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Bifocal right atrial pacing (BP) has been reported to increase arrhythmia-free intervals in patients with paroxysmal atrial fibrillation (PAF) under antiarrhythmic drugs. This study compares AF burden with unifocal pacing (UP) vs BP under sotalol. In 19 patients with PAF a DDDR pacemaker with right atrial lateral and CS ostial leads was implanted. Sotalol was initiated. After a 3 month back-up pacing period patients were randomized to continuous UP or BP for 3 months and crossed over for 3 more months. Primary endpoint was AF burden. Secondary endpoints included number of episodes, time to first recurrence and safety of BP. The intention to treat analysis revealed 12.4% AF during back-up, 6.2% during UP and BP (p = 0.91 UP vs BP, p = 0.08 back-up vs UP and p = 0.07 back-up vs BP). Per protocol analysis showed no advantage of either pacing mode (UP 4.8% and BP 5.4% AF, p=0.64). Overdrive pacing reduced AF burden to 6.2 vs 8.8% during back-up (p=0.09). Septal lead dislodgement occurred in 3 patients. Atrial pacing tends to reduce AF burden in patients with PAF under sotalol. An incremental effect of BP vs UP cannot be confirmed. BP may be complicated by elevated lead dislodgement rates.

This study investigated the effects of long-term cardiac resynchronization therapy (CRT) on the neurohormonal and cytokines levels in CHF patients and its correlation with changes in functional capacity (peak VO(2) and VO(2) AT) and left ventricular function (LVEF).Brain natriuretic peptide (BNP), norepinephrine (NE), tumor necrosis factor alpha (TNF alpha), tumor necrosis factor alpha receptor 1 (TNF alpha R1) and interleukin 6 (IL-6) were collected from 22 patients of the PATH-CHF II study (LVEFor =30%, NYHA II-IV and QRSor =120 ms) at baseline and at the 12-month follow-up. Peak VO(2), VO(2) AT and LVEF were recorded. All patients were implanted with a CRT device using atrioventricular sequential left ventricular pacing.CRT led to a significant improvement of peak VO(2) (from 13+/-2.4 ml/kg/min to 14.8+/-2.8 ml/kg/min, p0.05) and VO(2) AT (from 9+/-2 ml/kg/min to 10.1+/-1.9 ml/kg/min, p0.05). LVEF increased significantly from 22.2+/-6.2% at baseline to 32+/-10.1% at 12-month follow-up (p0.05). A significant reduction of BNP (from 332.9+/-295.2 to 193.4+/-253 pg/ml, p=0.049) and NE (410.6+/-306.0 to 274.4+/-174.3 ng/l, p=0.027) was also observed with CRT.Long-term CRT is associated with a significant decrease of BNP and NE levels and a significant improvement in functional capacity and LVEF.

Background Previous studies in patients and in dogs with experimentally induced heart failure (HF) showed that electrical signals applied to the failing myocardium during the absolute refractory period improved left ventricular (LV) function. We examined the effects these same cardiac contractility modulating (CCM) electrical signals on myocardial oxygen consumption (MVO 2 ) in both patients and dogs with chronic HF. Methods and Results Six dogs with microembolizations-induced HF and 9 HF patients underwent CCM leads and generator (OPTIMIZER II) implantation. After baseline measurements, CCM signals were delivered continuously for 2 hours in dogs and for 30 minutes in patients. MVO 2 was measured before and after CCM therapy. In dogs, CCM therapy increased LV ejection fraction at 2 hours (26 ± 1 versus 31 ± 2 %, P = .001) without increasing MVO 2 (257 ± 41 versus 180 ± 34 μmol/min). In patients, CCM therapy increased LV peak +dP/dt by 10.1 ± 1.5 %. As with dogs, the increase in LV function after 30 minutes of CCM therapy was not associated with increased MVO 2 (13.6 ± 9.7 versus 12.5 ± 7.2 mL O 2 /min). Conclusions The study results suggest that unlike cAMP-dependent positive inotropic drugs, the increase in LV function during CCM therapy is elicited without increasing MVO 2 .

