAE. QT interval, QTc, QT dispersion, and Tpeak–end did not change significantly immediately after CRT. However, 3 days after CRT, Tpeak–end in patients with MAE was significantly increased when compared with patients without MAE (p < 0.05). We divided patients into two groups according to change in Tpeak–end after 3 days of follow‐up (increased Tpeak–end group; n = 27, decreased Tpeak–end group; n = 40). The increased Tpeak–end group demonstrated a significant increase in MAE (p < 0.05). Conclusions: Increased Tpeak–end at 3 days after CRT was associated with a significant increase in MAE, and this could be a useful predictor of ventricular proarrhythmias. O049 EVALUATION OF LEFT INTRAVENTRICULAR SYNCHRONY IN ASYMPTOMATIC LEFT BUNDLE BRANCH BLOCK PATIENTS BY NON‐INVASIVE PARAMETERS OBTAINED FROM RADIONUCLIDE VENTRICULOGRAPHY Pastor A; Perea J; Leguizamón J; Villanueva A; Jiménez S
 Hospital Universitario de Getafe (Madrid), Spain Introduction: Radionuclide ventriculography (RNV) has been used to assess ventricular synchrony by means of phase and amplitude parametric images and their quantitative‐derived parameters: the mean (M) phase angle (PA) represents mean time of ventricular contraction onset and the standard deviation (SD) of the PA relates to the synchrony of ventricular contraction. Methods: We evaluated parameters obtained from RNV of left intraventricular synchrony in 16 normal ECG controls and compared them with a group of 36 asymptomatic patients (P) with a left bundle branch block (LBBB, no previous cardiac history, referred for routinely evaluation at the cardiology outpatient room. MPA and the SD of the PA was derived and measured from the phase histogram obtained in the best left anterior oblique view. Both the MPA and the SD of PA were expressed in grades (°) or msec (MPA° or SD° x RR interval/360°). Results: Mean left ventricular ejection fraction (LVEF) was 39 ± 9% in 15 LBBB P, while in 21 LBBB and controls P, LVEF was 60 ± 5% and 62 ± 6% respectively. MPA measures in (°) or ms were non statistically significant between groups. However, SDPA measures in (°) or msec were significant less in control and LBBB/EF ≥50% P compared with LBBB/EF ≤ 50% P (24 ± 14°/36 ± 22° vs 58 ± 14°, p < 0.001 and 55 ± 31ms/86 ± 53ms vs 130 ± 34ms, p < 0.001). No differences in SDPA values were observed between control/LBBB/EF≥ 50% P. In LBBB P an inverse correlation between SD and LVEF was found (r =– 0.73, p < 0.001), so the greater SD of PA, the less LVEF. Conclusion: Abnormal LV systolic function is present in 42% of asymptomatic LBBB P, referred for routinely evaluation. An important subset of LBBB P who show left intraventricular electrical dyssynchrony may have not mechanical dyssynchrony data estimated by RNV parameters being similar to normal P. We can speculate if depressed LVEF found in 42% of the LBBB group is due to the LBBB‐dependent electrical asynchrony itself or vice versa O050 SENSOR EQUIPPED IMPLANTATION TOOLS FOR LV LEAD PLACEMENT USING A NOVEL NON‐FLUOROSCOPIC INTRA‐CARDIAC DEVICE TRACKING SYSTEM: IN ANIMAL EVALUATION Piorkowski C; Sommer P; Rolf S; Doring M; Eitel C; John S; Wetzel U; Arya A; Gaspar T; Hindricks G
 University of Leipzig, Heart Center, Department of Electrophysiology, Germany Background: Cardiac resynchronisation therapy has evolved as standard treatment for patients with advanced heart failure and asynchronous ventricular contraction. Difficulties implanting the LV lead may result in long procedure and fluoroscopy times. Hereby we report on an animal evaluation of specialized sensor‐equipped implantation tools for LV lead placement using a novel non‐fluoroscopic intra‐cardiac device tracking system. Methods: The novel non‐fluoroscopic tracking system consists of an electromagnetic field controller mounted on a conventional X‐ray system. Interventional intracardiac devices equipped with a miniaturized single coil sensor can either be projected over fluoroscopy or tracked non‐fluoroscopically at the precise position of the sensor within the electromagnetic field. Sensor equipped EP catheters, CS sheaths, target vein sub‐selectors, and angiography guidewires were tested for LV lead positioning in a porcine animal model. Results: In one porcine subject, the CS was non‐fluoroscopically engaged after jugular venous access using a sensor‐equipped steerable EP catheter and a sensor‐equipped CS sheath. Acquisition of occlusive CS venograms was performed and utilized to reconstruct a 3D model of the CS venous anatomy and to serve as the underlying image for non‐fluoroscopic target vein access achieved by sensor‐equipped sub‐selectors and guidewires.Utilization of live fluoroscopy during CS navigation procedures, which should be reduced by the unique "road mapping" algorithm with cardiac and respiratory motion compensation, was monitored and reported. Conclusions: A novel non‐fluoroscopic device tracking system together with sensor equipped implantation tools were able to support a new workflow of LV lead implantation in a porcine animal model. Future studies should examine applicability of this technology in the clinical setting and demonstrate the actual effect on any reduction of fluoroscopic time and exposure to both patients and operators. CHANNELOPATHIES O051 CRITICAL VENTRICULAR REPOLARIZATION PROLONGATION PRECEDING TORSADE DE POINTES IN ACQUIRED LONG QT SYNDROME Chiladakis I; Zagkli F; Kalogeropoulos A; Koutsogiannis N; Alexopoulos D
 University Hospital of Patras, Greece Objective: There is a strong but not causal association between ventricular repolarization prolongation and torsade de pointes (Tdp) in acquired long QT syndrome (aLQT). We determined the preferred method of ventricular repolarization assessment which best identifies the critical degree of ventricular repolarization prolongation exacerbating Tdp. Methods: We evaluated the electrocardiograms immediately before the occurrence of Tdp in 29 patients (age 63 ± 16 years) with aLQT. Drug‐induced ventricular repolarization prolongation had 17 patients. The QT (QTc) and the JT (JTc) intervals were measured by the use of six different QT/JT heart‐rate correction methods. We compared the distribution of QT(QTc) intervals for patients with normal QRS duration against the proposed cutoff levels of concern at 450ms, 480ms and 500ms, and the distribution of JT (JTc) intervals for patients with wide QRS complex at the cutoff levels of 310ms, 330ms and 360ms, respectively. Results: The study included 25 patients with normal QRS duration of QRS 106 ± 9 ms and QT interval of 543 ± 60 ms, and 4 patients with wide QRS complex of 162 ± 9 ms and JT interval 434 ± 58 ms. In the whole patient group as well as in patients with normal QRS duration the correction formulae of Hodges and Fridericia yielded highest detection probability for Tdp at all three cutoff levels (i.g. at the 480ms cutoff level, t = 7.34, p < 0.001, and t = 6.70, p < 0.0001, respectively, and at the 500 ms cutoff level, t = 5.28, p < 0.001, and t = 4.77, p < 0.005, respectively). For patients with wide QRS complex, greatest detection performance for Tdp showed the uncorrected JT interval (t = 3.55, p < 0.05) followed by the Hodges formula (p = NS) at the level of 330ms. Conclusions: Assessment of ventricular repolarization based on the use of the Hodges or alternatively Fridericia formula best identifies the likelihood of Tdp development. The uncorrected JT interval may be of comparable usefulness in patients with wide QRS complex. O052 RIGHT VENTRICLE MAPPING IN PATIENS WITH BRUGADA SYNDROME Ficili S; Galeazzi M; Lavalle C; Russo M; Chiarelli G; Santini L; Amati F; Mele F; Pandozi C; Santini M
 dipartimento Cardiovascolare, Ospedale San Filippo Neri – Roma‐Italy Background: The role of structural heart disease and sodium channel dysfunction in the induction of electrical instability in Brugada syndrome is still known. However recent paper had showed that endomyocardial biopsy detected structural alterations in subjets with Brugada syndrome and arrhythmias. Objective: To investigate the role of structural alterations in subjects with Brugada syndrome and inducible at electrophysiological study (EPS). Methods: We studied 28 consecutive probands (24 males, 4 females) with clinical and istrumental diagnosis of Brugada syndrome. All probands were Caucasian. According to the most recently proposed diagnostic criteria, the clinical presence of BS was based on demonstration on the ECG of a type 1 or a type 2 that was converted to type 1 after flecainide test (2 mg/kg). All patients were inducible at EPS. A bipolar voltage mapping was also performed by CARTO system. In a subset of patients (8), the electroanatomical right ventricular map was integrated with MR/CT image to assure the contact between the tip of catheter and endocardial tissue. In 2 patients intracardiac echo (ICE) was used to investigate the structural alterations. Genetic study for SCN5A mutational screening was also performed onto DNA obtained from peripheral blood sample of all 148 patients. Results: Programmed electrical stimulation induced VF in all the patients. The electroanatomical mapping showed normal potentials of the right ventricle in all the patients. The mean number of acquired points was (325 ± 25 points) with an average mapping period of 24 ± 4 minutes. Structural alterations were non detected by ICE. Genetic study revelead 3 mutation (mutation rate 21,4%) IVS‐24/CT in two patients (B6 and B 11) and R 1512 W in one patient (B15). Conclusion: Substrate right ventricular mapping of Brugada patients does not highlight any alterations. O053 MUTATION SPECTRUM IN KCNQ1 AND KCNH2 GENES IN IRANIAN LONG QT SYNDROME PATIENTS Banihashemi K; Saber S; Houshmand M; Moradmand Z; Aryan H; Fazelifar AF; Haghjoo M; Emkanjoo Z; Eftekharzadeh M; Zaklyazminskaya EV
 Medical Science Department, IECF, Ministry of Science, Research and Technology, Tehran, Iran Background: Long QT Syndrome (LQTS) is a heterogeneous group of inherited arrhythmic disorders characterized by QT interval prolongation, and associated with high risk of sudden cardiac death (SCD). At present more than 10 genes were detected as causative. But mutations in KCNQ1 and KCNH2 genes encode the cardiac potassium channels account about 60% of all LQTS patients. Material and Methods: We had 40 Iranian LQTS index patients under our observation. Clinical examination was performed in Rajaei Hospital, and Tehran Arrhythmia Clinic. Genetic screening was performed by direct sequencing of all coding area of KCNQ1 and KCNH2 genes in Special Medical Center. Results: We did find 3 mutations in KCNQ1 gene, in 3 out of 40 (about 8%) index patients. About 46% of patients are carrying common single nucleotide polymorphisms (SNPs). Screening of KCNH2 coding and adjacent intronic area did not reveal any of disease‐causing mutation, but 40% of patients were carrying intervening SNPs in KCNH2 gene. Conclusion: We found surprisingly low prevalence (8%) of mutations in KCNQ1 gene. Lack of mutation in KCNH2 gene in Iranian LQTS patients is also rather confusing. This is not in concordance with findings in other populations. This discrepancy may reveal different molecular mechanisms in Iranian LQTS patients due to different pathogenic candidate genes, or phenomena such as allelic drop‐out. Further molecular investigations in other known genes involved in LQTS pathogenicity may elucidate its genotype‐phenotype correlation in Iran. E‐HEALTH AND ARRHYTHMIAS O054 ARRHYTHMIA TELEMONITORING IN SYMPTOMATIC AND ASYMPTOMATIC PATIENTS IN GEORGIA (REPUBLIC OF) Gegenava T; Gegenava M; Kirtava Z; Patients with arrhythmia, syncope, epilepsy
 Tbilisi State Medical University Introduction: Mobile telemedicine (m‐Health) represents an important recent sub‐segment of e‐Health and a rapidly growing branch of telemedicine. A classical example demonstrating the impact of telemedicine on diagnosis is the event recording of arrhythmias. Method: We investigated 47 outpatients with different types of arrhythmia (n = 27 male and n = 20 female, age – 12–80 year. Among them were n = 7 patients with unexplained syncope, n = 10 patients with epilepsy, n = 2 patients after radiofrequency catheter ablation, n = 5 patient after aorto‐coronary bypass graft surgery. Control group was performed with n = 10 sportsmen. Investigations were made by 3‐lead electrocardiograph‐ECG Loop Recorder in automatic recording/transmitting mode. Results: Arrhythmias were registered during 7–68 hours of observation. n = 22 (48%) patients had arrhythmia symptoms. n = 25 (52%) patients were asymptomatic. Cases of sinus brady‐ and tachyarrhythmia, sick‐sinus syndrome, atrial fibrillation, supraventricular tachycardia (SVT) supraventricular premature complexes (SVPCs) and ventricular premature complexes (VPCs) have been correctly recognized by automatic recognition software and recorded. We also studied n = 2 patients after radiofrequency catheter ablation (RFA). Arrhythmia relapse was shown in both of them (SVT, SVPCs), but mostly they were asymptomatic. We studied also n = 10 patients with epilepsy and discovered n = 3 patients with SVT and n = 2 patients with sinus tachycardia. Among n = 7 patients with unexplained syncopes, we revealed n = 2 patients with sinus tachycardia, n = 2 patients with SVT. Asymptomatic episodes revealed mostly in study group p = 0.001, there were no different between gender p = 0.05. Conclusions: Mobile telecardiology represents feasible methodology to monitor arrhythmia outpatients in Georgia, promoting earlier discharge of non‐life‐threatening cases, improving patients' comfort of life and increasing their mobility with enhanced safety. O055 A NEW WEB‐BASED NATIONAL DATABASE: THE HELLENIC CARDIOLOGY SOCIETY ABLATION REGISTRY. RESULTS OF THE 2008–2010 YEAR PERIOD Vassilikos V; Efraimidis M; Billis A
 First Cardiology Dept, AHEPA University Hospital, Thessaloniki, Greece In 2008 the radiofrequency ablation procedures (RFA) registry of the Hellenic Cardiology Society (HCS) was created. This is a dynamic, web‐based application, which acts as the interface for storing and retrieving patients' demographic data and ablation procedures. Access to the site is permitted only to registered users. The purpose of this study is the report of the results of RFA procedures performed in Greece over the 2008–2010‐year period. There are 24 licensed centers to perform RFA in Greece. During the 2008–2010 year period 3413 RFA procedures were performed in 3222 patients in 19 centers. 5 centers did not contribute data for various reasons. It is interesting that >50% of the total number of procedures were performed at 4 high volume centers (>100 cases/year). Male:Female ratio was 54% vs 46% and the mean age was 51.2 years. The most common procedure was slow pathway ablation for atrio‐ventricular reentry tachycardia (AVNRT), the second was accessory pathway related tachycardias (AVRT), and the third was atrial fibrillation ablation. Success rates were high (92%), complication rate was 2.6% (serious complications <1%) and total relapse rate was 9% at six months follow‐up. The electronic RFA registry in Greece confirmed that all RFA procedures are performed in Greece with high success and low complication rates, comparable to the European and US standards. The experience and results from the first three‐ year period use of the application are very interesting and encouraging, thus indicating the need for development of similar national databases at the National level. GENETICS O056 NEW SCN5A GENETIC VARIANT IN IRANIAN PATIENT WITH BRUGADA SYNDROME Saber S; Banihashemi K; Houshmand M; Fazelifar AF; Haghjoo M; Emkanjoo Z; Alizadeh A; Zaklyazminskaya EV
 Petrovsky Russian Research Center of surgery, RAMS, Moscow, Russia Background: Brugada syndrome (BrS) is an autosomal dominant cardiac arrhythmia characterized by ST elevation in V1‐V3, pseudo‐Right bundle branch block (RBBB), high risk of sudden cardiac death (SCD) due to polymorphic ventricular tachycardia and apparently normal heart. Mutations in SCN5a gene cause 15–20% of BrS cases. Clinical examination: Physical examination, standard 12‐leads ECG, echocardiography and 24‐Holter monitoring were performed for index patient. Genetic screening: included PCR‐based Senger sequencing of all coding exons and adjacent introns area of SCN5a gene. Results: We observed male BrS patient, 46 y.o, at first hospitalization. He had atypical chest pain, syncope and positive family history of Sudden Death (his brother at 5 y.o). Brugada‐pattern, type 1 was registered on resting ECG (HR = 70, QTc = 465 ms, PR = 200 ms, without other arrhythmia). Myocardial structural was normal by Echo‐CG examination. Genetic screening revealed a new rare variant c.C5787T (p.R1929C) in SCN5A gene. This change has not been observed in other ethnic groups. Single‐chamber ICD was implanted with a regular checking every 3 months. During first month after implantation, patient got two appropriate shocks, and the one inappropriate. Quinidine administration (200 mg/twice daily) was prescribed. Three years later, patient interrupted quinidine therapy and had one appropriate shock. After this episode quinidine therapy was resumed and no appropriate shock or any other major cardiac events were registered during next three years. Conclusion: We have recently identified new possibly disease‐causing c.C5787T variant in SCN5A gene in patient with Brugada syndrome. This variant was not found in other ethnic groups. Population analysis in ethnically‐matched control group is in progress now. Long‐term quinidine therapy seems to be efficient in events‐free surviving in BrS patient. This drug can be promising in control of ventricular tachycardia in BrS but cohort study has to be performed to verify their efficiency. O057 AMINO ACID SUBSTITUTIONS IN THE PORE OF THE CAV1.2 CALCIUM CHANNEL AFFECT ANOMALOUS MOLE FRACTION EFFECT OF THE CHANNEL Li Z; Huang H; Yang B; Gao GF; Peterson BZ; Huang CX
 Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China Introduction: The nature of ion permeation through ion channel is the electrophysiological basis of arrhythmias and has long been the subject of investigation. The anomalous mole fraction effect (AMFE) is an important probe of ion‐ion interactions in the pore of voltage‐gated Ca2+ channel and depends on holding voltage, total ion concentration and the intrinsic binding properties of the channel. The amino acid residues at position 1144 differed from several classes of voltage‐gated Ca2+ channels are important to the pore's permeation of multiple Ba2+ and Ca2+ ions. Methods: We substituted Phe‐1144 (F, CaV1) with glycine (G, CaV2) and lysine (K, CaV3) and observe the effects of mutation on voltage and concentration dependences of AMFE. Whole‐cell currents were recorded in the external solutions mixing of Ca2+ and Ba2+ such that the Ba2+/(Ba2++ Ca2+) was 0, 0.3, 0.5, 0.7, 0.9, 1.0 and with total divalent cation concentration held at 2, 10 or 20 mM at holding potential from −80 to −20 mV. Results: IBa/ICa determined under 2 mM differs from IBa/ICa determined under higher concentrations (10 and 20 mM) and also differed while tail currents were evoked at potentials from −80 to −20 mV. The AMFE was greatest when tail currents were evoked at relatively positive potentials (−20 mV) and when the total divalent cation concentrations were kept low (2 mM). AMFE is attenuated for F1144G while accentuated for F1144K compare with wild‐type respectively. Conclusions: These results indicate that glycine and lysine substitutions of Phe‐1144 affect on AMFE via different mechanisms. Phe‐1144 substitutions confer to structure‐based models for Ca2+ channel permeation. The residues at position 1144 determine the permeation of several classes of voltage‐gated Ca2+ channels. O058 ALTERATIONS IN THE EXPRESSION OF GENES RELATED TO CONTRACTILE FUNCTION AND HYPERTROPHY OF THE LEFT VENTRICLE IN CHRONICALLY PACED PATIENTS FROM THE RIGHT VENTRICULAR APEX (PRELIMINARY RESULTS) Simantirakis EN; Kontaraki I; Arkolaki EG; Chrysostomakis SI; Nyktari EG; Patrianakos AP; Vardas PE
 Cardiology Department, University Hospital of Heraklion Background: Long term asynchronous ventricular activation from right ventricular apex results in reduced systolic and diastolic function. The purpose of this study is to assess in the peripheral blood alterations of the expression of genes related to contractile function and hypertrophy of the left ventricle, after right ventricular apical pacing in patients with preserved left ventricular systolic function. Methods: Patients were divided into two categories, based on the cumulative percentage of ventricular pacing post‐implant. Group A consisted of those paced due to atrioventricular conduction disturbances (ventricular pacing> 90%), while group B of those with preserved intrinsic atrioventricular conduction. At the time of implantation and 3 months later, we evaluated in the peripheral blood concentrations of mRNA of sarcoplasmic reticulum calcium ATPase (SERCA) and β‐myosin heavy chain (β‐MHC). We also estimated echocardiographically left ventricular end‐diastolic and end‐systolic diameter and left ventricular ejection fraction. Results: We have collected data for 30 patients during a period of 3‐months follow up. In group A at 3‐months follow‐up, mRNA levels of SERCA were decreased (9,3 ± 1,49 vs 4,04 ± 1,33 p = 0,021) and β‐MHC mRNA levels were increased though not significantly (62,12 ± 46,97 vs 424 ± 245 p = 0,127). Left ventricular end‐diastolic diameter, left ventricular end‐systolic diameter and left ventricular ejection fraction remained unaltered (46.5 ± 2.2 vs 47.85 ± 2.18 p = 0.7, 27.8 ± 2 vs 32.4 ± 2.2, p = 0.4 and 61 ± 2.8 vs 59 ± 2.1, p = 0.7 respectively). In controls all measured parameters showed no significant changes. Conclusions: Permanent right ventricular apical pacing is associated with alterations, in the peripheral blood, in the expression of genes regulating left ventricular contractile function and hypertrophy. These findings are traceable, while at the same time left ventricular function has not been deteriorated. O059 GENETIC VARIATION OF SCN5A IN KOREAN PATIENTS WITH SICK SINUS SYNDROME Kim YN; Lee YS; Park HS; Jung BC; Shin DG; Cho YK; Lee SH; Han SM; Lee MH; Daegu Arrhythmia Gene Study Group
 Keimyung University Dongsan Medical Center Purpose: Recent western studies have been shown that the genetic variation of SCN5A is related with sick sinus syndrome (SSS). To determine the SSS‐associated genetic variation in Korean patients, we investigated the genetic variation of the SCN5A in Korean patients with SSS. Methods: We enrolled 30 patients with SSS, who diagnosed by sinus pause more than 3.0 sec in Holter monitoring, and 30 control. All exons including the putative splicing sites of the SCN5A gene were amplified by PCR and sequenced directly or after subcloning using an ABI PRISM 3100 Genetic Analyzer. The structure model of the human SCN5A domain was obtained from the Automated SWISS‐MODEL. Results: A total of 9 genetic variations in 30 patients were identified. Among these, 7 variations (G87A‐A29A, IVS9–3C>A, A1673G‐H558R, G3823A‐D1275N, T5457C‐D1819D, T5963G‐L1988R, C5129T‐S1710L) have been reported in previous studies and 2 variants (A3075T‐E1025D, T4847A‐F1616Y) were firstly found. In three‐dimensional modeling of SCN5A domain, only 1 variation site (F1616Y) was able to be analyzed. Conclusion: There were 2 novel genetic variations (E1025D, F1616Y) in the SCN5A gene in Korean patients with SSS. However, further functional study might be needed. IMAGING MODALITIES O060 PULMONARY VEINS VARIATIONS PATTERNS DETERMINED BY MULTI SLICE COMPUTED TOMOGRAPHY AN ATRAIL NON FLUOROSCOPIC GEOMETRY Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A
 Instituto Cardiovascular de Buenos Aires (ICBA) Objective: To determine pulmonary veins drainage patterns determined by multi slice 64 computed tomography (MSCT‐64). Method: A total of 153 MSCT of patients with atrial fibrillation eligible for pulmonary veins isolation (PVI) were analyzed. The images were fused with the left atrium En Site (Nav X) Verissmo System electro‐anatomic map obtained during PVI. The primary end point was to determine the number of pulmonary ostiums located at each side of the LA, therefore the most common anatomic drainage pattern variations. We defined single Ostia as the ones which did not showed vein bifurcations in the endoscopic view; Common Ostia as the ones that showed vein bifurcation and primary trunk to those presenting vein bifurcation >5 mm away from the ostium. Results: The mean age was 57.88 years (± 9.68 DS); 80.73% male and 19,27% female. 69.87% presented 2 left ostiums; 93.97% showed 2 right ostium, corresponding to the superior and inferior PVs. A single left ostia was seen in 18.07% of the cases; 8.43% showed a left single trunk; 6.02% presented right single ostia and 4.08% a third right ostium. The correlation between the atrial geometry and MCCT‐64 was 100%. Conclusion: The presence of 4 pulmonary vein ostium corresponds to the known left atrium anatomy. This study suggests the most frequent anatomic drainage pattern variations in the following order: a unique left ostia, a single left trunk containing both superior and inferior left PVs, a single right ostia and less frequent a third right ostium corresponding to the middle vein. Knowing the LA anatomy may help to select the most suitable strategy during PVI. O061 OPTIMAL FLUOROSCOPIC PROJECTIONS FOR ANGIOGRAPHIC IMAGING OF THE LEFT ATRIUM APPENDAGE: LESSONS LEARNED FROM THE INTRAPROCEDURAL RECONSTRUCTION OF THE LEFT ATRIUM AND PULMONARY VEINS Kriatselis C; Nedios S; Tang M; Gerds‐Li JH; Fleck E
 Deutsches Herzzentrum Berlin Introduction: Percutaneous left atrium appendage (LAA) obliteration is a new strategy for prevention of embolic events in patients with atrial fibrillation. Selective angiography of the LAA in standard fluoroscopic projections is used to identify the LAA ostium. Anatomical variability is an important limitation of this imaging approach. Methods: Hundred patients (67% men, age: 60 ± 12 years) undergoing a PV isolation procedure received intraprocedural rotational angiography and three‐dimensional reconstruction of the left atrium (LA), the pulmonary veins (PVs) and the LAA. For each patient, 33 angiographic projections, from RAO 80° to LAO 80°, in steps of 5°, were evaluated. Optimal projections of the LAA ostium were defined at sagittal plane: (i) clear identification of both superior and inferior segments of the LA–LAA junction and (ii) no overlapping between LA and LAA ostium. At frontal plane: (i) clear identification of all four quadrants of the LAA ostium and (ii) visualisation of the maximal horizontal ostial diameter. Results: A reconstruction of the LA, the PVs and the LAA was obtained for 97 patients. The optimal fluoroscopic projection for the LAA ostium in a sagittal plane was RAO 30 in 82 out of 100 patients (82%). Projections in RAO 25 and 35 were optimal in 71% of the patients. RAO 45 resulted in optimal sagittal LAA visualisation in 45%. The optimal ostial projection in a frontal plane for the LAA ostium was LAO 40 in 60 out of 100 patients (60%). Optimal LAA visualisation was feasible in 50% in LAO 45 projections and in 38% in LAO 35 projections. Conclusion: If selective angiography of the LAA is performed to facilitate implantation of an occlusion device, fluoroscopic projections should be carefully selected to avoid suboptimal visualisation. The preselected projections proposed in our study: RAO 30 and LAO 40 result in optimal sagittal and frontal angiographic projections of the LAA ostium respectively in the majority of patients. IMPLANTED CARDIOVERTER DEFIBRILLATORS O062 ICD THERAPY IN THE ELDERLY: LONG‐TERM PREDICTORS OF BENEFIT AND MORTALITY Wolber T; Haegeli L; Steffel J; Schmid C; Duru F
 University Hospital Zurich Background: Implantable cardioverter defibrillator (ICD) therapy reduces arrhythmic and all‐cause mortality in patients at high risk of sudden death. However, its clinical benefit in elderly patients is uncertain. The aim of this study was to assess the long‐term efficacy of ICD treatment in elderly patients and to identify markers of successful ICD therapy and risk factors of mortality. Methods: We performed multivariate analysis of a prospective long‐term database from two tertiary care centres including 1118 consecutive patients implanted with an ICD. Predictors of ICD therapy and risk factors for mortality were assessed in patients aged 75 years or older at ICD implantation compared with younger patients. Results: The mean follow‐up time was 45 ± 40 months. The rates of ICD therapy were similar among both age groups. No significant predictors of ICD therapy could be identified among older patients. Median estimated survival was 165 months among patients younger than 75 years, and 81 months among those aged 75 and older (P = 0.004). Age (HR 1.23 per year; P = 0.05), reduced ejection fraction (HR 1.82 per 10% decline; P = 0.02) and impaired renal function (HR 1.40 per 10 ml/kg/m2 eGFR decline; P = 0.05) are risk factors of mortality in patients aged 75 years and older. However, mortality of older patients is similar to that of the age‐matched general population irrespective of the delivery of ICD therapy. Conclusion: ICD therapy is effective for treatment of life‐threatening arrhythmias in all age groups. However, prevention of sudden cardiac death may have limited impact on overall mortality in older patients. Despite a similar rate of appropriate ICD therapies, the risk of death is increased twofold in ICD recipients aged 75 years or older compared with younger patients. Patients with reduced ejection fraction and impaired renal function are at highest risk. O063 SERUM MARKERS OF COLLAGEN TURNOVER PREDICT FUTURE SHOCKS IN ICD RECIPIENTS WITH DILATED CARDIOMYOPATHY ON OPTIMAL TREATMENT Kanoupakis EM; Kallergis EM; Mavrakis HE; Goudis CA; Saloustros IG; Koutalas EP; Chlouverakis GI; Vardas PE
 Cardiology Dpt, University Hospital of Heraklion Objectives: We investigated prospectively whether serum markers of collagen turnover could be used as predictors for the occurrence of malignant ventricular arrhythmias in patients with non‐ischemic dilated cardiomyopathy (NIDC) implanted with an implantable cardioverter defibrillator (ICD) for primary prevention. Methods: Serum C‐terminal propeptide of collagen type‐I (CICP), C‐terminal telopeptide of collagen type‐I (CITP), matrix metalloproteinase (MMP)‐1, and tissue inhibitor of matrix metalloproteinases (TIMP)‐1 were measured as markers of collagen synthesis and degradation in 70 patients with mildly to moderate symptomatic heart failure due to NIDC with LVEF <35%, who received an ICD for primary prevention of SCD. Patients were evaluated for any appropriate ICD delivered therapy, whether shock or antitachycardia pacing, during a 1‐year follow‐up period. Results: Appropriate device therapies were delivered in 14 of the 70 patients during the follow‐up period, with antitachycardia pacing in 2, antitachycardia pacing with shocks in 4, and shocks in 8. Preimplantation MMP‐1 levels were significantly higher in patients who had appropriate ICD‐delivered therapy than in those who did not have any therapy (27.7 ± 1.6 ng/ml vs. 24.1 ± 2.5 ng/ml, respectively, p < 0.001). The same was true for baseline serum concentrations of TIMP‐1 and CITP (89 ± 14 ng/ml vs. 58 ± 18 ng/ml, p = 0.008 and 0.46 ± 0.19 ng/ml vs. 0.19 ± 0.07 ng/ml, p < 0.001, respectively). Conclusions: Undoubtedly, ECM alterations play a crucial role in the constitution of an arrhythmogenic substrate in NIDC and, given the availability of therapies to prevent fatal ventricular tachyarrhythmias, the quest for factors that have a very good correlation with appropriate ICD discharges in these patients is logical. Our results confirm the role of serum markers of collagen turnover as predictors of arrhythmic events in ICD recipients and could provide an auxiliary tool in this context. O064 EARLY DETECTION OF CHRONIC MYOCARDIAL ISCHEMIA IN A PATIENT IMPLANTED WITH AN ICD CAPABLE OF INTRACARDIAC ELECTROGRAM MONITORING Papavasileiou LP; Forleo GB; Santini L; Romeo F
 University of Rome "Tor Vergata". Department of Internal Medicine, Division of Cardiology. Rome, Ita We report the detection of intracardiac ST‐segment variation in a 75 year‐old man affected by ischemic heart disease; previous coronary artery by‐pass surgery (1983, 1995) previous percutaneous coronary treatment (2002, 2006) and ICD implantation (AnalyST Accel TM DR, St. Jude Medical, Sylmar, USA). During routine in‐clinic visits pacing thresholds were stable and no arrhythmic or ischemic events were documented. Remote monitoring with the Merlin system was provided, but unfortunately the patient was not able to use. In September 2010 he reported stress angina so antiischemic treatment was potentiated. The first week of January 2011 he was admitted to the emergency department for unstable angina. He reported that episodes of angina became more frequent and more graving since September. During ICD interrogation; 140 ST episodes were documented. During inspection of the intracardiac electrograms (IEGM) a clear ST segment depression >2 mm was documented initially for higher cardiac rate. A coronary angiogram (CA) was performed and two saphenous grafts (SVG), for obtuse marginal (OM) and right coronary artery (RCA), resulted occluded. The two grafts were patent in previous CA, performed in 2006. PCA and bare metal stent implantation was performed in native right coronary artery and SVG for OM. In March 2011, an in‐clinic ICD follow‐up was performed and no new ST events were documented and patient reported to be asymptomatic. Comment: We report the correct documentation of ST‐segment modification by the AnalyST Accel ICD in patient with stress angina. Of note, clinical manifestation of stress angina and myocardial ischemia, as reported by patient during last in clinic FU, preceded ST segment modification detected by the algorithm only by few days. In fact, patient reported reduction of angina threshold during time and the algorithm initially recognized ST modifications in high frequencies and over time reported episodes of ST depression for lower heart rates. O065 ROLE OF IMPLANTABLE CARDIOVERTER‐DEFIBRILLATORS IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES Gkouziouta A; Adamopoulos S; Leontiades E; Kostopoulou A; Elivanis  ; Maounis T; Pavlides G; Voudris V; Bairaktaris A
 Onassis Cardiac Surgery Centre Purpose: Left ventricular assist devices (LVADs) have been used effectively as a "bridge" to cardiac transplantation and as destination therapy in patients with advanced heart failure(H.F.). Patients with H.F. are prone to ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation ‐VT/VF) and implantable cardioverter‐defibrillators (ICDs) reduce the morbidity and mortality. No indication guidelines for ICD implantation in patients with LVADs exist. We retrospectively reviewed the role of ICDs in patients with LVADs in our centre. Methods: 65 patients were supported with VADs since 2003 in the Onassis Cardiac Surgery Centre as a bridge to transplantation. 26 patients(40%)were supported with LVADs. Devices used were:HeartMate XVE, Novacor LVAS, LVAD Berlin Heart, INCOR LVAD and Heartware. All VT/VF and the type of therapy delivered by the ICDs were analyzed from time of LVAD implantation. Concurrent anti‐arrhythmic medications were documented. Results: Indications for LVADs were non ischemic dilated cardiomyopathy in 65% and ischemic cardiomyopathy in 35%.19(73%)patients had ICDs implanted prior to VAD implantation. VT/VF occurred in 10 patients (52.5%)(8 non‐ischemic and 2 ischemic) post‐LVAD. 7 patients were defibrillated while antitachycardia pacing was utilized in 8 of them. All of them were in heart failure treatment(including amiodarone)and 3 of them were on anti‐arrhythmic medications (mexilitine, or procainamide). 4 patients had a single VT/VF event which was terminated by the ICDs and did not require any management changes. A pt died of intractable VT/VF in another hospital due to complications of an unsuccessful ablation. Conclusions: Patients on LVAD support have VT/VF events. Anti‐arrhythmic drugs were not always successful in terminating VT/VF. ICDs terminated these events and may contribute to decreased morbidity and mortality in patients with LVADs. Prospective studies analysing their role would provide guidelines for ICD implantation in patients on LVADs. O066 THE EFFECT OF REMOTE MONITORING ON JAPANESE CRT‐D PATIENTS Nakajima J; Suga C; Wakaba H; Hirahara T; Sugawara Y; Ako J; Momomura S
 Division of Cardiovascular Medicine, Jichi Medical University Saitama Medical Center, Japan Abstract: Recently, device remote monitoring (RM) has been applied in clinical settings especially in heart failure. However, the effect of RM for heart failure practice is controversial. The aim of this study was to verify the effect of RM for heart failure on cardiac resynchronization therapy‐defibrillator (CRT‐D) patients in our institution. Methods and Results: We retrospectively analyzed hospital files of fifty‐seven CRT‐D consecutive patients who were followed up in our out‐patient clinic every three‐four months; thirty patients were out‐patient clinic only (non‐RM group), and twenty‐seven patients were in addition controlled with RM (RM group). There were no differences between two groups regarding clinical background, i.e., NYHA functional class, serum BNP, and QRS duration. Kaplan‐Meier curves of clinical adverse event free rates were obtained. During a median follow‐up of 865.4 ± 445.6 days, clinical adverse events were death in nine patients (two in RM group, and seven in non‐RM group), and heart failure hospitalization in nineteen patients (nine and ten respectively). Three device‐related adverse events also occurred, one in RM group and two in non‐RM group. As comparing the RM group with non‐RM group, Kaplan‐Meier curves of clinical adverse events did not show statistically significant difference. Conclusion: RM failed to show clinical benefit in terms of reducing the clinical adverse events in CRT‐D patients. We need to consider how to utilize the information from RM to improve clinical outcome of heart failure patients. O067 PATTERNS OF ICD USE IN PATIENTS ENLISTED FOR HEART TRANSPLANTATION: A SINGLE CENTRE RETROSPECTIVE ANALYSIS 2006–2010 Sedlacek K; Jurkuvenas P; Hoskova L; Malek I; Kautzner J
 IKEM, Clinic of Cardiology, Videnska 1958/9, 140 21 Prague, Czech Republic Purpose and methods: We retrospectively analyzed indications for ICD (and CRT‐D) use and occurrence of appropriate ICD therapies in patients enlisted for heart transplantation between 2006–2010. Potentially life‐saving therapy was defined as ventricular tachycardia (≥ 150 bpm) or fibrillation, adequately terminated by antitachycardia pacing or shock. Results: During the study period, 223 patients were enlisted for heart transplantation. Among 89 non‐urgent candidates receiving an ICD, 36 patients were implanted at the time of the waiting list enrollment ("bridging" indication; mean time on the waiting list 301 days; mean time from implant to transplantation 367 days) and 53 received an ICD earlier (conventional primary or secondary indication; mean time on the waiting list 180 days; mean time from implant to transplantation 729 days). In the bridging strategy group, potentially life‐saving therapies were recorded in 8 patients (22%; 3 with ischemic and 5 with non‐ischemic cardiomyopathy). In the conventional indication group, appropriate ICD therapy was registered in 19 patients (36%; 9 with ischemic and 10 with nonischemic cardiomyopathy). The incidence of potentially life‐saving therapies was thus 19% per year in both groups with minimal difference between ischemic and non‐ischemic disease etiology. Among 16 patients who died during the study period, no sudden death was identified. Nine of the deceased patients had an ICD and 3 of them received potentially life‐saving therapies unrelated to their cause of death. Conclusions: ICD was effective in preventing of sudden cardiac death in patients enlisted for heart transplantation. The rate of adequate therapies justifies consideration of ICD bridging indication in ambulatory patients waiting for heart transplantation. Cost‐effectiveness is probably limited by the short time between implantation and heart transplantation comprising approximately year in this study. O068 LONG‐TERM FOLLOW‐UP OF PATIENTS RECEIVING ICDS FOR SECONDARY PREVENTION IN THE ISLAND OF CRETE Kanoupakis EM; Koutalas EP; Mavrakis HE; Kallergis EM; Saloustros IG; Stokkos K; Psathakis E; Solidakis G; Vardas PE
 Cardiology Dpt, University Hospital of Heraklion Crete Introduction: Implantation of ICDs has proven its efficacy in various subgroups of patients having experienced spontaneous malignant arrhythmic episodes. However, relative scarcity of data exists regarding long‐term follow‐up outcomes of this population in the context of tertiary hospitals‐ICD implantation centres beyond randomized clinical trials borders. In the following analysis the survival and the incidence of appropriate ICD therapy for ventricular arrhythmias in patients who underwent ICD implantation at our institution, the only in the island of Crete, was examined. Methods and Results: We acquired data from patients with ischemic (ICM), non‐ischemic dilated (DCM) and hypertrophic cardiomyopathies as well as in patients with inherited channelopathies who received an ICD from 1997 to 2009 for secondary prevention of sudden cardiac death. Of 188 ICD recipients 53 deaths were observed (28.2%). Median survival was 118 months (95% CI: 100–135). Eighty six patients (45.7%) had ICD therapy. Of the delivered therapies, 16,3% were inappropriate. Median shock‐free survival was 64 months (95% CI: 53.8–74.2). Median survival between the largest subgroups, ICM and DCM patients, differs in favor of DCM ones in a statistically marginal non‐significant way (89 months vs 131 months, p = 0.053. Conclusion: In a close geographical region, where the general level of health care is good and well appreciated by the population, the survival and the incidence of appropriate ICD therapy for ventricular arrhythmias is in accordance with that of the international large trials. O069 THE ACCURACY OF THORACIC IMPEDANCE MEASUREMENT BY CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICES IN PATIENTS ON DIALYSIS Kimura R; Inoue K; Toyoshima Y; Doi A; Masuda M; Sotomi Y; Iwakura K; Fujii K
 Sakurabashi Watanabe Hospital The measurement of thoracic impedance by implantable device (Medtronic Optivol) is expected to be useful for early detection of heart failure, but the accuracy of thoracic impedance measurement in human body is not yet fully investigated. Here we report two cases of heart failure and chronic dialysis. Case 1 with ischemic cardiomyopathy, NYHA class III, QRS width 210 ms, left ventricular ejection fraction (EF) 35% with dyssynchrony, underwent CRTD (Medtronic Concerto) implantation. After 4 months the patient was admitted because of heart failure. The trend chart of the thoracic impedance showed the distinctive pattern of oscillation. The thoracic impedance increased from the baseline value during the therapy for heart failure. Case 2 with dilated cardiomyopathy, NYHA class III, QRS width 160 ms, EF 21% with dyssynchrony, underwent CRTD (Medtronic Concerto) implantation. After 4 months the patient was admitted because of pneumonia and heart failure. The trend chart of the thoracic impedance also showed the distinctive pattern of oscillation. The thoracic impedance slightly decreased during the therapy for heart failure. In both cases, it is important to note that the increase and the decrease of the thoracic impedance perfectly coincided with the schedule of dialysis on a daily basis. Thus, the trend chart of the thoracic impedance showed the distinctive pattern of periodical oscillation. Those patients had dialysis on Monday, Wednesday and Friday. The thoracic impedance sharply increased on these days, and rapidly decreased on other days without exception. This fact clearly indicates that the measurement of thoracic impedance has enough accuracy and temporal resolution to detect the daily change of the fluid status in human body before and after dialysis. Though the algorithm to calculate thoracic impedance index (Optivol index) seems to have room for refinement, the thoracic impedance monitoring for the detection of heart failure is feasible. O070 OCCURRENCE OF ICD INTERVENTIONS INFLUENCES THE OUTCOME OF PATIENTS IMPLANTED FOR SECONDARY PREVENTION OF SUDDEN CARDIAC DEATH POST MYOCARDIAL INFARCTION Svetlosak M; Sasov M; Leclercq C; Martins R; Daubert JC; Mabo P; Hatala R
 National Institute of Cardiovascular Diseases, Bratislava, Slovakia Background: Occurrence of appropriate (AI) or inappropriate (InI) ICD interventions relates to a worse prognosis of patients implanted for primary prevention of sudden cardiac death (SCD) post myocardial infarction (MI). However, less is known about their prognostic value in patients implanted for secondary preventative reasons in the era of modern reperfusion therapy of MI. Aim: To analyze the impact of ICD interventions (AI or InI) on mortality in a secondary preventative cohort of post‐MI patients. Methods: This retrospective analysis included all consecutive post‐MI patients implanted with an ICD for secondary SCD prevention in a single centre between 2000 and 2007 (n = 148; mean age 65 ± 10 years; mean left ventricular ejection fraction 33 ± 8%). We analyzed the total mortality of patients with AI comparing to the other patients. The impact of InI or ICD shocks for any reason was studied thereafter in the same way. Results: After a mean follow‐up of 51 ± 27 months we found at least one AI in 96 (65%) and at least one InI in 37 (25%) patients, 27 (18%) patients had both AI and InI, 37 (25%) patients died. Patients experiencing an AI had a significantly higher mortality comparing to the others (OR 2,92; 95% CI 1,18–7,23; P = 0,02). There was a non‐significant trend for a higher mortality in the group with InI (32% vs. 23%; P = 0,23). However, when only ICD shocks irrespective of their appropriateness were considered, they were associated with a higher mortality (OR 2,32; 95% CI 1,05–5,15; P = 0,04). Conclusion: In our cohort of consecutive patients with ICD implanted in the setting of secondary prevention of SCD after MI, AI and ICD shocks (delivered as AI or InI) were related to a higher mortality. These findings correspond to the data from primary preventative post‐MI ICD populations and highlight the need for a careful follow‐up and management of the underlying disease in patients experiencing an AI, as well as the use of algorithms minimizing ICD shocks. O071 IMPLANTABLE CARDIOVERTER‐DEFIBRILLATORS IN ARRHYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA: A SINGLE CENTER EXPERIENCE Hatzinikolaou‐Kotsakou E; Kotsakou M; Latsios P; Reppas E; Moschos G; Beleveslis T; Tsakiridis K
 Electrophysiology Department Saint Luke's Hospital‐Thessaloniki‐Greece Introduction: Arrhythmogenic Right Ventricular Dysplasia (ARVD) is associated with potential life‐threatening ventricular tachyarrhythmias and an increased risk of sudden death. Our purpose was to study the outcome of ARVD patients treated with an implantable cardioverter‐defibrillator (ICD). Methods and Results: We included 28 ARVD patients(pts) with ICD (60% male, ages 15–58, median 36). Twenty four pts for secondary prevention and for primary prevention 4 pts. Primary prevention based: 1) on the clinical criteria 2) EP study findings and 3) familiar history. The mean follow‐up was 35 ± 18 months. Complications associated with ICD implantation included need for lead repositioning (n = 4). During follow‐up, one patient underwent heart transplantation. During this period 19/28 (70%) pts received a mean of 4.7 (range 2–68) appropriate ICD therapies. Two (50%) of the pts who underwent ICD implantation for primary prevention had appropriate ICD discharges. The median period between ICD implantation and the first shock was 6‐months. ICD electrical storms were observed in 3 pts. Inappropriate shocks were seen in 9 pts. Predictors of appropriate therapy were fulfillment of the ARVD criteria (82% vs 25% respectively, p < 0.001), the frequency of the daily PVCs > 3.500 (72% vs 29% respectively, p < 0.001) induction of VT during EPS (70% vs 35% respectively, p < 0.001), syncope (82% vs 31% respectively, p < 0.001) and severe RV dysfunction in echocardiography (69% vs 14% respectively, p < 0.02). The inappropriate shocks were seen in patients with very frequent atrial tachyarrhythmias. Conclusions: Patients with ARVD have a high arrhythmia rate requiring appropriate ICD therapies. ICD treatment appears to be well tolerated and effective in the management of patients with ARVD. O072 WORK BURDEN OF CLINICIAN IN REMOTE MONITORING OF IMPLANTABLE CARDIOVERTER‐DEFIBRILLATORS Papavasileiou LP; Panattoni G; Santini L; Mahfouz K; Schirripa V; Magliano G; Vecchio F; Minni V; Forleo GB; Romeo F
 University of Rome "Tor Vergata," Department of Internal Medicine, Division of Cardiology, Rome, Italy Background: The efficacy, accuracy and safety of remote monitoring (RM) as well as patient's satisfaction is well demonstrated. Work burden of remote monitoring has not be estimated. In addition in most European countries reimbursement schemes of RM clinics are currently unavailable. Our study aimed to establish the work burden related to RM. Methods: Consecutive patients with implanted cardioverter defibrillators (ICD) were enrolled to RM. Parameters analyzed: total work hours (WH) of follow‐up with RM, WH/patient, total WH/patient in RM vs total WH/patient without RM. Results: 119 patients with mean follow‐up of 13,5 ± 12,4 months. 19 patients were unable to perform transmissions and so exclude from the study. The network received 843 transmissions. Mean number of transmissions per patient was 8,5. There were 514 event‐free transmissions while 329 transmissions regarded one or more events. Total WH used in RM were 308,55 (80 hours for training visits and first in clinic visit, reviewing event‐free transmissions 26 h, 27 hours for reviewing transmissions with events, 12,25 hours for transtelephonic contact of patients and 163,3 hours for in clinic visits of patients after transmissions or transtelephonic contact). WH/pt with RM was 3,08 while WH/pt without RM was 1,6. Statistical analysis' resulted to be significant regarding total WH but not regarding WH/pt with RM (p < 0,0001 and p = ns, respectively). Conclusions: Work burden of clinician is superior in patients with remote monitoring. In order to expand remote monitoring in all patients reimbursement formulas should be made. O073 EARLY DETECTION OF A SPRINT FIDELIS LEAD FRACTURE WITH THE CARE LINK MONITORING SYSTEM. Papavasileiou LP; Schirripa V; Minni V; Panattoni G; Sergi D; Mahfouz K; Santini L; Forleo GB; Magliano G; Romeo F
 Department of Cardiology, University of Rome "Tor Vergata," Rome, Italy In October 2007, Medtronic's vigilance process announced that the Sprint Fidelis high‐voltage implantable cardioverter‐defibrillator (ICD) lead (Medtronic, Inc., Minneapolis, MN, USA) is prone to fracture and voluntarily removed it from the market. The advisory recommended the use of lead impedance monitoring alerts to identify impending lead fractures in order to reduce the adverse events, including inappropriate shocks. We report the case of a 75 years old patient with an In Sync ICD implanted in October 2007 in primary prevention. Routine in clinic follow‐up revealed stable impedance thresholds (448 Ohm). At September 2010 patient was provided with Carelink remote monitoring system and he performed first manual transmission on January 2011. During inspection of transmission lead impedance was out of range (1088 Ohm) and short VV intervals were 7. Patient was immediately asked to reach the emergency room of our hospital. During ICD interrogation data confirmed imminent fracture of lead. Patient did not recognize the audible alerts. When asked he confirmed hearing alerts, but he failed to recognize them. The patient was hospitalized and the next day a new ICD lead was implanted through the subclavian vein. This is the first report of successful prevention of lead failure of Sprint Fidelis lead with the Care Link remote monitoring system. It is reported that With RV Pacing Impedance Alert set to 1,000 ohms, 47% of patients would have four or more days notice, an additional 2% would have two days notice, and an additional 2% would have one day notice. The ICD lead fracture might induce inappropriate intervention and in extreme cases might be fatal. The remote monitoring systems automatically perform transmissions in case of lead integrity alerts and/or clinical‐arrhythmic events. Extended use of RM systems can help fast and correct detection of technical or clinical problems regarding patients with implantable devices. PACING O074 IMPACT OF MULTIPLE PACING SITES ON LEFT VENTRICULAR FUNCTION. EXPERIMENTAL STUDY Kaladaridou A; Bramos D; Skaltsiotes I; Kottis G; Papadopoulou E; Daskalakis C; Agrios I; Matthaios I; Antoniou A; Toumanidis ST
 Dpt. Of Clinical Therapeutics, Medical School, University of Athens, Purpose: Left ventricular (LV) torsion and apical rotation(rotap),are very important contributors to LV performance. The purpose of this study is to examine the effect of simultaneous multiple pacing (P)sites on LV function including rotational and torsional parameters in intact myocardium. Methods: In 9 healthy pigs atrio‐ventricular epicardial P in multiple P sites was performed simultaneously. Classic right ventricular apical(RVap)P was combined with: 1) LVapex lateral 2) LV basal posterior 3) RV basal anterior 4) RV basal anterior+LV basal posterior. Moreover, 5) LV basal posterior+ LVapex lateral, 6) LV basal posterior+RV basal anterior and 7) RV basal anterior+LV apex lateral P in a random order were performed. LV torsion was calculated by measuring LV basal and apical rotation from basal and apical short‐axis epicardial planes with speckle‐tracking technique using EchoPac software. LV torsion, ejection fraction (EF), cardiac output(CO), rotap, untwisting rate in sinus rhythm were compared to every P combination. Results: CO reduced significantly in:RVap+LVbasal posterior, RVap+RV basal anterior, RVap+RV basal anterior+LV basal posterior, LV basal posterior+LVapex lateral and LVbasal posterior+RVbasal anterior P in comparison to CO in sinus rhythm. EF and LV torsion in sinus rhythm revealed superior in comparison to EF and LV torsion in every P combination. Rotap reduced significantly in: RVap+LVapex lateral, RVap+LV basal posterior, RVap+RVbasal anterior, RVap+RVbasal anterior+LVbasal posterior and RVbasal anterior+ LVapex lateral P. Finally, untwisting rate reduced significantly in: RVap+LVapex lateral, RVap+LV basal posterior, RVap+RVbasal anterior+LV basal posterior, LV basal posterior+LVapex lateral P in comparison to untwisting rate in sinus rhythm. Conclusions: Different combinations of multiple pacing sites did not increase haemodynamic and rotational deformation parameters of intact LV myocardium. O075 INITIAL EXPERIENCE WITH A NEW MAGNETIC RESONANCE CONDITIONAL PACEMAKER SYSTEM UNDERGOING MAGNETIC RESONANCE IMAGING: PRELIMINARY RESULTS OF THE PROMRI SINGLE CENTER PILOT STUDY Wollmann C; Vock P; Steiner E; Mayr H
 Hospital of St. Pölten‐Lilienfeld, Dep. of Cardiology Introduction: The purpose of our study is to evaluate safety of a new magnetic resonance imaging (MRI) conditional pacemaker (PM) system (Evia SR‐T and DR‐T with Safio S53/S60 active screw‐in leads, Biotronik SE & Co KG, Berlin, Germany) under MRI conditions. We report preliminary results of the ProMRI single center pilot study. Methods: Patients implanted with Evia SR‐T or DR‐T PM and Safio leads at our institution are eligible for enrollment in this single center prospective non‐randomized pilot study. Patients undergo a non‐diagnostic MRI of the brain and the lumbar spine at 1.5 Tesla. PM are interrogated before and after MRI to assess potential changes of lead parameters (right atrial (RA)/right ventricular (RV) sensing [mV], pacing threshold [PT, V/0.4 ms], pacing impedance [Ohm]). Patients are followed for 3 months with in‐hospital visits at 4 weeks and 3 months after MRI. Continuous variables are expressed as mean ± SD. Results: By now, 27 patients (female 11, age 74 ± 10 years, higher degree AV block 10, sick sinus syndrome 5, atrial fibrillation with significant bradycardia 12, dual chamber PM 13) were enrolled in the study. Twenty‐three patients completed the 4 weeks FU by now and 11 patients the 3 month FU, respectively. Except for RV pacing impedance paired Student's t‐test revealed no significant changes of lead dependent parameters when comparing measurements immediately before and after MRI. When comparing lead measurements assessed immediately before MRI with measurements assessed at the 1 month and 3 month FU, no statistically significant differences were found. One‐way ANOVA revealed no statistically significant differences for all parameters when comparing all available FU. No MRI related adverse events occurred. Conclusion: The new MRI conditional Evia pacemaker system demonstrated unobtrusive function under MRI conditions. Observed differences in lead measurements between the different follow‐ups were in clinically accepted ranges. O076 THE EFFECT OF AAI AND DDD PACING MODE ON LEFT VENTRICULAR STRAIN, TWIST AND CORONARY FLOW PARAMETERS Papadopoulou E; Kalantaridou A; Hatzidou S; Pamboucas C; Toumanidis S; Antoniou A
 Dpt. of Clinical Therapeutics, Athens Medical School, Alexandra hospital, Athens, Greece Background: RV apical pacing may induce detrimental effects on left ventricular (LV) function and coronary flow. In this study we evaluated the effect of DDD and AAI pacing mode on cardiac mechanics and potential changes on coronary blood flow. Methods: This preliminary study included 14 patients who have received DDD pacemaker for sick sinus syndrome or carotid sinus syndrome and presented with sinus rhythm at their regularly scheduled visit at the pacemaker clinic. All patients had their ventricular lead placed in the RV apex. Patients underwent a complete transthoracic echocardiographic examination while in sinus rhythm and subsequently underwent non‐invasive Doppler assessment of coronary flow in the LAD and speckle tracking echo of basal and apical short‐axis planes during AAI and DDD pacing mode for 5 min with a 5 min interval in sinus rhythm. Results: Rotation of the base was significantly decreased in DDD pacing compared to AAI pacing (−7.44 ± 2.55o vs. −5.26 ± 2.85o, p = 0.012) as well as LV twist (17,65 ± 4.12o vs. 13.99 ± 5.5o, p = 0.05). Time to peak basal rotation during DDD pacing (expressed as percentage of systole) was significantly shortened (98.8%± 2.06% vs. 86.21%± 10.48%, p = 0.002). Circumferential strain of the base and time to peak significantly deteriorated in DDD compared to AAI pacing (−16.41 ± 3.00% vs. −13.65 ± 4.60%, p = 0.04 and 97.25%± 7.00% vs. 103.64%± 8.72%, p = 0.04 respectively). Apical rotation and circumferential strain did not change significantly. Flow in the LAD, expressed as velocity–time integral, decreased significantly in DDD pacing (10.42 ± 2.49 cm vs. 9.12 ± 1.94 cm, p = 0.002). Conclusions: Acute DDD pacing mode showed a detrimental effect on LV twist, rotation of the base and in LAD flow in comparison to AAI pacing mode. Further study is needed to support the above preliminary data. O077 INACCURACY OF THE 12‐LEAD ELECTROCARDIOGRAM IN PREDICTING LEAD POSITION IN RIGHT VENTRICULAR OUTFLOW TRACT PACING Salahuddin S; Sharma G; Jagia P; Sharma S; Bahl VK