We tested a simple noninvasive method for cardiac resynchronization therapy (CRT) optimization using standard finger photoplethysmography (FPPG).CRT can increase left ventricular cardiac output in patients with heart failure and ventricular conduction delay. Optimal therapy delivery depends on an appropriate AV delay. Multiple invasive and noninvasive methods have been attempted to identify patients and the best AV delay for CRT, but all suffer from a combination of high patient risk, cost, complexity, and low reproducibility.FPPG and invasive aortic pressure data were simultaneously collected from 57 heart failure patients during intrinsic rhythm alternating with very brief periods of pacing at 4 to 5 AV delays. After correcting data for artifacts, the median percentage responses for each AV delay were classified as positive, negative, or neutral compared to baseline (Wilcoxon rank test).FPPG correctly identified positive aortic pulse pressure responses with 71% sensitivity (95% CI: 60-80%) and 90% specificity (95% CI: 84-94%) and negative aortic pulse pressure responses with 57% sensitivity (95% CI: 44-69%) and 96% specificity (95% CI: 91-98%). The magnitude of FPPG changes were strongly correlated with positive aortic pulse pressure changes (R(2) = 0.73, P.0001) but less well correlated with negative aortic pulse pressure changes (R(2) = 0.43, P.0001). FPPG selected 78% of the patients having positive aortic pulse pressure changes to CRT and identified the AV delay giving maximum aortic pulse pressure change in all selected patients.FPPG can provide a simple noninvasive method for identifying significant changes in aortic pulse pressure with high specificity, including identifying patients in whom aortic pulse pressure increases with CRT and the AV delay giving the maximum aortic pulse pressure.

Background Mortality in severe congestive heart failure rises with the incidence of an inter- and intraventricular conduction delay and doubles if atrial fibrillation (AF) occurs. Electrical cardioversion (CV) is frequently regarded as less promising in these patients. Encouraged by first conversions during defibrillation threshold (DFT) testing we consecutively attempted electrical cardioversion in 30 patients selected for cardiac resynchronization therapy (CRT). Methods After successful CV an additional atrial electrode was placed during implantation of a CRT device (ICD or pacemaker) to ensure AV sequential biventricular pacing. Regular clinical follow-up examinations up to 2 years were performed. Results In 23 (75%) of 30 patients (onset of AF at least 6 months earlier), sinus rhythm (SR) could successfully be restored. Under antiarrhythmic medication in 21 patients SR was still present after 333±142 days. Furthermore, a significant increase of EF from 22% to 31% (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P{

Background:Implantable cardioverter/defibrillator (ICD) treatment has reduced the mortality of patients with a high risk of sudden cardiac death. However, ICD discharges may cause anxiety with respect to new discharges and lead to preventive, for example, phobic, behavior. This study evaluated the frequency of panic disorders and agoraphobia in patients with ICD and assessed the risk factors in their development. Hypothesis:Treatment with ICD represents a risk factor in the development of anxiety disorders. Methods:Ninety patients with ICD were examined using a standardized lifetime Diagnostic Interview of Psychiatric Syndromes (DIPS). This interview makes it possible to estimate the incidence of panic disorders and agoraphobia. The impact of the severity of the underlying cardiac disease, the number of ICD discharges, and the subjective appraisal of the shock experience on the development of panic disorders and agoraphobia was assessed. Results: Fifteen patients (16.7%) developed anxiety disorders after ICD implantation. The incidence was 21% in patients with and 6.9% in patients without ICD discharge. In patients with two or more ICD discharges annually, the incidence of panic disorders and agoraphobia was higher than that in patients with a single ICD discharge annually (62 vs. 10%, p < 0.01). The intensity of self-observation of their body was significantly related to the development of anxiety disorders (p < 0.001). Conclusion:Panic disorders and agoraphobia are frequent side effects of ICD treatment. Risk factors in the development of these disorders are two or more ICD discharges annually and a negative cognitive appraisal of ICD discharges. Therapeutic efforts should aim at reducing the number of ICD discharges and provide early psychological treatment.