 All India Institute of Medical Sciences, New Delhi, India Introduction: The 12‐lead electrocardiogram (ECG) and fluoroscopic landmarks are usually the only guides available to achieve a true septal location in right ventricular outflow tract (RVOT) pacing. These have, however, not been properly anatomically validated. We sought to validate these using cardiac computed tomographic (CT) angiography to confirm lead position within the RVOT. Methods: 34 patients with pacemaker leads in the RVOT position were subjected to a cardiac CT angiogram (64‐slice Dual Source Siemens Definition) for lead localization within the RVOT as anterior, free wall or septal location. 12‐lead ECGs were analysed during forced pacing. Fluoroscopic images of the pacemaker leads were also obtained in 4 standard views‐AP, LAO, RAO and lateral views. Results: Cardiac CT angiography was performed in 34 patients with a mean age of 59 ± 13 years (25 males). 17 patients (50%) were found to have an anterior lead location within the RVOT, while 17 (50%) had a septal position. Mean QRS axis and QRS duration did not differ significantly among the two groups (QRS axis: 71 ± 5.4° vs 74 ± 4.3° (P‐0.20) and QRS duration: 153 ± 21.1 vs 148 ± 19.3 msec (P‐0.55) for anterior versus septal respectively). A negative QRS in lead I could not distinguish an anterior from a septal lead location (10/17 vs 13/17, P‐0.46, anterior vs septal). Similarly, notching in none of the limb leads, including inferior leads, was helpful in differentiating the two groups. In the fluoroscopic LAO view, the lead was directed rightward in all 17 patients with septal location, but also in 14/17 patients in the anterior location (P‐0.22).The lateral view revealed posterior direction of lead in 12/17 patients with septal location, and in only 3/17 patients with anterior lead location (P‐0.003). Conclusions: Conventional ECG criteria are inaccurate in differentiating septal from anterior RVOT pacing. Also, the fluoroscopic LAO view is insufficient in predicting septal lead placement. O078 SHORT TERM EFFECT OF RIGHT VENTRICULAR OUTFLOW TRACT COMPARED WITH CONVENTIONAL APICAL PACING ON LEFT VENTRICULAR FUNCTION AND SYNCHRONY IN PATIENTS WITH NORMAL BASELINE CARDIAC FUNCTION Sharma G; Singh H; Patel C; Ray A; Sharma P; Bahl VK
 All India Institute Of Medical Sciences, New Delhi, India Objectives: Chronic ventricular pacing is known to adversely affect left ventricular (LV) function. We sought to have an objective assessment of LV function and dyssynchrony in patients with right ventricular outflow tract (RVOT) and RV apical (RVA) pacing using equilibrium radionuclide angiography (ERNA). Methods: Thirty three patients who underwent dual‐chamber, rate‐modulated (DDDR) pacemaker implantation were prospectively included. All patients had no history of cardiac disease and baseline normal left ventricular function. Out of 33 patients, 19 had pacemaker lead positioned at RVOT site and 14 at the RVA site. All patients underwent ERNA within 2 week post pacemaker implantation and at 6 month follow‐up. All studies were acquired under forced pacing at heart rate of 100/min. Standard deviation of LV mean phase angle (SD LV mPA) expressed in degrees, which was derived by Fourier first harmonic analysis of phase images was used to quantify left intra‐ventricular synchrony and LV ejection fraction (LVEF) were evaluated at baseline and at follow up. Results: There was no statistically significant difference between the RVA and RVOT groups at baseline with respect to LVEF (52.9 ± 6.38% vs. 50.8 ± 6.70%; p 0.271) and SD LV mPA (13.3°± 7.36° vs. 14.4°± 6.17°; p 0.412). Similarly, no significant difference was observed between the groups at 6 month follow up (LVEF 51.3 ± 9.07% vs. 51.5 ± 9.48%; p 0.855, SD LV mPA 15.3°± 9.23° vs. 15.1°± 5.24°; p 0.560). Conclusions: No significant difference in LVEF & LV synchrony was observed between RVOT and RVA pacing in patients with normal baseline LV function at 6 month follow‐up. A longer follow up with ERNA annually is underway to see the effect of chronic pacing from the two locations. O079 CLOSED LOOP STIMULATION IMPROVE HAEMODINAMIC RESPONSE DURING MENTAL STRESS TEST Proietti R; Manzoni GM; Castenuovo G; Lombardi L; Vegliante N; Pietrabissa G; Quaglia C; Spoto A; Sagone A
 Cardiac Electrophysiology Laboratory Luigi Sacco Hospital. Milan. Italy Cloose Loop Stimulation (CLS) algorithm is a form of rate adaptive pacing, able to provide an effective pacing rate profile not only during physical exercise but although during mental stress. To test this hypothesis CLS or accelerometers sensor (AS) rate response was compared intraindividually during a mental stress test. Methods: 36 patients (mean age 76 ± 9)implanted with a VVI‐CLS Cylos Biotronik underwent mental stress test in different pacing configuration: non‐rate adaptive mode (VVI), accelerometer sensor (AS) mode (VVIR), and CLS respectively. A modified Stroop test was used in order to induce mental stress. Heart rate (HR), systolic and diastolic blood pressure and pacing percentage burden were collected for 5 minutes before, during and 5 minutes after the test. Results: Our study show that the average peak HR during mental stress test was significantly higher in CLS configuration than in AS and non adaptive mode. Further the average HR increase (calculated as the difference in minimum HR and the HR peak) during mental stress test was wider in CLS configuration than in VVIR and VVI. Finally, the percentage of pacing beats during mental stress test was higher in CLS configuration than with the other algorithms. Table I Within‐subjects effects on Hemodynamic outcomes OutcomesCLSASVVIp‐value*Peak HR92.8 ± 12.678.9 ± 6.5 77.8 ± 7.5<0.000HR increase22.7 ± 16.78.2 ± 8.6 6.6 ± 6.3<0.000Peak SBP172.6 ± 15.5 156.7 ± 12.2 145.5 ± 13.7<0.000SBP increase51.8 ± 24.718.4 ± 13.7 16.4 ± 10.3<0.000% Pacing48.4 ± 17.927.4 ± 17.5 25.8 ± 17.6<0.000Notes: *= Greenhouse‐Geisser corrected Wilk's Lamba Test.SBP = systolic blood pressure Conclusion: CLS showed to be more effective than AS mode in providing a rate‐adaptive pacing during mental stress. Results support the issue that CLS algorithm can detect an hemodynamic demand due to an emotional upheaval and supply a proper heart rate increase. O080 AAIsafer PACING REDUCES THE PERCENTAGE OF RIGHT VENTRICULAR PACING IN PATIENTS UNDERGOING PULSE GENERATOR REPLACEMENT. Stazi F; Mampieri M; Verde M; Cardinale M
 Dipartimento Apparato Cardiocircolatorio, A O. San Giovanni Addolorata, Roma. CLI Foundation Introduction: Several trials have shown that high percentages of right ventricular pacing (RVP) induce an increased risk of mortality and heart failure, particularly when the RVP percentage is > 40%. Accordingly, the AAISafeR® (Sorin Group) algorithm was specifically developed to decrease the RVP. The aim of this study was to assess if this pacing mode actually decreased the unnecessary RVP in patients undergoing pulse generator replacement. Methods: Thirty‐six patients (M = 20, F = 16, mean age 80 ± 7 years) with standard DDD pulse generators (22 for sinus node disease and 14 for atrioventricular block) underwent generator replacement with a device programmed with the AAIsafeR algorithm. Results: Pre‐replacement analysis of the 36 patients showed a mean RVP percentage of 82 ± 28% and 31/36 (86%) had a RVP percentage > 40%. Twenty‐three days after the pulse generator replacement the mean RVP percentage was 21 ± 36% (p < 0,0001 compared to the pre‐replacement analysis) and only 9 patients (25%) had a RVP percentage > 40%. Conclusions: In our study, that uses the same patients as the control of themselves, the AAIsafeR algorithm significantly decreases the RVP percentage compared to the standard DDD stimulation. O081 AV NODAL ABLATION AND PACING FOR ATRIAL FIBRILLATION (AF) AND HEART FAILURE (HF) – LONG TERM EXPERIENCE Obel IWP; Daniels J; Marcer G
 Milpark Hospital, Johannesburg, ZA Atrial fibrillation commonly accompanies heart failure. When heart failure is severe (NYHA grade III‐IV) the prognosis is extremely poor. AV node ablation provides excellent rate control but adds ventricular dyssynchrony unless bi‐ventricular pacing is instituted. Method: 407 Patients (26% female) have been followed for up to 19 years (m = 4.68 yrs). Age m = females 67.5 years, males 64 years. All patients had chronic AF with poor rate control. NYHA III‐IV = 220 patients (54%) all receiving optimal medical therapy and monitoring. Bi‐ventricular pacing (BiV) was instituted initially for broad QRS or previously paced patients or as clinically indicated following AV nodal ablation and RV pacing. 189 patients received BiV pacing. Ischaemic heart disease (IHD) – 73 (59%), non‐ischaemic cardiomyopathy – 89 (28%). Follow up by referring doctors and others at pacemaker clinic. Underlying heart disease included ischaemic heart disease (25% female, 71% male), cardiomyopathy (41% female, 59% male), valve disease (56% female, 44% male) and miscellaneous (58% female, 42% male). Results: There were 142 deaths. 38% non cardiovascular and 21% unknown. Heart failure deaths (14.8%) were more frequent in ischaemic patients. The effect of or delay to bi‐ventricular pacing did not appear to support the concept of routine bi‐ventricular pacing in this group of patients. Disease aetiology appeared to have a greater influence on mortality than mode of pacing. This may represent the effects of case selection for BiV pacing. The shortcomings of Warfarin as an anticoagulant in the real world situation are profound. Conclusion: AV node pace and ablate is an attractive and simple approach to uncontrollable AF and HF. Better anticoagulation is essential. O082 THE EFFECT OF THE RIGHT VENTRICULAR MID‐SEPTAL PACING FOR LEFT VENTRICULAR FUNCTION AND HEMODYNAMICS STATUS IN PATIENTS WITH PERMANENT PACEMAKER IMPLANTATION Baimbetov AK; Iskakova BK; Moldabekov TK; Oshakbayev KP
 Republican Scientific Center of Emergency Medical Care, National Medical Holding, Kazakhstan Purpose: To compare the effect between the right ventricular apex (RVA) pacing and the right ventricular mid‐septal (RVMS) pacing for left ventricular function and hemodynamics status in patients with bradyarrhythmias. Methods: We observed 58 patients (age 59 ± 19 years, 19 men), who underwent permanent pacemaker implantation suffering from AV block III. We evaluated 28 patients with RVMS‐pacing and 30 patients with RVA‐pacing. Left atrial volume index, Pulsed‐wave Doppler‐derived mitral inflow indices, colour M‐mode flow propagation velocities (Vp), Tissue Doppler measurements of systolic and diastolic (e') velocities at four mitral annular sites and mitral E/e' ratio, were assessed by transthoracic echocardiography, before and 6 month after implantation. Results: Permanent RVA‐pacing contributes to increase inter‐ & intra‐ventricular dyssynchrony and to increase pressure into the left atrium that lead to diastolic dysfunction of LV, as a result mechanical dyssynchrony caused by dyssynergia of systolic activation of walls LV. However, RVMS‐pacing procedure did not lead to increase intraventricular dyssynchrony and to impairment of hemodynamics status of LV. Conclusion: This study reveals that permanent RVMS‐pacing procedure contributes to less left ventricular dysfunction and mechanical dyssynchrony of walls LV compared with a conventional RVA‐pacing procedure in patients with permanent pacemaker implantation. O083 IS LEFT SIDED SINGLE LEAD VDD OR DDD PACING FEASIBLE? Obel IWP; Daniels J; Camps T; Smeets P; Obel OA; Lindemans F
 Milpark Hospital, Johannesburg, ZA Cardiac resynchronisation therapy (CRT) can provide great relief for heart failure patients. However, ± 30% of heart failure patients (pts) do not respond. Most attention has been centered on the site of the LV lead, provision of optimal LV filling and an excess of intravascular/cardiac leads. Intra‐atrial delay (sensed or paced) may contribute to poor left sided A‐V timing. We explored the possibility of a single lead, capable of sensing and pacing both left atrium and left ventricle, optimally placed in the coronary sinus (CS) to address these problems. Methods: Five prototypes were implanted in pts with standard CRT indications including 13 pts with chronic atrial fibrillation. In total, 36 pts received 1 of 5 prototypes. Underlying heart disease; ischaemic cardiomyopathy (18), non‐ischaemic cardiomyopathy (16), sinus node disease where right atrial pacing was impossible (1) and congenital heart block/single venous access (1). In 5 pts intra atrial conduction (pace or sense RA) was tested. Results: The site of the atrial bipole was the proximal CS, regardless of the final site of LV lead (9F lead placed without sheath or guide wire). Pacing and sensing results are given in the table below: LA Sense mVLA PaceLV Sense mVLV PaceV@0.5msV@0.5msAcute3.581.813.221.28(1.5–7.1)(1–3)(5.6–34)(0.4–3.0)Chronic (m = 21.4 months)10 ± 4.8mV1.8 ± 2.5V* Not possible in 2 pts Pacing and LV pacing was satisfactory up to 4 yrs with one LV lead displacement. Intra atrial conduction time increased from 97 ms to 147 ms with RA pacing. Time from LA sense to RV (at permanent RV site) was 83 ms longer from RA than LV. In the last 7 pts R‐wave size was measured via the atrial (CS) electrode and varied from 1.0–8.0 mV. Conclusion: Our experience showed the potential value and feasibility of long term single lead, left sided atrioventricular pacing. O084 LONG‐TERM RESULT OF THE CLINICAL TREATMENT FOR PACEMAKER INFECTION WITH VACUUM‐ASSISTED WOUND CLOSURE (VAC) Satsu T; Saga T; Onoe M; Miyashita N
 Department of Cardiovascular Surgery, Kinki University, School of Medicine Background: Although pacemaker infection is a rare, but life‐threatening complication, the optimal treatment of such infections is poorly defined in the literature. Methods: We describe 9 cases (8 patients), treated for an infected pacemaker at our and colleague institutes between 2008 and 2011. The pacemaker generator was partially exposed in four patients. The pacemaker pockets were fenestrated and treated with vacuum‐assisted wound closure (VAC). Results: Purulent fluid cultures were positive for methicillin‐sensitive Staphylococcus (four cases), methicillin‐resistant Staphylococcus (four cases), and Bacillus cereus (one case). Infection was eradicated in eight patients without the need for aggressive surgery or removal of the intra‐vascular lead. Fenestrated wounds in two cases were re‐sutured without replacement of the entire pacemaker system. The others were implanted with new pacemakers in the contra‐lateral side after removing the infected generator. However, in only a case (73‐year‐old man, who had been operated for pacemaker implantation before 42 days) VAC did not lead to eradicate the infection, and intra‐vascular lead was removed using traction. A pacemaker became infected again in one patient without removing the entire pacemaker system nine months later. The VAC therapy was repeated and the infection was eradicated by removing the pacemaker generator but not the intra‐vascular lead. The mean durations of VAC and hospitalization were 30.3 and 47.4 days, respectively. The patients remained completely asymptomatic after VAC, with no evidence of recurrent infection for 1–41 months (mean: 24.6 months) after discharge. Conclusions: Although complete removal of an infected pacemaker system is essential, less invasive VAC might serve as the first option for treating pacemaker infection when the risk of total system explantation is high, such as among the very elderly. O085 SAME DAY CONTRALATERAL DEVICE IMPLANTATION IN PATIENTS WITH POCKET INFECTION UNDERGOING DEVICE EXTRACTION Mountantonakis SE; Tschabrunn CM; Cooper J
 Electrophysiology Section, Division of Cardiology, University of Pennsylvania, Philadelphia, USA Introduction: Minimal data exist regarding the timing of device reimplantation following an extraction for infection. Pacemaker‐dependent patients pose a management challenge, given the ongoing need for pacing support after infected device extraction, but with the risk of infection of newly implanted hardware. Methods: Clinical and procedure‐related data were retrospectively collected on pacemaker‐dependent patients who underwent device and lead extraction for local pocket infection only, and who had a new contralateral device implanted on the same day, to investigate outcomes. Results: 15 patients (11 male, mean age 77, range 58–93) with pacemaker‐dependence underwent device (8 pacemaker, 4 ICD, 3 bi‐v ICD) and complete lead extraction (mean 2.5 leads per patient, range 1–5; mean implant duration 6.2 years, range 6 weeks‐16 years) for simple pocket erosion or purulent pocket infection, but negative blood cultures and no evidence of systemic infection. Femoral vein temporary pacing support was used during the extraction and a new contralateral permanent device was implanted on the same day, following a new complete sterile prep (9 pacemaker, 5 ICD, 1 bi‐v ICD). The infected pocket was managed with debridement with full capsule resection (sent for culture), and primary wound closure except for leaving the wound end open with a Penrose drain in place. Intravenous antibiotics were used prior to the procedure and continued for a mean of 2 days post‐procedure, with oral antibiotics used thereafter for a mean course of 2 weeks. All infected pockets healed, with daily dressing changes and gradual withdrawal of the drain. No infections of the new device system occurred, with a mean follow‐up of 32 months (range 4–66 months). Conclusions: In the setting of simple device erosion and pocket infection a new contralateral device can be implanted on the same day as the extraction. This strategy can be particularly useful in patients with pacemaker‐dependence. O086 SAFETY AND ELECTRICAL PERFORMANCE OF THE NEW CAPSUREFIX MRI LEAD IN PATIENTS WITH STANDARD PACING INDICATION Pignalberi C; Lacopino S; Santini L; Piraino L; Calò L; Bongiorni MG; Aquilani S; Magris B; Forleo G; Santini M
 San Filippo Neri Hospital – Department of Cardiology, Roma Introduction: Magnetic Resonance Imaging (MRI) is one of the most widely used non‐invasive imaging modalities because of its unique ability to discriminate soft tissues. We aimed to evaluate long‐term clinical outcomes and electrical performances of first MRI safe cardiac pacing system in patients treated for bradycardia in the clinical practice of 16 Italian centers. Methods: 318 patients (64% male; mean age 71 ± 13y) with Class I or II indication for dual chamber pacemaker implantation according ACC/AHA/HRS guidelines received a Medtronic EnRhythm MRI SureScanTM with CapSureFix MRI leads. Data were collected at implant and every 6 months after implant, to characterize the atrial and ventricular lead pacing capture threshold, impedance and sensing amplitude changes through a long term follow‐up period and procedure or device‐related complications. Results: Preliminary analyses were performed on 292 patients who had at least 1 follow‐up visit. Median follow‐up time was 16 months (25th – 75th percentile 9 – 22 months). At implant and at follow‐ups pacing thresholds, sensing and impedances were stable and comparable with literature data. In particular at 6 months follow‐up, atrial and ventricular sensing were 3 ± 1 mV and 9 ± 4 mV respectively, thresholds were 0.7 ± 0.4 V and 0.7 ± 0.6 V at 0.5 ms, and impedances were 524 ± 106 Ω and 535 ± 79 Ω. When considering atrial and ventricular leads together, we observed 11 lead dislodgements out of 584 leads (1.9%). This dislodgement raw rate decreased from 2.7% (8/292), in the first 146 patients, to 1.0% (3/292) in the second 146 patients. Conclusions: Adoption of the new EnRhythm MRI SureScanTM and CapSureFix MRI lead in the Italian clinical practice has confirmed that the pacing system is safe and that lead measurements are stable in the long run. The temporal trend of lead dislodgements suggests that a learning curve is associated with the use of this new MRI lead. O087 LONG TERM EFFICACY OF AAISAFER AND MVP STIMULATION TO MINIMIZE THE PERCENTAGE OF RIGHT VENTRICULAR PACING IN AN UNSELECTED POPULATION OF PATIENTS Stazi F; Mampieri M; Verde M; Cardinale M
 Dipartimento Apparato Cardiocircolatorio. A. O. San Giovanni Addolorata. Roma. CLI Foundation Introduction: High values of right ventricular pacing (RVP) can be deleterious increasing the probability of mortality and heart failure, particularly when the RVP percentage is >40%. The AAISafeR® (Sorin Group) and MVP® (Medtronic) have shown to minimize the RVP percentage. Aim of the study was to assess the long term efficacy of these pacing modes in an unselected population of patients undergoing pacemaker or defibrillator placement. Methods: Fiftyfour patients (M = 33, F = 21, mean age 76 ± 10 years) who underwent placement of a pacemaker (N = 41, sinus node disease = 27, atrioventricular block = 14) or defibrillator (N = 13) both with pacing minimizing algorithms (AAISafeR®= 40, MVP®= 14) were studied. Results: After a mean follow‐up of 18 ± 21 months the mean RVP percentage was 18 ± 30% and 43 patients (80%) had a mean RVP percentage <40%. The median percentage of RVP was 0,9%. Conclusions: In our study after 18 months of follow up AAIsafeR and MVP allow a low RVP percentage in an unselected population of patients. Moreover, the majority of the patients presents a RVP percentage <40%. O088 CLS ALGORITHM IS ASSOCIATED WITH SIGNIFICANT COGNITIVE IMPROVEMENTS IN A SMALL SAMPLE OF ELDERLY PATIENTS Manzoni GM; Proietti R; Castelnuovo G; Spoto A; Lombardi L; Sagone A
 Istituto Auxologico Italiano Introduction: CLS (Closed Loop Stimulation) algorithm showed to provide a rate‐adaptive stimulation in response to haemodynamic demand due to emotional upheaval in chronotropically incompetent patients. We hypothesized that the hemodynamic benefits supplied by CLS algorithm may extend to neuro‐cognitive functioning through enhanced cerebral blood perfusion. Methods: In order to test this hypothesis, we conducted a small‐scale three‐arm randomized controlled clinical trial involving 45 implanted patients randomly assigned to three pacing configurations: CLS (n = 15), Accelerometer Sensor (AS) mode (n = 15) and non rate‐adaptive mode (n = 15). A pool of ten neuro‐psychological tests tapping main neuro‐cognitive domains (memory, attention, language, visuo‐spatial skills and executive function) was administered to each participant before randomization and one year after. Mean change scores in cognitive measures were compared among the three pacing configurations at 1‐year follow‐up. Results: Statistically significant differences in change scores were found on attention and executive functioning measures. On average, patients in CLS configuration showed significant improvements on such measures, while patients in AS and non rate‐adaptive modes showed non‐significant deterioration trends. No statistically significant difference was found in change scores for the other neuro‐cognitive parameters. Conclusion: CLS algorithm showed to be effective in improving attention and executive functioning in a small sample of chronotropically incompetent patients one year after pacing configuration. Large‐scale trials are needed to corroborate such preliminary and novel results. O089 PATTERNS OF PACEMAKER AND ICD IMPLANTATION IN SOUTHERN AFRICA Okreglicki A; Scott Millar R; for the Cardiac Arrhythmia Society of South Africa
 University of Cape Town Introduction: World surveys of cardiac pacing show implant rates <5/million in most of Africa. In South Africa it is >12fold higher and increasing. Despite this, provision of pacing is not homogenous within South Africa; great variations in implantation rates, indications and implant practice exist. Methods: Implantation data from South Africa submitted to the World Society of Arrhythmias Surveys in 2001, 2005 and 2009, device company sales data, questionnaires to implanters and South African data from the international Panorama registry were analysed. Results: Pacemaker implantation rate in South Africa increased from 39 to 47 and 60/million in 2001, 2005 and 2009 respectively; corresponding ICD implantation rates: <1, 2 and 6/million. South Africa accounted for 99% of pacemakers implanted in southern Africa. No ICDs were implanted in other countries. Company sales data show that of all pacing leads sold, 33% were atrial, 57% ventricular and 10% coronary sinus. Biventricular pacing/ICD devices (CRT‐D) increased from 37% of the total ICDs in 2005 to 51% in 2009. The Panorama registry revealed differences in primary indication by hospital type (1 public and 12 private): AV block: 69.1% vs 19.3%; Sinus node disease: 19.8% vs 66.9% (p < 0.001) and in devices implanted: in patients with AV block, 2 or 3 chamber pacemakers were implanted in 12.5% in public and 76.1% in private. Conclusions: Despite limitations in methods of data collection, implantation of arrhythmia devices in southern Africa has increased 7% annually. Significant differences in implant rates exist between countries and also in indications and especially implantation practice within South Africa; these need to be recognized in analysis of any pacemaker related data included in surveys from this region. Although financial, equipment and personnel constraints account for most differences between the countries, these do not apply for many of the differences observed in South Africa. O090 VENTRICULAR PACING IN ICD PATIENTS AND CLINICAL OUTCOME Vecchio F; Santini L; Papavasileiou L; Schirripa V; Sergi D; Tota C; Cioè R; Magliano G; Forleo GB; Romeo F
 Division of Cardiology, Department of Internal Medicine, University of Rome "Tor Vergata" Purpose: Few data are available about the influence on outcomes of right ventricular pacing in patients implanted with implantable cardioverter defibrillators (ICD). Methods: We analyzed 285 consecutive patients who underwent ICD implantation at our institution between September 2003 and November 2010. Patients were divided in two groups "Vp > 50%" (n = 39, 33 males, age 64,8 ± 11,6 years) and "Vp < 50%" (n = 246, 233 males, age 65,7 ± 12 years) based on the percent of right ventricular pacing during follow‐up. Results: Mean follow–up was 24.12 ± 18.4 months. The two groups were homogenous regarding age, sex, ejection fraction, type of device (single or dual chamber) and pharmacologic treatment. No statistically significant differences were observed between the two groups regarding episodes of AF and appropriate discharge of the device. Nevertheless, the Vp > 50% group experienced appropriate discharge earlier (time to 15,75 months vs 39,5 months, p < 0.05) The group with Vp < 50% presented more episodes of non sustained ventricular arrhythmias (NSVT 66/264 vs 19/39, p = 0,05). Conclusion: Despite what communally thought right ventricular pacing seems to be protective in ICD recipients. O091 CONTINUOUS RIGHT VENTRICULAR APICAL PACING CAUSE ASYMPTOMATICALLY REDUCED CARDIAC FUNCTION WITHIN TWO YEARS Yamada T; Arita T; Ohshima M; Okamoto K; Murata T; Iseikai Hospital
 Cardiovascular Center Puropose: To elucidate long‐term outcome after continuous right ventricular pacing for cardiac function. Methods: Forty patients with advanced or complete atrio‐ventricular block who needed permanent pacemaker and their ejection fraction were preserved or mild reduced (more than 45%) were analayzed. Their cardiac function was evaluated by cardiac echocardiography at pre‐implanatation, one week after implanatation, 12 months and 24 months after pacemaker implantation. Ventricular permanent pacemaker leads were all placed at right ventricular apex. And optimal atrio‐ventricular delay was adjusted by echocardiography within 1 week after implanatation. Results: Mean age was 71.7 and percent male was 46.2%. QRS widths were changed as following, 161.4 msec (1 W), 165.3 msec (12 M) and 165.9 msec (24 M). Percent ventricular pacing were more than 98% all the period. Systolic function (= ejection fraction) significantly decreased gradually after pacemaker implantation, 1W‐12 M (0.605–0.592, P = 0.0065), 1 W‐24 M (0.605–0.576, P = 0.0017), respectively. Tei index was also significantly reduced, 1 W‐12 M (0.652–0.612, P = 0.0832), 1 W‐24 M (0.652–0.576, P = 0.0071), but NYHA classes were not significantly changed (1.67 – 1.75: P = 0–4352) at 2 years after implantation. Conclusion: Continuous long term right ventricular apical pacing might reduce cardiac function. O092 ELETRICAL AND MECHANICAL ATRIAL REMODELING PREVENTION USING MINIMAL VENTRICULAR PACING AND RIGHT OUTFLOW TRACT VENTRICULAR LEAD IN SINUS NODE DISEASE Menezes A Jr; Carneiro ARC; Oliveira BL; Souza LA; Neto WJS
 Catholic University of Goias Introduction: Will the minimum ventricular stimulation of the pacemaker when associated with alternate ventricular stimulation site reduce the incidence of Permanent or Intermittent Atrial Fibrillation (AF) in long‐term?Objectives: Compare the synergetic effects of the minimum ventricular stimulation management (IRS PLUS) and right ventricular outflow tract (RVOT) stimulation in sick node syndrome (SND) patients in electrical and mechanical atrial remodeling to RVOT stimulation alone. Methods: 50 SND patients were submitted to a dual chamber pacemaker implantation. The atrial leads were positioned in the right atrium septum and the ventricular lead in the right outflow tract. Patients were randomized in two groups, GROUP I (IRS plus ON in the first 6 months, then the next 6 months the IRS PLUS was turned OFF, then again turned ON for the next 12 months) e Group II (exact the opposite sequence of group I). After 6, 12, 18 and 30 months all patients were submitted to: 1) Follow‐up, 2) Pacemaker telemetry of the AF burden and Mode Switches 3) Transesophageal Echo and 4) Completion of SF‐36 form. Results: All data were calculated using the Mann‐Whitney Test 1) AT‐ AF burden in IRS Plus OFF was higher in all evaluations (6, 12, 18 and 30 months)‐ p < 0,00012) Left Atrial Volume in IRS ON was smaller than in IRS plus OFF in all evaluations either.3) Quality of Life (SF‐ 36 had not changed during the follow‐up (p>0,05)4) Note that during the 30 month follow‐up 7 patients presented permanent AF, for this reason they were excluded. GROUP I = 1 patient and GROUP II = 4 patients. Conclusion: Minimum ventricular stimulation associated with right ventricular outflow tract stimulation reduced the AF burden and left atrium remodeling due to a lower incidence of Atrial Fibrillation in 30 months follow‐up. SUDDEN CARDIAC DEATH O093 ARRHYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA: CLINICAL POLYMORPHISM AND THE ROLE OF ACCOMPANYING MYOCARDITIS Blagova OV; Nedostup AV; Morozova NS; Kogan EA; Gagarina NV; Sedov VP; Shestak AG; Zaklyazminskaya EV; Frolova YuV; Dzemeshkevich SL
 I.M.Sechenov I Moscow State Medical University, B.V.Petrovsky Russian Scientific Center of Surgery Objective: To study clinical polymorphism of arrhythmogenic right ventricular dysplasia (ARVD), prevalence and a role of accompanying myocarditis. Methods: We did observe group of 15 patients (9 females; 6 males, 45,5 ± 15,9 y.o.) with clear (n = 9) and suspected (n = 6) diagnosis of ARVD. Investigations included heart CT/MRI; PCR detection of virus genomes, anti‐heart antibodies (AB); one right ventricle (RV) biopsy; and 2 autopsy. Genetic analysis is in progress now for all patients. Results: Three variants of ARVD phenotypes were sorted out. Group 1, "Typical" (or "latent arrhythmic", n = 8; 44.5 ± 12.9 y.o.), with frequent persistent «idiopathic» premature ventricular beats from RV, nonsustained ventricular tachycardia (VT); lack of major ECG criteria in the presence of intra‐myocardial fat. The prevalence of myocarditis was 50%, and Epstein‐Barr virus was detected in 1 case. Patients from group 2 (n = 2, 71 y.o.), "Arrhythmic" developed stable VT alongside with major ECG criterias; RV dilatation of various degree; myocarditis is not revealed. Group 3 is ARVD with biventricular heart insufficiency (n = 5, 39.7 ± 13.5 y.o.); prevalence of myocarditis is 60%. Two patients within this group died; and Herpes virus types 1, 6 in myocardium were detected in both. Three patients have got ICD, for 4 patients ICDs were recommended, for 2 patients RFA were performed. Conclusions: The ARVD can be found in patients of any age and gender. The fat inclusion is revealed by MRI in 82% (from 11 patients), and detected by CT in 83% (from 6), but criteria's of the diagnosis do not fulfill. Inexplicable RV dilatation always requires exclusion of ARVD. Dysfunction of the left ventricle (due to fibro‐fatty replacement or myocarditis) make correct diagnosis ARVD more complicated. For isolated ARVD is not peculiar increase of a anti‐heart AB. Biopsy with viral genome detection seems to be very helpful in diagnostics of ARVD, myocarditis by itself or in combination. O094 RESULTS OF THE SOUTH AFRICAN REGISTRY FOR ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY (ARVC): SOME NOVEL GENETIC AND OTHER FINDINGS Okreglicki A; for the Cardiac Arrhythmia Society of South Africa
 University of Cape Town Introduction: ARVC is a heart muscle disorder characterized by ventricular arrhythmias, heart failure and sudden death often occurring in the young and in athletes, familial in >50% and with mutations in genes encoding essential desmosomal proteins. First described in South Africa in 1997 and reported in 2000, it has been found in all segments of African society. The ARVC Registry of Southern Africa has enrolled probands and affected first degree relatives since 2004. Methods: Results of the SA ARVC registry which provides diagnostic validation, assessment of clinical risk and therapy, and genetic screening were analyzed. Results: Of 259 individuals with suspected ARVC enrolled in the registry, 67 have definite diagnosis according to the ARVC Task Force Criteria: 68% male; median age 27yrs; most frequent presenting symptom: palpitations; most frequent ECG abnormality: abnormal T‐wave inversion; ventricular tachycardia documented in >80%; >60% involved in sports; annual mortality ± 3% with history of syncope and VT strongest independent predictors of death. Genetic screening in 36 of the first 50 unrelated index cases revealed: in 25% disease‐causing mutations in the PKP2‐gene encoding plakophilin 2 of the desmosome; 5 being novel mutations; and in 2 individuals compound heterozygosity giving an allelle 'double dose' effect and severe phenotype. Screening in 62 definite ARVC cases of the DSP‐gene encoding desmoplakin found mutations in 2; the same mutation occurred in 6 of 150 patients with dilated cardiomyopathy (DCM). Conclusions: ARVC in South Africa is not uncommon and similar in many respects to other international reports. However, the registry is unique in showing: younger age of death (<40yrs), strongly predicted by syncope and VT; high rate of sport participation; compound and novel mutations in the commonly affected PKP2‐gene; and the demonstration of DSP‐gene mutations in both ARVC and DCM patients suggesting a common spectrum of heart disease. O095 CLINICAL AND GENETIC CHARACTERIZATION OF JAPANESE PATIENTS WITH ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY Ohno S; Nishio Y; Nagaoka I; Miyamoto A; Kimura H; Itoh H; Makiyama T; Horie M
 Cardiovasacular Department, Shiga University of Medical Science Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart disease characterized by fibrofatty replacement of right ventricle (RV). ARVC often presents ventricular tachycardia (VT) of RV origin, heart failure and sudden death. Recently numerous mutations in desmosomal genes—plakophilin‐2 (PKP2), desmoplakin (DSP), desmoglein‐2 (DSG2), desmocollin‐2 (DSC2)—have been shown to cause ARVC. The incidence rate of these gene mutations was reportedly 30∼40% in Europe, but in Asia, it remains unstudied. Methods and Results: This study aimed to elucidate the clinical characteristics in Japanese ARVC patients. The diagnosis of ARVC was established in accordance with new criteria (Circulation, 2010). We examined consecutive 33 Japanese ARVC probands (definite, borderline and possible) from 33 unrelated families. Twenty‐eight probands (84%) were diagnosed as definite, 4 (12%) as borderline and 1 (3%) as possible. The cohort consisted of 25 males (75.8%) and 8 females. The frequency of male patients was higher as reported. We screened four genes: PKP2, DSP, DSG2 and DSC2 using direct sequencing methods. We identified gene mutations in 15 patients (45%): 9 patients with PKP2, 5 DSP, 4 DSG2 and 1 DSC2 mutations. Four of them were compound mutations: 2 PKP2 + DSG2, 1 PKP2 + DSP, and 1 DSP + DSG2. We also identified homozygous mutation carriers in 1 patient with PKP2, 2 DSP and 1 DSG2. The frequency of PKP2 mutation carriers was as high as reported previously. Conclusions: We identified mutations of ARVC‐related genes in 15 of 33 patients (45%). The prevalence of the mutation carriers in four desmosomal genes appeared to be higher in Japan than Europe. As the cardiac arrest can be an initial manifestation of ARVC, the identification of genetically affected family members (even though asymptomatic) would also offer a strong clinical modality to prevent sudden death. O096 A FIVE‐YEAR FOLLOW‐UP OF PATIENTS WITH HEART FAILURE: CLINICAL PREDICTORS OF ARRHYTHMIC VS ALL‐CAUSE MORTALITY Stergiou P; Flevari P; Lagou S; Ntai K; Kolokathis F; Filippatos G; Anastasiou‐Nana M
 2nd Department of Cardiology, Attikon University Hospital, Athens, Greece Background: Risk stratification for sudden cardiac death (SCD) in heart failure remains suboptimal. LV ejection fraction (LVEF) is currently used for guiding cardioverter‐defibrillator implantation, but is also associated with pump failure. Aim of this study was to identify readily available clinical markers that increase the risk of arrhythmic vs clinical parameters associated more with all‐cause mortality. Methods: A cohort of 386 patients was assessed, with heart failure of dilated (n = 252) or ischemic (n = 134) etiology. LVEF, 6‐min walking test, atrial fibrillation (AF), QRS duration, QT duration, hyponatremia, serum urea, and LV hypertrophy were estimated in order to identify i) prognostic factors of SCD or rapid sustained ventricular tachycardia (VT) and ii) factors associated with all‐cause mortality. VTs faster than 180 bpm were taken into account (verified by either surface ECG or intracardiac defibrillator recordings) and were used as SCD surrogate end‐points. Cox stepwise regression was used for analysis. Results: During a 5‐year period, all‐cause mortality was 27.7%, while SCD or sustained VT 7.7%. Regarding all‐cause mortality, AF (p < 0.001), LVEF (p = 0.001), serum urea (p = 0.047), and 6‐min walking test (p < 0.001) were independent predictors. On the other hand, AF (p = 0.005), LVEF (p = 0.015), as well as hypertrophy (p = 0.01) were independent predictors of arrhythmic death. Interestingly, the presence of AF was associated with a 4‐fold increased risk in all‐cause mortality and an 11‐fold risk in SCD or sustained VT. It is also remarkable that hypertrophy was related with an almost 13‐fold risk of SCD or sustained VT. Conclusion: In patients with heart failure, a reduced LVEF is equally predictive of long‐term all‐cause and arrhythmic mortality, while the presence of AF or LV hypertrophy increases significantly the risk of life‐threatening ventricular tachyarrhythmias. More studies are needed to test the clinical utility of these findings. O097 NO INFLUENCE OF SCAR TISSUE ON MICROVOLT T‐WAVE ALTERNANS Kraaier K; Olimulder MAGM; Galjee MA; van Dessel PFHM; van der Palen J; Wilde AAM; Scholten MF; Twente ICD Cohort Study (TICS)
 Medisch Spectrum Twente, Enschede, The Netherlands Background: Microvolt T‐wave Alternans (TWA) is an electrocardiographic marker for predicting sudden cardiac death. In this study, we aimed to study the relation between TWA and scar assessed with cardiac magnetic resonance imaging (CMR) in patients with ischemic (ICM) or dilated cardiomyopathy (DCM). Methods: Sixty‐three patients with positive or negative TWA and complete CMR examination were included. Using CMR and the delayed enhancement technique, ejection fraction (LVEF), end‐diastolic volume (LVEDV) and scar characteristics were assessed. Results: Overall, positive TWA (n = 29) was related to male gender (p = 0.01), lower LVEF (p = 0.05) and increased LVEDV (p < 0.01). After multivariate analysis, male gender (p = 0.01) and lower LVEF remained significant (p = 0.04). Scar characteristics (presence, transmurality, and scar score) were not related to TWA (all p > 0.5). In the patients with ICM (n = 35) scar was detected in 32. Positive TWA (n = 14) was related to older infarct age (median 17 years, range 2–32 versus median 5 years, range 0–21, p = 0.05). Trends were found for male gender (p = 0.07) and higher LVEDV (p = 0.09). In patients with DCM (n = 28), scar was detected in 11. Trends were found between positive TWA (n = 15) and male gender (p = 0.10), lower LVEF (p = 0.10), and higher LVEDV (p = 0.09). In both subgroups, the presence, transmurality or extent of scar was not related to TWA (all p > 0.45). Conclusion: Neither in patients with ICM or DCM a relation was found between the occurrence of TWA and the presence, transmurality or extent of myocardial scar. Overall there was a significant relation between heart failure remodeling parameters and positive TWA. O098 QT COMBINED WITH TIME DOMAIN‐TWA AND T‐WAVE MORPHOLOGY COULD PREDICT COMPLETE HEART BLOCK RELATED TORSADE DE POINTES Simeonidou E; Kastellanos S; Varounis C; Michalakeas C; Koniari C; Nikolopoulou A; Anastasiou‐Nana M
 2nd Cardiology Dept, Attikon University Hospital, Athens, Greece Purpose: It is known that complete heart block (CHB) predisposes infrequently to torsade de pointes (TdP), mainly through QT prolongation with consequences even after permanent pacemaker implantation (PPM. T‐wave alternans (TWA) is linked to vulnerability to life‐threatening arrhythmias and an increase in TWA precedes the onset of ventricular tachyarrhythmias. Purpose of the study was to examine the contribution of the time domain TWA (TD‐TWA) combined with ECG T‐W morphology in prediction of TdP during CHB. Methods: 60 consecutive patients (pts), (35w, 25m), mean age 77 ± 7 years, referred for PPM implantation because of CHB underwent 12 leads ECG assessment and 24h Holter monitoring, if their escape rhythm was satisfactory with temporary pacing back‐up. TD‐TWA was assessed by the MMA method on a MARS Holter analyser. The maximum TD‐TWA in either modified lead V1, V2, V3 was derived and its value defined as positive when the voltage was ≥75 uV. T‐wave morphology was defined as broad, notched, small and late, deep inverted. The longest QT in any of the 12 ECG leads was measured. Results: There were not reversible causes of CHB. Nineteen out of 60 pts (33%) developed mainly short runs of TdP and bradycardia was the only cause. Neither the escape rhythm HR nor the QRS width predicted the risk of TdP. TWA (OR 1.171 with 95% CI: 1.057–1.310, p = 0.003), QT (OR 1.034 with 95% CI:1.012–1.056, p = 0.002), and notched TW morphology (OR = 8.00 with 95% CI:1.36–46.81, p = 0.021) were correlated with greater risk of TdP. All pts needed PPM implantation. In the TdP group LPR was programmed to 80 bpm. Pts were followed up for 1 year and interrogation of each pts data was negative for TdP. Conclusions: In CHB pts positive TD‐TWA, prolonged QT and notched T‐waves are associated with increased risk for TdP. Prediction of this risk is helpful in precautionary PPM programming to avoid recurrence of TdP after PPM implantation until the QT shortens to normal. O099 J WAVE AND FRAGMENT QRS ON ECG ASSOCIATED WITH ALL‐CAUSE MORTALITY AND SUDDEN CARDIAC DEATH IN PATIENTS WITH CHF Pei J; Li N; Chen J; Gao Y; Zhang Y; Zhang P; Cao K‐J; Pu J
 Fuwai Cardiovascular Hospital, Peking Union Medical College,Chinese Academy of Medical Sciences Objective: Although sudden cardiac death (SCD) secondary to J wave and fragment QRS (fQRS) is not a rare phenomenon in patients without structure heart diseases, whether they are risk factors for SCD in chronic heart failure (CHF) patients is not known. The aim of this study was to investigate the prevalence and predictive values of J wave and fQRS for SCD in patients with CHF. Methods: The electrocardiograms of 1570 hospitalized CHF patients with dilated cardiomyopathy (DCM, 572 cases) and ischemic cardiomyopathy (ICM, 998 cases) aged from 18 to 79 years were analyzed regarding the relationship between ECG characteristics and all‐cause mortality, SCD and Non‐SCD (NSCD). Results: During a median follow‐up period of 36 months, 21.49% patients died, of whom 35.84% died of SCD. The prevalence of J wave and fQRS in the inferior leads of patient group were significantly higher than that of control group (p < 0.01). After adjustment for age, gender, heart failure classification, QRS width, QTc interval, 24‐hour average heart rate, left or right bundle branch block, and medications, Cox regression analysis revealed that J wave in the inferior leads was associated with all‐cause mortality (HR, 2.655; 95% CI, 1.774–3.973), NSCD (HR, 2.122; 95% CI, 1.265–3.560) and SCD (HR, 4.095; 95% CI, 2.132–7.863), in DCM respectively, However, in ICM, only fQRS in the inferior leads was associated with all‐cause mortality (HR, 1.889; 95% CI, 1.444–2.471), NSCD (HR, 1.441; 95% CI, 1.001 –2.079) and SCD, (HR, 2.714; 95% CI, 1.809–4.072] respectively. Detailed analysis showed that the HR in men was higher than that in women for the NSCD and SCD groups. Conclusions: The presence of J wave and/or fQRS in the inferior leads of CHF patients indicated 2 to 4‐fold higher risk of all‐cause mortality, NSCD and SCD. They may serve as the independent predictors for the prognosis in this population. Key Word: J wave, fQRS, sudden cardiac death, chronic heart failure O100 ARRHYTHMIA RISK STRATIFICATION WITH NON‐INVASIVE DEPOLARIZATION AND REPOLARIZATION ARRHYTHMIC RISK MARKERS IN ASYMPTOMATIC YOUNG INDIVIDUALS WITH INCIDENTALLY FOUND PROMINENT J‐WAVE Simeonidou E; Michalakeas C; Kastellanos S; Varounis C; Koniari C; Dai C; Psarogiannakopoulos P; Stassinos V; Anastasiou‐Nana M
 2nd Cardiology Dept, Attikon University Hospital, Athens, Greece Purpose: The J‐point elevation is a common electrocardiographic variant considered for years as benign ECG manifestation. Recently a high prevalence of this pattern was found in patients (pts) with idiopathic VF. Although the J wave is synonymous to early repolarization, recently there was some evidence that maybe is a delayed depolarization abnormality. Aim of the study was to evaluate the prevalence of late potentials (LPs) testing (depolarization marker) and time domain T‐wave alternans (TD‐TWA) (repolarization marker) in healthy young individuals with prominent J‐wave. Methods: The study population was consisted of 77 consecutive healthy young individuals (13 w, 62 m), mean age 30 ± 13 years, with incidental discovery of J‐point elevation on the 12 lead ECG. Eighty consecutive healthy young individuals with normal ECG served as control population. All pts consented to LP testing by SAECG and time domain T‐wave alternans (TD‐TWA) by 24 hours Holter monitoring. LPs were considered positive when at least 2 criteria were met. The greater TD‐TWA was chosen for assessment and it was defined as positive when the max voltage was >75 uV. Results: On 360 ± 85 days follow‐up (fu)nobody developed significant arrhythmias. The ECG localization of J‐wave was 17 inferior, 43 anterior and 15 diffuse. LPs were positive in 22 pts (28%) and TD‐TWA in 11 pts (15%). Prevalence in healthy subjects with normal ECG 4% and 3.2% respectively. Neither max TWA (p = 0.751) nor LPs (p = 0.493) were correlated to J‐ point ECG localization. Conclusions: In our population of healthy young individuals with prominent J‐point, the prevalence especially of the depolarization marker LPs is significantly higher than in healthy subjects without prominent J‐wave, without any arrhythmic consequences in one year's fu. Validation in larger population and longer fu is needed. O101 ARRHYTHMOGENESIS FACTORS IN NEWBORNS Kovalev I; Svintsova L; Child's Heart Center
 Institute of Cardiology Objective: To determine risk criteria of formation and advance of heart rhythm disturbances in newborns. Results: 102 patients (14 healthy incl.) were examined. Extrasystoles – 32,4%, bradyarrhythmias – 25,7%, tachyarrhythmias – 22,9%, WPW syndrome – 18,9%. Rhythm disturbances preserve only in 5,4% by the sixth month of life. Longer persistence is typical for extrasystole and WPW syndrome. Heart rhythm disturbances are marked much more often in newborns whose mothers had acute respiratory disease during pregnancy (p = 0,049), and who were born from the primipregnancy (p = 0,041). Bradyarrhythmias and tachyarrhythmias have similar factors which can potentially favor arrhythmia manifestation: intracranial hypertension according to neurosonography and changes of hormonal profile of thyroid body towards hypofunction. Established fact that higher value of systolic pressure in the right ventricle (p = 0,047) is the peculiarity of intracardiac hemodynamics in the group of newborns with heart rhythm disturbances. Presence of extrasystole in newborns is related with increase of troponin level I (p = 0,015) and activation of parasympathetic link of vegetative nervous system (increase of pNN50 (p = 0,009) and SDNNi (p = 0,037). Association of bradyarrhythmias with level of myocardial antinuclear antibodies in blood (x2 = 4,89; p = 0,027) are marked for fact in newborns. Conclusion: Thus, autoimmune component is important link of bradyarrhythmias pathogenesis, which, probably, is formed into antenatal period with the help of maternal antibodies. Destructive processes in myocardium, accompanying by increase of troponine I level in blood serum, and also activation of parasympathetic link of vegetative nervous system during extrasystole depend, on the contrary, on factors connecting with intra‐ and postnatal periods. Infection during pregnancy can influence, indirectly, on the process abnormality of obliteration of additional conduction tracts at WPW syndrome. O102 REDUCED DECELERATION CAPACITY OF HEART RATE RISK STRATIFIES PATIENTS PRESENTING WITH PRESERVED LEFT VENTRICULAR EJECTION FRACTION (LVEF>35%) FOR SUDDEN CARDIAC DEATH Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Aggelis A; Kartsagoulis E; Stefanadis C; APRET
 First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: Previous studies reported that the cut off point of ≤2.5 ms from the Deceleration Capacity (DC) of heart rate is a powerful predictor of mortality in post myocardial infarction patients (pts). We used the same cut off point to examine whether it is an adequate sudden cardiac death (SCD) risk predictor in patients with preserved left ventricular systolic function (LVEF > 35%). Methods: We prospectively screened 104 pts (age: 64 ± 14.0 years, male: 84%, NYHA class: 2.1 ± 0.4, LVEF: 41.7 ± 6.5, CAD: 84%, DCMP: 16%) with ECG, SAECG, ECHO and 24‐hour HOLTER. After 15.5 ± 13.7 months of follow up, patients were classified into the High risk (12 pts, mean LVEF: 39 ± 5.5%) and the Low risk (92 pts, mean LVEF: 42 ± 6.5%, p = 0.1) groups according to three SCD events/surrogates: 1. clinical VT/VF (5 pts) 2. ICD's appropriate activation (2 pts) 3.confirmed SCD (5 pts). LVEF, filtered QRS (SAECG), DC ≤ 2.5 ms, NSVT > 1/24 hour, VPBs > 240/24 hour, mean Heart Rate (HR) and SDNN /HRV (24‐hour HOLTER), were calculated and statistically analyzed for the two groups. Results: DC ≤ 2.5 ms was a statistically significant predictor of SCD (Long rank test p = 0.02). After Cox regression analysis adjusted for LVEF, fQRS, NSVT > 1/24 hour, VPBs > 240/24 hour, HR and SDNN /HRV (24 hour HOLTER), the cutoff point of DC ≤ 2.5 ms remained an important and independent SCD predictor with HR 6.007 (p = 0.01) 95% CI: 1.513–23.854. Conclusions: In the present pts cohort, the cut off point of DC ≤ 2.5 ms was an important and independent predictor of SCD. Further evaluation of the reduced DC of heart rate in a larger population with longer follow up is justified. O103 CLINICAL PROFILE OF PATIENTS WITH ELECTRICAL VENTRICULAR TACHYCARDIA/FIBRILLATION STORM: A TWO‐YEAR REVIEW OF CLINICAL PRESENTATIONS, RISK FACTORS AND OUTCOMES Ona RL; Ramirez MF
 University of Santo Tomas Hospital (USTH), Espana, Manila, Philippines Electrical storm refers to multiple occurrences of ventricular tachycardia or fibrillation occurring three or more times in a 24 hour period. We reviewed the clinical profile and outcome of patients admitted for electrical storm at the USTH from June 2008 to February 2011. Ten patients, 6 males and 4 females aged 30 to 72 years old were included in the study. There were 3 cases of acquired long QT syndrome, 2 cases of congenital long QT syndrome, 1 case of ischemic and 2 cases of dilated cardiomyopathy s/p ICD implantation and 2 cases of NSTEMI (anterior wall). Seven of the nine patients presented with mild to severe hypokalemia. Four had mild hypocalcemia. Most of the patients were managed medically with antiarrhythmics, a combination of intravenous amiodarone and lidocaine. Four patients underwent temporary pacemaker insertion for overdrive pacing. One patient with NSTEMI developed the electrical storm after emergency coronary bypass surgery. Among the 2 patients with congenital long QT syndrome, one underwent implantation of an internal cardioverter‐defibrillator(ICD) while the other one, while awaiting funds for device therapy, is being managed medically. Two patients with cardiomyopathy and CHF underwent ICD implantation while the other patient with already a previous implant developed storm with multiple ICD shocks. Eight patients were discharged from the hospital improved, all of whom are still following up and stable. Two patients with electrical storm had multiple organ failure and died. These were the cases of NSTEMI who developed electrical storm after coronary bypass surgery and a case of electrical storm secondary to acquired long QT syndrome due to severe hypokalemia and drugs. In our 2 year review of electrical storm patients, the major etiologies include long QT syndrome, and ischemic cardiomyopathy with heart failure. Hypokalemia and hypocalcemia were the common electrolyte abnormalities associated with the occurrence of electrical storm. SUPRAVENTRICULAR TACHYCARDIAS O104 THE ROLE OF NON‐CORONARY CUSP ABLATION APPROACH IN THE TREATMENT OF PERINODAL ATRIAL TACHCARDIAS: PREFERENTIAL OR ADJUNCTIVE? Ju W; Chen M; Yang B; Chen H; Zhang F; Yu J; Cao K
 Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 2100 Backgroud: Ablation in the noncoronary aortic cusp (NCC) potentially has a role in the treatment of perinodal atrial tachycardias (ATs). Objectives: To characterize the role of NCC ablation in the treatment of perinodal ATs among a cohort of patients with perinodal ATs. Methods: One hundred and seven patients with focal ATs who underwent electrophysiologic study and radiofrequency catheter ablation were enrolled in the study. The electrophysiological characteristics and the target electrograms of those who need NCC ablation and other patients of perinodal ATs were compared. Results: Totally 18 cases were revealed to have the focal ATs located in the perinodal area. Among them, only 4 cases (22%) warrant ablation in the NCC, whereas the remainder could be successfully eliminated by ablation from the endocardial right atrium at the perinodal region. There were no clinical and electrophysiological clues observed to have the potential to predict the true original site, including the onset behavior, the earliest activation site in the right atrium, the configuration of the unipolar recording, as well as the time to termination during the ablation in the perinodal area. Conclusions: Approximately one fifth of the perinodal ATs warrant ablation in the NCC. However, no clinical and electrophysiological clues could predict the potential site of the perinodal ATs. The NCC ablation may serve as a adjunctive role in the treatment of the perinodal ATs. O105 DIRECT MID‐ISTHMUS APPROACH FOR RADIO‐FREQUENCY ABLATION OF CAVOTRICUSPID ISTHMUS‐DEPENDENT ATRIAL FLUTTER Cheng T; Liu Y; Kongstad O; Hertervig E; Yuan S
 Department of Arrhythmias, Lund University Hospital, Lund, Sweden Aims: To test the feasibility and efficacy of the direct mid‐isthmus (DMI) approach for ablation of cavotricuspid isthmus‐ (CTI‐) dependent atrial flutter (AFL). Methods: Patients were randomly assigned to receive either conventional linear radio‐frequency (RF) ablation between the tricuspid annulus and inferior vena cava (the linear approach) or RF ablation at sites with the highest electrical signals, usually in the middle of the CTI (the DMI approach). Sustained, bi‐directional CTI block was the endpoint. Procedure parameters and follow‐up data were obtained. Results: In total, 80 patients were included, 40 each for the linear approach and the DMI approach. To achieve sustained bi‐directional CTI block, the linear approach needed 841 ± 594 S or 14.0 ± 9.9 RF applications, with total fluoroscopy time of 18.6 ± 9.4 min and total procedure time of 152 ± 58 min, as compared to the DMI approach which needed 350 ± 319 s (p < 0.0001) or 5.8 ± 5.3 RF applications (p < 0.0001), with total fluoroscopy time of 14.8 ± 6.0 min (p < 0.05) and total procedure time of 111 ± 36 min (p < 0.0005). The CTI block was obtained with 3 or less RF applications in 18 patients in the DMI group (45%), but only in 2 patients in the linear ablation group (5%). During follow‐up of 28 ± 14 months, recurrence cases were 2 in the linear and 1 in the DMI group (NS). Conclusions: During RF ablation of typical AFL, directly targeting the muscular bundles in the middle of the CTI can significantly reduce the amount of RF energy needed for bi‐directional CTI block, with shorter fluoroscopy and procedure times. This direct mid‐isthmus approach may be recommended for clinical use to replace the conventional linear approach. O106 DEPRESSION OF ST SEGMENT AS PROGNOSTIC VALUE IN SUPRAVENTRICULAR TACHYCARDIAS Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A
 Instituto Cardiovascular de Buenos Aires (ICBA) Background: ST depression is a known high risk marker in acute coronary syndromes, accounting for higher mortality and infarction rates in this subgroup. However, it is unknown weather this phenomenon has similar implications during supraventricular tachycardia. Objective: To determine accuracy of ST depression to predict further coronary events, myocardial revascularization need, cardiac heart failure, and all cause mortality in supraventricular tachycardia (SVT). Methods: Patients eligible for radiofrequency ablation of SVT were included. Only the ones presenting nodal re‐entrant tachycardia were considered. Pre‐existing bundle branch blocks and AV re‐entrant tachycardia were excluded. ST morphologies and cycle length variations during tachycardia were analyzed. Follow up (6 months to 5 years) determined: Mortality rates (total and cardiovascular), MI and unstable angina incidence, CABG or PTCA need. Two groups were compared: the ones which developed pathologic ST depression (descendent or horizontal ST morphology) and the ones that did not develop ST depression or developed a non pathological ST depression (ascendant). Results: Total of 68 patients, age (49,57 ± 13 years); 66,3% males. Incidence of UA was 8.82%; 7,35% required percutaneous angioplasty; 2,94% total mortality (non cardiac); 1,47% developed cardiac insufficiency. The group that developed non pathologic ST or non ST depression were older (55.47 ± 11,1 years); males (82,76%) and showed a higher incidence of UA (15,38%); CABG or PTCA requirement (12.82%); CI (2,56%) and all cause mortality (5,12%). Conclusions: ST segment depression failed to predict higher mortality rates and CAD in this subgroup. This study suggests that ST depression is not a high risk marker in SVT and has no prognostic value in this subgroup. O107 RISK OF MALIGNANT ARRHYTHMIAS IN INITIALLY SYMPTOMATIC PATIENTS WITH WPW SYNDROME: RESULTS OF A PROSPECTIVE FOLLOW‐UP STUDY Pappone C; Vicedomini G; Petretta A; Vitale R; Saviano M; Pappone A; Baldi M; Cuko A; Giannelli L; Santinelli V
 Maria Cecilia Hospital Objectives: This study was designed to assess characteristics and predictors of malignant arrhythmias (MA) in initially symptomatic patients with WPW syndrome. Background: The available amount of detailed long‐term data in patients with WPW syndrome is limited and no prospective electrophysiological studies looking at predictors of MA are available. Methods: Among 8575 symptomatic WPW patients with atrioventricular reentrant tachycardia (AVRT) referred for EPT, 369 (mean age, 23 ± 12.5 years) declined catheter ablation and were followed. Primary endpoint of the study was to evaluate over a 5‐year follow‐up predictors and characteristics of patients developing MA. Results: After a mean follow‐up of 42.1 ± 10 months, MA developed in 29 patients (mean age, 13.9 ± 5.6 years, 26 M) resulting in presyncope/syncope (25 patients) or resuscitated cardiac arrest (4 patients). Of the remaining 340 patients, 168 (mean age, 34.2 ± 9.0 years) remained asymptomatic up to 5 years and 172 (mean age, 13.6 ± 5.1) had benign recurrence including sustained AVRT (132 patients) or AF (40 patients). As compared with no‐MA group, MA group showed shorter AP‐AERP (p < 0.001), more often exhibited multiple AP (p < 0.001) and AVRT triggering sustained preexcited AF (AVRT‐AF) was more frequently inducible (p < 0.001). Multivariate analysis demonstrated that short AP‐AERP (p < 0.001) and AVRT‐AF (p < 0.001) were independent predictors of MA. Conclusions: Most initially symptomatic WPW patients remain asymptomatic or may have benign recurrences, but a minority of them may experience MA. Short AP‐AERP and AVRT triggering AF are independent predictors, which emphasizes the need of contextual catheter ablation in patients at highest risk. O108 RFA OF DRUG‐REFRACTORY TACHYARRHYTHMIAS IN SMALL CHILDREN Svintsova L; Kovalev I; Murzina O; Popov S; Child's Heart Center
 Institute of Cardiology Materials: Twelve RFA of tachyarrhythmias were performed to children of 1–12 months in our clinic during for the last five years. The minimum age of effective RFA is 48 days, the minimum weight is 3800 gr. Tachycardia was first disclosed in three children antenataly. In 8 cases tachycardia had the persistent paroxysmal course; in 4 cases it was paroxysmal. The presence of arrhythmogenic cardiomyopathy, accompanied by blood insufficiency, and also ineffectiveness of antiarrhythmics combinations including amiodarone were the indications of RFA performance in all cases. Results: WPW syndrome was diagnosed in five children: concealed WPW was in four of them, and manifest WPW was in one. Localization of accessory pathway: left posterior (n = 2), left anterolateral (n = 2) and right posteroseptal (n = 1). In all cases of left sided localization of accessory pathway an approach into the left atrium was carried out through the patent foramen oval. Intra‐atrial tachycardia was diagnosed in seven children. Localization of atrial ectopic focuses was determined in the area of right atrial auricle basis (n = 2), in the area of right atrial anterior wall (n = 3), in the area of His band (n = 1). The atrial reentry tachycardia happened in the area of the patent foramen oval in one case. The intra‐ and postoperative period in all patients was without complications. According to the Echo data reduction of atrium sizes, increase of left ventricle contractile function was marked in 5 – 10 days (p < 0,05). Follow‐up was from one month to five years. Tachycardia relapses were not disclosed. As a result of Echo investigations, pathology was not uncovered. Conclusion: RFA is an effective and safe method of tachyarrhythmia treatment including infants. All children of early age with hemodynamic and clinically significant tachycardias, refractory to antiarrhythmic therapy should be turned to specialized centers, having RFA experience at the given age. SYNCOPE O109 ADDITIONAL DIAGNOSTIC VALUE OF VERY PROLONGED OBSERVATION BY IMPLANTABLE LOOP RECORDER IN PATIENTS WITH UNEXPLAINED SYNCOPE Furukawa T; Maggi R; Bertolone C; Fontana D; Brignole M; Department of Cardiology
 Ospedali del Tigullio, Lavagna, Italy Introduction: In the literature, the average diagnostic yield of the implantable loop recorder (ILR) is reported to be 35% over an observation period generally less than 18 months. The aim of this study was to evaluate the diagnostic value of ILR during very prolonged observation. Methods and Results: Consecutive patients who had received one or more (in the case of battery exhaustion before diagnosis) ILR (Reveal/plus/DX, Medtronic. inc) from 2001 to 2010 were included. The diagnostic ECG was classified according to the ISSUE classification. We analyzed 157 patients (87 males, 69 ± 14 years): 70 of these were followed up for ≥18 months. The estimated cumulative diagnostic rates were 30%, 43%, 52% and 80% at 1, 2, 3 and 4 years, respectively; 26% of diagnoses were made after 18 months. The diagnostic yield was independent of structural heart disease, bundle branch block, number of syncopes, age and gender; the median time to diagnosis of ISSUE type 1 patients was shorter than that of the others (4 [2;10] v.s. 16 [6;23] months; p = 0.003). During the observation period, 3 patients (1.9%) died and none suffered arrhythmic death. Conclusions: Prolonging observation up to 4 years increased the diagnostic value of ILR in syncopal patients and was safe. A quarter of patients diagnosed needed more than 18 months of follow‐up. As consequence, when a strategy of prolonging monitoring is chosen, monitoring should be maintained even for several years until diagnosis is established. O110 SYNCOPE DUE TO IDIOPATHIC PAROXYSMAL AV BLOCK: LONG‐TERM FOLLOW‐UP OF A DISTINCT FORM OF AV BLOCK Brignole N; Deharo JC; De Roy L; Menozzi C; Blommaert D; Dabiri L; Ruf J; Guieu R; Department of cardiology
 Ospedali del Tigullio, Lavagna, Italy Objectives: We present data on patients with syncope due to paroxysmal atrioventricular (AV) block unexplainable in terms of currently known mechanisms. Background: Paroxysmal AV block is known to be due to intrinsic AV conduction disease or to heightened vagal tone. Methods: We evaluated 18 patients presenting with unexplained syncope who had: 1) normal baseline standard ECG; 2) absence of structural heart disease; and 3) documentation, by means of prolonged ECG monitoring at the time of syncopal relapse, of paroxysmal third‐degree AV block with abrupt onset and absence of other rhythm disturbances before or during the block. Results: The study group consisted of 9 males and 9 females, aged 55 ± 19 years, who had suffered from recurrent unexplained syncope for 8 ± 7 years and were subsequently followed up for up to 14 years (4 ± 4 years on average). The patients had no structural heart disease, standard ECG was normal and electrophysiological study was negative. In all patients, prolonged ECG monitoring documented paroxysmal complete AV block with one or multiple consecutive pauses (mean longest pause: 9 ± 7 sec) at the time of syncope; AV block occurred without P‐P cycle lengthening or PR interval prolongation. During the observation time no patient developed permanent AV block; on permanent cardiac pacing, no patient had further syncopal recurrences. Conclusions: Common clinical and electrophysiological features define a distinct form of syncope due to idiopathic paroxysmal AV block characterized by a long history of recurrent syncopes, absence of progression to persistent forms of AV block and efficacy of cardiac pacing therapy. O111 SUPINE VASOCONSTRICTION AND VASOVAGAL SYNCOPE Flevari P; Stergiou P; Leftheriotis D; Dagres N; Lekakis J; Anastasiou‐Nana M
 2nd Department of Cardiology, Attikon University Hospital, Athens, Greece Background: Vasovagal syncope (VVS) is characterized by a reduced vasoconstrictor reserve during sustained orthostatic stress. It has also been suggested that VVS is associated with forearm vasoconstriction during supine rest. The study addressed whether supine forearm vascular resistances (FVR) are related to the vasoconstrictor reserve during head‐up tilt test and its result. Methods: We studied 37 pts with recurrent VVS (at least 2 syncopal episodes during the last 6 months), mean aged (±SE) 46.5 ± 3.6 years who underwent 2 head‐up tilt tests (HUTs): an initial, positive examination, and a second one, 3 months later (with or without drugs. Group A patients comprised 28 patients with a subsequently negative HUT, while Group B consisted of the remaining 9 patients with a second, positive HUT. Strain‐gauge venous occlusion plethysmography was used to assess right forearm blood flow (FBF) and FVR i) at rest, in the supine position, just prior to HUT, ii) during the first 10 mins of HUT, every 30 sec. FBF was expressed as ml per min per 100 ml of forearm tissue volume and FVR was calculated as the mean blood pressure divided by FBF. Vasoconstrictor reserve was assessed as the mean% reduction in supine FVR. Results: In patients whose HUT remained positive, no changes were observed in supine FVR or vasoconstrictor reserve between the 2 examinations. On the contrary, in patients with a subsequently negative HUT, a decrease was observed in supine FVR (18.7 ± 1.7 vs 27.8 ± 1.8 at baseline, p < 0.05). An increase was observed in their vasoconstrictor reserve during the second HUT (122 ± 3.6 vs 109 ± 3.1 at baseline, p < 0.05). The % reduction in FVR between tests was associated with the% increase in vasoconstrictor reserve. Conclusion: VVS is characterized by vasoconstriction in the supine position. This increase in forearm FVR is pathophysiologically significant and seems to be the reason for the impaired vasoconstrictor reserve observed in this syndrome. O112 COMPARISON OF THE TILT TABLE TEST RESULTS IN ELDERLY AND IN NON‐ELDERLY PATIENTS Zimerman A; Pimentel M; Magalhães APA; Zimerman LI
 Hospital de Clínicas – Federal University of Rio Grande do Sul Introduction: The tilt table test is a useful diagnostic method in the evaluation of syncope. The comparison of the results between elderly and non‐elderly patients has not been elucidated. Objectives: To compare the results of the tilt table test in elderly and non‐elderly patients. Methods: A total of 640 tilt table tests were analyzed and patients were separated in two groups: elderly (≥65 years old) and non‐elderly (<64 years old). Tilt table test response was compared between groups. The protocol had a passive phase (20 minutes; 70 degrees inclination) and an active phase (1.25 mg sublingual nitrate and inclination during 10 minutes). Chi‐square test was used for statistical analysis, and p < 0.05 was considered significant. Methods: The tilt table test results of 640 patients were analyzed. The protocol used in the test was 20 minutes with an inclination of 70 degrees. In case there was no alteration, pharmacologic sensibilization was made with sublingual nitrate during ten more minutes. Patients whose age was ≥65 were considered to be elderly. Results: Patients were mostly females (63.8%) and mean age was 49.1 ± 22.2 years old. The tilt table test was considered positive in 334 patients (51.9%), from which 63.6% after nitrate use. The most frequent positive response was the mixed type (72.3%). The comparison of the results between elderly and non‐elderly patients is shown below. Test resultElderlyNon‐elderlyPositive 93 (45.8%)241 (54.9%)Negative110 (54.2%)196 (45.1%)Total203437p = 0.03. A greater proportion of negative results among elderly was observed both in men and in women, but was only significant in the second group. Conclusions: Elderly patients had significantly less positive results in the tilt table test. The greater presence of other causes of syncope in this age group may have contributed for this finding. TELEMONITORING FOR CARDIAC RHYTHM MANAGEMENT DEVICES O113 INTEGRATING OUT‐PATIENT AND REMOTE FOLLOW‐UP OF CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICE PATIENTS Chronaki C (1); Sfakianakis S (1); Petrakis Y (1); Yang M (2); Radulescu M (3); Eichelberg M (2); Laleci G (4); Hinterbuchner L (5); Arbelo E (6); Dogac A (5); iCARDEA project
 (1) FORTH, Gr (2) OFFIS, De (3) SFRG, A (4) SRDC, Tr (5) SALK, A (6) HCPB, ES Introduction: Annual costs of CVD in the European Union estimated at 192B€, comprise direct healthcare costs (57%), productivity losses (21%), informal care (22%). Health providers and CIED patients can benefit from integrated care engaging health teams in tele‐monitoring and e‐visits in responding to patient‐reported or device‐recorded events or replacing hospital followup. Guideline‐driven services based on consistently implemented standards have the potential to enable integrated care leading to productivity gains and potentially cost savings. The iCARDEA care planner employs AF and VT practice guidelines linked to hospital records, personal health records, and telemonitoring reports to reduce information overload and improve decision support. Thus, interoperability testing is critical for iCARDEA. Methods: IHE integration profiles specs constrain standards and terminologies to achieve interoperability. The care planner uses CM to subscribe and receive patient data, IDCO to process CIED reports, XPHR to exchange personal health data, XDS to share standardized clinical content, PIX/PDQ to cross‐reference patient IDs, and ATNA for security and auditing. Of‐the‐shelf testing tools for IHE profiles were collected and evaluated. Custom tools and anonymised data filled gaps. Results: Comprehensive survey and analysis noted limited test tools, benchmarks, and data sets for complex workflows. The IHE MESA and NIST tools cover most profiles. TestBATN can support testing complex business processes for multiple profiles. Off‐the‐shelf and custom tools with sample datasets were successfully used in testing iCARDEA. Conclusions: A guideline‐driven care planner and supporting components for AF and VT can support integrated healthcare processes for remotely managing CIED patients. Adhoc interoperability testing may works, but to ripe the benefits of integrated care, certified data sets, interoperability testing and benchmarking tools for eHealth must be adopted. VENTRICULAR TACHYARRHYTHMIAS O114 VENTRICULAR ARRHYTHMIAS ARISING FROM THE EPICARDIAL VENOUS ANATOMY: PREVALENCE, MAPPING AND ABLATION Mountantonakis S; Jauregui M; Dixit S; Hutchinson M; Riley M; Lin D; Garcia F; Gerstenfeld E; Callans D; Marchlinski F
 Electrophysiology Section, Division of Cardiology, University of Pennsylvania, Philadelphia, PA, USA Introduction: The purpose of this study is to examine the prevalence, mapping, and limitations in ablation of ventricular tachycardias or ventricular premature complexes (VT) arising from the coronary venous anatomy. Methods: Retrospective analysis of patients (pts) referred for ablation of VT who underwent detailed activation and pace mapping of ventricular outflow tracts, coronary venous system (CVS) and coronary cusps. Results: Among 294 pts with VT referred from catheter ablation, 37 (16 males, age 52 ± 16 years) had earliest activation in the CVS (41 ± 20 ms pre QRS). Of those, 16 (43%) had earliest in the distal great cardiac (GCV), 19 (51%) in the anterior interventricular vein (AIV) and 2 (5%) in the middle cardiac veins. In all cases, pacemaps generated from the vein system were better match then those from the cusps or endocardium. Successful RF ablation within vein was achieved in 23/37 patients (62%). Proximity to coronary vessel precluded adequate energy delivery in 14 pts (38%) and in 2 pts (5%) the ablation catheter could not be passed to the site of earliest activation identified by a 6 F catheter. Successful ablation was achieved at adjacent epicardial sites in 2 pts, from the adjacent left coronary cusp (LCC) in 6 pts and from the opposite endo in 2 pts to avoid coronary damage for overall success of 84%. Typically, longer ablation times with increased power were used/required at adjacent sites to achieve success. Conclusions: VTs commonly (13%) arise from the CVS and can be effectively eliminated with RF delivery within the veins in the majority of pts (62%). Limitations include presence of coronary arteries, adequate power delivery and decreased ability to position the ablation catheter at an earlier distant venous site. Ablation from the LCC and less frequently on the endocardial site opposite earliest recorded venous site can be alternatives sites of effective and safe ablation to improve overall outcome to >80%. O115 "CHANNELS" IDENTIFIED DURING SUBSTRATE MAPPING OF VENTRICULAR TACHYCARDIA (VT): ISTHMUS OR BYSTANDER? Mountantonakis SE; Park RE; Hutchinson M; Dixit S; Cooper J; Marchlinski F; Gerstenfeld E
 Electrophysiology Section, Division of Cardiology, University of Pennsylvania, Philadelphia, PA, USA Introduction: Substrate mapping in patients (pts) with ischemic cardiomyopathy (ICM) and VT may involve lowering the voltage cutoff that identifies scar (<1.5 mV) to identify "channels" within scar that contain the VT circuit. However, the number of "channels" present and their relationship to the VT isthmus is unknown. We assessed the relationship of "channels" to the VT isthmus in pts with mappable VT. Methods: Detailed bipolar endocardialvoltage maps (396 ± 140 points) from 20 males (age 69 ± 9 yrs) with ICM(EF 32 ± 9%) and tolerated VT were reviewed. Endocardial scar was defined by voltage < 1.5 mV. The voltage cutoff was reduced in steps of 0.1 mV until the maximum number of channels were seen. The VT isthmus was identified by entrainment criteria and tagged on the map. The first channel to appear and proximity to the VT isthmus was measured. Results: Inferior/anterior scar was present in 16/4 pts, respectively (scar area = 38 ± 20 cm 2). With lowering of the voltage cutoff, 25 "channels" through scar were identified in 15 pts (75%) at high/low voltage cutoffs = 0.97 ± 047 mV/0.50 ± 0.40 mV). The clinical isthmus was included in a channel in 11/20 pts (55%) or 11/25 (44%) channels. In 7/11 pts, the isthmus was included in the first channel to appear. Conclusions: Channels can be identified in 75% of patients by adjusting the voltage limits of bipolar maps, however only 44% harbor a clinical VT isthmus. O116 REVERSAL OF OUTFLOW TRACT VENTRICULAR PREMATURE DEPOLARIZATION INDUCED CARDIOMYOPATHY WITH ABLATION: EFFECT OF RESIDUAL ARRHYTHMIA BURDEN AND PRIOR CARDIOMYOPATHY ON OUTCOME Mountantonakis SE; Frankel DS; Garcia F; Lin D; Gerstenfeld E; Riley M; Hutchinson M; Dixit S; Callans D; Marchlinski F
 Electrophysiology Section, Division of Cardiology, University of Pennsylvania, Philadelphia, PA, USA Introduction: Outflow tract premature ventricular complexes (OTVPDs) can be associated with reversible left ventricular cardiomyopathy (LVCM). Limited data exists regarding outcome with ablation of OTVPDs and LVCM in patients with residual VPDs after ablation and preexisting LVCM. Methods: 69 patients (43 men; mean age 51 ± 16 years) with non‐ischemic LVCM (LVEF 35 ± 9%, diastolic diameter 5.8 ± 0.7 cm) were referred for ablation of frequent OTVPDs (29 ± 13% per 24 hours). Nineteen (28%) patients had more than one VPD morphology whereas the presence of LVCM was diagnosed prior to the occurrence of VPDs in 20 (29%) patients. Results: VPDs originated in the right or left ventricular outflow tract in 27 (39%) and 42 (61%) pts respectively. Ablation was not successful in 5 pts (7%) primarily due to proximity to coronary vessel. After a follow up of 11 ± 6 months, 44 (66%) patients had no VPDs (<1%), 15 (22%) had decreased (>80%) VPD burden and 8 (12%) had no clinical improvement with persistent (5 patients) or recurrent (3 patients) VPDs. Only patients with either complete resolution or decreased VPD burden had a significant improvement in their LV function and size (ΔEF 13 ± 9%, p < 0.001; ΔLVDD 0.4 ± 0.8 cm, p < 0.04). Although, the degree of LVEF improvement correlated negatively with the burden of residual VPDs (r‐0.574, p < 0.001) no significant difference was found between patients with complete elimination vs significant suppression of VPD burden. Patients with preexisting LVCM, had a more modest but significant improvement in LV function (ΔLVEF 8%, p < 0.001; ΔLVDD 0.3 mm, p 0.013). Conclusions: 1) Significant reduction and not complete elimination of VPD burden seems to be important in improvement of LVEF in patients with VPD‐related LVCM. This implies that in patients with pleomorphic VPDs, targeting the dominant focus (foci) may suffice as an endpoint. 2) Elimination of VPDs is beneficial even in pts with preexisting LVCM. O117 CHARACTERISTICS OF UNSUCCESSFUL CATHETER ABLATION OF VENTRICULAR ARRHYTHMIA Ban J‐E; Park Y‐M; Choi J‐I; Lim H‐E; Park S‐W; Kim Y‐H
 Arrhythmia Center, Korea University, Seoul, Korea Background: This study was to identify the electrophysiologic characteristics of unsuccessful catheter ablation (CA) of ventricular arrhythmias (VAs). Methods: Out of 302 patients undergoing CA of VAs, 43 consecutive patients (14.2%, 43 ± 14 years) who attempted but failed to eliminate VAs with the first CA (US group). US group was compared with successful CA group (S group) to assess predictors to affect unsuccessful ablation. Results: US group included 8 patients underwent unsuccessful CA and 35 patients underwent repeated CA due to arrhythmia recurrence. Presenting VA was ventricular tachycardia (VT) in 24 patients (55.8%) but premature ventricular complex in only 13 patients (30.2%). VT was more common in US group (55.8%) than that of S group (39.0%, P = 0.03). The ejection fraction of the left ventricle (LV) was lower in US group (38.0 ± 7.2%) than in S group (43.7 ± 6.9%, P = 0.02). The earliest activation time (EAT) prior to QRS onset in US group (29.8 ± 7.8 ms) was later than S group (37.4 ± 8.4 ms, P = 0.04). There was a significant difference in VAs origin from‐right ventricular outflow tract (RVOT) (41.8% in US group vs. 60.2% in S group, P = 0.02). There were no significant differences in QRS width during VAs between two groups. Conclusions: A VT as presenting VAs, the severity of LV dysfunction, later EAT and non‐RVOT origin were associated with unsuccessful CA, in whom repeated CA was often required. OTHER O118 USE OF THE LATITUDE PATIENT MANAGEMENT SYSTEM FOR HEART FAILURE PATIENTS: A SINGLE‐CENTER PROSPECTIVE STUDY Guarracini F; Zuccaro LM; Rebecchi M; de Ruvo E; Sciarra L; Fagagnini A; De Luca L; Martino A; Sforza M; Calò L
 Division of Cardiology, Policlinico Casilino, Rome, Italy Background: The risk stratification for hospitalization in heart failure (HF) patients is traditionally assessed during clinical visits. Latitude patient management System (LS) is the first HF management tool using wireless telemetry present in implantable cardioverter defibrillators (ICDs) and biventricular defibrillators (CRT‐D) that is linked to remotely collected blood pressure (BP) and body weight measurements. The aim of the present study was to evaluate the ability of LS to improve the clinical management of HF episodes in patients with implanted ICDs and CRT‐D devices. Methods and Results: This single‐center prospective study enrolled a population of 40 HF patients (mean age 66.6 ± 13.4, years, 31 males) who underwent CRT‐D or ICD implantation between September 2009 and June 2010 in our Hospital. All patients received a communicator and home‐monitoring equipment (including a weight scale and BP monitor) and underwent training. Significant clinical events were reported in 18 (45%) patients at a mean follow‐up of 12 ± 3 months. Pharmacological therapy optimization via telephone contact was sufficient to resolve clinical problems in 11 (61.2%) patients. An in clinical office evaluation was necessary to optimize the management or device‐programming in 2 (11.1%) patients. Five patients (27.7%) were hospitalized because they needed intravenous pharmacological therapy or interventional therapy for atrial or ventricular arrhythmias. No hospitalization for acute HF was present. High satisfaction was expressed by physicians who participated in the study. Conclusions: Our results suggest that LS may improve the clinical management of HF patients with an implanted ICD or CRT‐D. Further studies are needed to compare the clinical impact of LS with standard care methods. O119 REDUCED DECELERATION CAPACITY OF HEART RATE PREDICTS TOTAL MORTALITY IN HEART FAILURE PATIENTS Arsenos P; Gatzoulis K; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Aggelis A; Pietri G; Kartsagoulis E; Stefanadis C; APRET
 First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: Previous studies reported that the Deceleration Capacity (DC) analysis of heart rate is a powerful predictor of mortality (TM) in post myocardial infarction patients. We examined whether DC is an adequate TM predictor in heart failure patients [mean Left Ventricular Ejection Fraction (LVEF) = 32.6 ± 10.1%], as well. Methods: We prospectively screened 230 patients (age: 64 ± 13.4 years, male: 83%, NYHA class: 2.3 ± 0.5, CAD:82%, DCMP: 18%) under optimum treatment with ECG, SAECG, ECHO and 24 hours HOLTER. After 17 ± 16.1 months of follow up, 37 deaths occurred (arrhythmic = 13, pump failure = 17, non cardiac = 7). Echocardiographically determined LVEF, filtered QRS (SAECG), NSVT episodes > 1/24 hours, VPBs > 240/24 hours, DC, mean Heart Rate, SDNN/HRV, mean QTc (24 hour HOLTER), were calculated and statistically analyzed for the two groups. Results: In univariate analysis, DC was a statistically significant predictor of TM (Log rank test p = 0.007). Furthermore after Cox regression analysis adjusted for LVEF, fQRS, NSVT episodes >1/24 hours, VPBs > 240/24 hours, mean Heart Rate, SDNN, and QTc (24 hour HOLTER), DC remained an important and independent TM predictor with Hazard Ratio: 0.862 (p = 0.01) 95% CI: 0.764–0.973. A cut off point of DC < 2.5 presented Hazard Ratio: 2.925 (p = 0.01) 95% C.I.: 1.287–6.647. Conclusions: In our patients cohort with impaired systolic function and short term follow up, DC was an important and independent predictor of TM. Further evaluation of the reduced DC of heart rate in a larger population with longer follow up is needed. O120 ATRIAL SENSING PERFORMANCE OF ICD LEADS WITH FLOATING ATRIAL DIPOLE Schirdewan A 1 ; Safak E 1 ; Schmitz D 2 ; Konorza T 3 ; Wende C 4 , on behalf of the Linoxsmart S DX Master Study Investigators
 1 Charité Berlin , 2 Elisabeth Hospital Essen , 3 University Hospital Essen , 4 Marien Hospital Papenburg (Germany) Purpose: In this clinical investigation the atrial sensing quality of the single‐coil ICD lead Linoxsmart S DX has been investigated. This ICD lead has an additional floating atrial dipole which enables the detection of right atrial signals. Therefore IEGM‐recording and statistics of the atrium in a single chamber ICD system can be provided. Methods: The Linoxsmart S DX ICD lead has been implanted with a Lumax VR‐T 540 DX ICD of BIOTRONIK in 116 patients in 7 European countries. Atrial sensing was investigated at pre‐hospital discharge, 1, 3 and 6 month follow‐up. The patients were asked to take three body positions: lying dorsal and normal breathing, sitting and palms pressing together, and sitting with Jendrassik manoeuvre. The atrial sensing performance was observed in all three positions. The atrial senses were analyzed using the respective IEGMs. Results: In 1074 out of 1163 atrial sensing tests, appropriate atrial sensing performance was determined by the investigator. This results in a rate of appropriate atrial sensing of 92.3%. Appropriate atrial sensingUnder‐sensingOver‐sensingRate of appropriate atrial sensingLying dorsal, normal breathing364/38811/38813/38893.8%Sitting, palms together354/38814/38820/38891.2%Sitting, Jendrassik Manoeuvre356/38712/38720/38792.0%Total1074/116337/116353/116392.3% In six patients necessary ICD lead repositionings were successfully performed. Conclusion: This clinical investigation showed that the ICD lead Linoxsmart S DX with an additional floating atrial dipole provides an appropriate atrial sensing rate of 92.3%. O121 MESH ABLATOR VERSUS CRYOBALLOON PULMONARY VEIN ABLATION OF SYMPTOMATIC PAROXYSMAL ATRIAL FIBRILLATION Koch L 1 ; Haeusler KG 2,3 ; Herm J 2,3 ,; Safak E 1 ; Fischer R 1 ; Heuschmann PU 3 ; Werncke T 4 ; Endres M 2,3 ; Fiebach JB 3 ; Schultheiss H ‐P 1 ; Schirdewan A 1 
 1 Department of Cardiology and Pneumology, Charité Campus Benjamin Franklin Berlin, Germany ; 2 Department of Neurology, Charité ‐ Universitaetsmedizin Berlin, Germany ; 3 Center for Stroke Research, Charité ‐ Universitaetsmedizin Berlin, Germany ; 4 Department of Radiology, Charité ‐ Universitaetsmedizin Berlin, Germany Background: Catheter ablation of the pulmonary veins (PV's) is a promising therapeutic approach for symptomatic atrial fibrillation (AF). The prospective randomized single‐center study "Mesh Ablator versus Cryoballoon Pulmonary Vein Ablation of Symptomatic Paroxysmal Atrial Fibrillation" (MACPAF) compared the efficacy and safety of two balloon‐based pulmonary vein ablation systems. Methods: Patients with symptomatic paroxysmal AF were randomized 1:1 for a first procedure of PV ablation using the Arctic Front® (Medtronic, Inc.) or the HD Mesh Ablator® catheter (C.R. Bard, Inc.). The primary endpoint was complete PV isolation (PVI). Results: Overall, 32 (mean age 62.3 ± 8.4 years, 40.6% female; median CHA2DS2‐VASc score 2.0 (1–3) underwent PV ablation according to study criteria. Complete PVI was achieved in 13 (76.5%) of 17 Arctic Front® patients but in none of the 15 HD Mesh Ablator® patients (p<0.0001). There were one major and two minor complications in each study arm but no clinically evident stroke. Postprocedural AF recurrence was detected within hospital stay in 2 (11.8%) Arctic Front® patients and in 7 (46.7%) HD Mesh Ablator® patients (p = 0.049). Conclusions: The MACPAF study revealed a superiority of the Arctic Front® catheter concerning complete PVI. Because of the insufficient efficacy of the HD Mesh Ablator® catheter, the safety board decided to stop the MACPAF study prematurely. [ABSTRACT FROM AUTHOR]

The article offers information on conferences on systems research and practice that will be held in July 2013, including the 9th Hellenic Society for Systemic Studies (HSSS) National and International Conference in Volos, Greece, the 57th World Conference of the International Society for the Systems Sciences in Hai Phong City, Vietnam, and the 31st International Conference of the System Dynamics Society in Cambridge, Massachusetts.

As far back as the ninth century BCE in Greece, a talent was a form of currency. In the 21st century, talents remain currency as the special gifts of knowledge, skills, and personal characteristics that individuals bring to organizations. Talent management, also known as human capital management, HCM, is a focus of leadership studies that increasingly strives to acknowledge and measure the tangible contributions that individuals make to the bottom line. In this symposium, we offer a position paper by Ted Harro and Leslie Miller who detail an innovative approach to address how leaders of organizations can create a consistent, positive flow of talent necessary to support success. Our respondents, Karen Kirwan, Dave Wondra, and Edward Perez, each add their perspectives to this timely discussion. [ABSTRACT FROM AUTHOR]

This article presents information related to organization of the sixth international symposium on applied stochastic models and data analysis in Chania, Crete, Greece, during May 3-6, 1993. The symposium will include three kinds of contributions, invited papers, classical communications and problems relative to any confrontation of real life problems on the two mentioned topics and a number of proposed solutions. The symposium will be focused on the following fields, real life problems and theoretical results in data analysis and stochastic modelling, interactions between data analysis, applied stochastic models and artificial intelligence including neural networks, probabilistic and statistical computation, and forecasting.

The article highlights proceeding of meeting of the International Economic Association (IEA), held at Corfu, Greece on September 3, 1958. Those present in the meeting were president of the association Erik Lindahl, vice president Louis Baudin, treasurer E.A.G. Robinson and others. The executive committee considered the advisability of holding open congresses at intervals in conjunction with the meetings of the council. The secretary reported that she had received a suggestion from the president of the Austrian association that a congress might be held either in Salzburg or in Vienna concurrently with the 1962 meeting of the council. The treasurer briefly reported on the refresher course for teachers of advanced economics, organized by the IEA under contract with United Nations Educational, Scientific, and Cultural Organization (UNESCO), at Murree in Pakistan during the previous few weeks. The course was based on the UNESCO program for participation in the activities of Member States. Preliminary reports indicated that the course had been welcomed with great interest by Pakistani economists and the results appeared to be satisfactory.

As far back as the ninth century BCE in Greece, a talent was a form of currency. In the 21st century, talents remain currency as the special gifts of knowledge, skills, and personal characteristics that individuals bring to organizations. Talent management, also known as human capital management, HCM, is a focus of leadership studies that increasingly strives to acknowledge and measure the tangible contributions that individuals make to the bottom line. In this symposium, we offer a position paper by Ted Harro and Leslie Miller who detail an innovative approach to address how leaders of organizations can create a consistent, positive flow of talent necessary to support success. Our respondents, Karen Kirwan, Dave Wondra, and Edward Perez, each add their perspectives to this timely discussion. [ABSTRACT FROM AUTHOR]

The article discusses the 15th International Philosophy of Nursing (IPONS) Conference held on 25–28 August 2011, at the West Park Centre in Dundee, Scotland. Several speakers at the conference included professor Sam Porter, Queen's University, Belfast, Peter Allmark, of Sheffield Hallam University and Robert Newsom from Guildford Technical Community College in North Carolina. Several papers presented at the conference focused on the theme of 'Healthcare and the Politics of Austerity.'

As far back as the ninth century BCE in Greece, a talent was a form of currency. In the 21st century, talents remain currency as the special gifts of knowledge, skills, and personal characteristics that individuals bring to organizations. Talent management, also known as human capital management, HCM, is a focus of leadership studies that increasingly strives to acknowledge and measure the tangible contributions that individuals make to the bottom line. In this symposium, we offer a position paper by Ted Harro and Leslie Miller who detail an innovative approach to address how leaders of organizations can create a consistent, positive flow of talent necessary to support success. Our respondents, Karen Kirwan, Dave Wondra, and Edward Perez, each add their perspectives to this timely discussion. [ABSTRACT FROM AUTHOR]

The article reports on the European Meeting of the Econometric Society scheduled to be held in Athens, Greece September 4-7, 1979. Proposals for papers to be presented during the meeting are being solicited by the Program Committee. Information is included regarding submission of papers and registration for the meeting.

As far back as the ninth century BCE in Greece, a talent was a form of currency. In the 21st century, talents remain currency as the special gifts of knowledge, skills, and personal characteristics that individuals bring to organizations. Talent management, also known as human capital management, HCM, is a focus of leadership studies that increasingly strives to acknowledge and measure the tangible contributions that individuals make to the bottom line. In this symposium, we offer a position paper by Ted Harro and Leslie Miller who detail an innovative approach to address how leaders of organizations can create a consistent, positive flow of talent necessary to support success. Our respondents, Karen Kirwan, Dave Wondra, and Edward Perez, each add their perspectives to this timely discussion. [ABSTRACT FROM AUTHOR]

As far back as the ninth century BCE in Greece, a talent was a form of currency. In the 21st century, talents remain currency as the special gifts of knowledge, skills, and personal characteristics that individuals bring to organizations. Talent management, also known as human capital management, HCM, is a focus of leadership studies that increasingly strives to acknowledge and measure the tangible contributions that individuals make to the bottom line. In this symposium, we offer a position paper by Ted Harro and Leslie Miller who detail an innovative approach to address how leaders of organizations can create a consistent, positive flow of talent necessary to support success. Our respondents, Karen Kirwan, Dave Wondra, and Edward Perez, each add their perspectives to this timely discussion. [ABSTRACT FROM AUTHOR]

Highlights the Fifth Symposium on Epilepsy Management-Epilepsy and Comorbidity: A Global Approach to Patient Management, which was held in Athens, Greece on April 2003. Examination of epilepsy management; Definition of a global approach to patient care; Use of effective solutions in the daily practice.

This article presents information about meetings related to economics which will be held during the year 1992-1993. The Fourth conference on Panel Data will be held at Budapest University of Economics during June 18-19, 1992. The conference is aimed at giving to people concerned with panel data an opportunity to meet together. The program will consist of invited and contributed papers in the following fields: Applied Studies in Economics, Management, Marketing, Statistical and Econometric Methods; Panel Data Base Problems. The 13th Annual French-Belgian Meeting of Statisticians will take place in Lille, France during November 19-20, 1992. The Sixth International Symposium on "Applied Stochastic Models and Data Analysis: The Ins and Outs of Solving Real Problems" will be held in Chania, Crete, Greece during May 3-6, 1993. In 1981, 1983, and 1985 an International Symposium on Data Analysis was organizeed. In 1988 and 1991 the Symposia were enlarged including, "Applied Stochastic Models." The enthusiastic welcome and positive comments after the fifth meeting have prompted to organize the Sixth International Symposium on Applied Stochastic Models and Data Analysis in Chania during May 3-6, 1993.

Information on issues discussed at the 28th New Phytologist Symposium held in Rhodes, Greece in May 2012 on the functions and ecology of the plant microbiome is presented. Topics include rhizosphere microbiology and biochemical cycling, soil microbial communities, and phyllosphere and endophytic microbial communities. The symposium featured several phytologists including Jeff Bennetzen, Julia Vorholt, and Phil Hugenholtz.

Information on the 11th World Congress in Fetal Medicine held in Kos, Greece on June 24-28, 2012 is presented. Topics include fetal therapy, management of myelomeningocele study (MOMS), and non-invasive prenatal diagnosis. Among the participants and presenters on the conference include doctor Dagan Wells, Alan Flake, and Rossa Chiu.

The article discusses the highlights of the IV Congress of the World Conference of Associations of Theological Institutions (WOCATI) held in Neapolis, Thessaloniki, Greece from May 31 to June 7, 2008. The event was organized by WOCATI and the Ecumenical Theological Education (ETE) programme of the World Council of Churches (WCC) and attended by 60 participants. The congress tackled the diversity of approaches to theological education. The recommendations of the congress to the churches are enumerated.

The International Congress of the Hellenic Anthropological Association (HAA), Athens, 21-23 November 2003 [ABSTRACT FROM AUTHOR]

Provides information on the 39th Annual Congress of the European Society for Surgical Research in Athens, Greece, on May 12 to 15, 2004.

The article presents the summaries of some of the discussions and outcomes of the working groups of the Association for Dental Education in Europe (ADEE) held during the 2006 annual meeting in Athens, Greece. According to the author, these summaries are the views of the members of individual groups and not necessarily those of ADEE or the "European Journal of Dental Education."

This article reports on events related to endodontics. The 46th Annual Association of Endodontics will be held on May 3-7, 1989 at New Orleans, Louisiana. Traditionally, the first day of the meeting gives preregistered participants the opportunity to update their clinical skills, and this year the topics were "Endodontic Surgery" and "The Use of Electronic Devices." The newly formed Hellenic Society of Endodontics founded in April 1998 will be holding a symposium on Endodontics in Athens, Greece on November 4-5, 1989.

The article highlights the 29th General Assembly of the Eurographics (EG) Association for Computer Graphics held at the Creta Maris Conference Centre in Crete, Greece on April 17, 2008. An annual report of the activities of the association was presented by the chairman. He also outlined the organizational structure of the association and stressed the importance of the workshop series. The event featured symposia and workshops. Accounts for the period January 1 to December 2007 was presented by treasurer Werner Hansmann.

A calendar of international events related to psychology is presented, which includes the 2nd International Conference on Psychology in Athens, Greece, on July 14-17, 2008, the 116th Annual Convention of the American Psychological Association in Boston, Massachusetts, on August 14-17, 2008, and the International Congress of Applied Psychology in Melbourne, Victoria, on July 11-16, 2010.

The article presents information about conferences related to numerical linear algebra and its applications as of July 1, 1995. "International Symposium on Electromagnetic Fields in Electrical Engineering" will be held in Thessaloniki, Greece between September 25 and 27, 1995. "Linear Algebra in Optimization" conference will be held between September 25 and 27, 1995 in Toulouse, France. "Eigenvalues and Beyond" conference will be held between October 17 and 20, 1995 in Toulouse, France.

This article informs about conferences and events about periodontology which are scheduled to held from March 1996 to September 1996. On March 13-16, 1996, 4th International Congress of Behavioral Medicine International perspectives on behavioral medicine and Health will held at Washington DC. A seminar by Hellenic Society of Periodontology will be held on March 30, 1996 at Athens, Greece. On March 30, 1996 The William B. Clark Symposium featuring Advances in Periodontology will be held at Radisson Hotel, Gainesville, Florida.

The article offers information on topics related to statistics. It states that the Census at School program which encourage children to study statistical skills would also be introduced in South Africa, and Australia. It says that the 58th World Statistics Congress of the International Statistical Institute (ISI) would be held in Dublin, Ireland from August 21-26, 2011, while the 5th International Conference on Mathematics & Statistics would take place in Athens, Greece from June 13-16, 2011.

A calendar of events related to neurology is presented. The first migrating course on epilepsy will be held on May 27 to June 3, 2007 in Babe, Serbia. A seventeenth meeting of the European Neurological Society (ENS) will be held on June 16-20, 2007 in Rhodes, Greece. A Baltic Sea summer school on epilepsy will be held on August 19-23, 2007 in Druskininkai, Lithuania.

The article presents information about some upcoming events related to diabetes. Diabetes Great Britain Annual Professional Conference, will be held from April 20-22, 2005 at Scottish Exhibition and Conference Centre, Glasgow, Scotland. The next meeting of European Diabetic Nephropathy Study Group, will be held from May 13-14, 2005 in Arnhem, the Netherlands. 15th Meeting of the EASD Eye Complication Study Group, will be held from May 27-29, 2004 in Coimbra, Portugal. 14th ECO, International Conference Centre of the Athens Concert Hall will be held from June 1-4, 2005 in Athens, Greece.

The article presents an information on an international symposium on behavioral medicine, entitled Behavioral Treatment of Disease to be held in Porto Carras, Chalkadiki, Greece. The symposium is sponsored by the Scientific Affairs Division of North Atlantic Treaty Organization. It will be entirely non-political and non-military in character. The objective of the symposium is twofold. First, to communicate the content of the developing area of behavioral medicine to scientists and second, to provide a medium for high level interchange of information among investigators.

The article announces the forthcoming second annual meeting of the Society of Behavioral Medicine in November 1980 in New York. The convention's opening session features a Diet-Heart debate. There will be numerous symposia, practica and workshops. The Society has recently moved its national office to Baltimore, Maryland. In July 1981 an international symposium on Behavioral Medicine, entitled "Behavioral Treatment of Disease," will be held in Greece.