Right ventricular pacing at various sites and shortened atrioventricular (AV) delay has failed to demonstrate a convincing short-term and long-term improvement of left ventricular function. Left-ventricular-based stimulation offers a new therapeutic option for patients with symptomatic congestive heart failure and conduction disturbances, especially of left bundle-branch block configuration. Left ventricular mechanical improvement seems mainly dependent on the pacing site, in addition to optimizing the AV delay. Predominantly retrospective data suggest that pacing the posterolateral free wall results in the greatest hemodynamic improvement. Based on the evaluation of different pacing sites in 2 patients, we noted that site is of major importance for maximal improvement of left ventricular function, and pacing at a suboptimal site can even deteriorate left ventricular contractility. Moreover, lead technology has advanced rapidly and different areas of the left ventricle can now be reached transvenously for acute and chronic placement. Therefore, ongoing trials will help to identify the optimal pacing site and might indicate whether invasive testing will be required in the future.

A 64-year-old woman was referred to the arrhythmia outpatient clinic after she had experienced syncope without preceding symptoms and frequent paroxysmal, near syncopal episodes over the last 8 months. The ECG revealed alternation of sinus bradycardia and frequent ectopic atrial beats, normal PR interval and right bundle branch block with consecutive repolarization abnormalities. Holter ECG showed frequent periods of asystole up to 4.3 seconds. Laboratory findings were normal. Pacemaker therapy for symptomatic sinus node dysfunction was clearly indicated. The patient’s past history revealed the diagnosis of Erdheim-Chester disease with osseous, cutaneous, mesenteric, and right atrial involvement 22 years ago. This disease belongs to …

This study evaluates the acute and chronic resynchronizing effects of AV sequential left ventricular (LV) pacing on LV function in patients with impaired cardiac function and conduction disorders by 3-dimensional transesophageal echocardiography.Twenty-nine patients with congestive heart failure, with LV ejection fraction (LVEF)or = 30%, QRS durationor = 120 milliseconds, and New York Heart Association Class II to IV, were implanted with a cardiac resynchronization device using an LV lead only, according to the invasively determined hemodynamic optimal pacing site and AV delay. Patients underwent 3-dimensional transesophageal echocardiography before randomization to treatment (baseline) and at 12-month follow-up (resynchronization--12 months). Three-dimensional volumes were acquired on resynchronization and during intermittent switch-off at intrinsic depolarization. The values of stroke volume were 43.2 +/- 13.3 (intrinsic-baseline), 51.7 +/- 17.4 (intrinsic--12 months), 57.2 +/- 15.6 (resynchronization-baseline), and 64.6 +/- 18.9 (resynchronization--12 months). Analysis of variance demonstrated a significant effect of resynchronization at different periods (P.001) and a significant time effect (P.05) for stroke volume. Similar results were observed with ejection fraction (LVEF). No effect was observed with LV end-diastolic volume, whereas a therapy effect with no time effect was observed with LV end-systolic volume.A significant acute increase of LV stroke volume and LVEF was found by resynchronization by LV pacing alone. A continuous improvement of LV stroke volume and LVEF occurred with time of follow-up (reverse remodeling). The initial therapeutic effect persisted during 12-month follow-up independently of time of follow-up and QRS width. No significant decrease of LV end-diastolic size during chronic resynchronization was detected in contrast to previous studies with resynchronization by biventricular pacing.

A 59 year old white man was admitted to our hospital because of unstable angina. His past medical history was significant for an inferior myocardial infarction at the age of 52, hypertension, and hyperlipidaemia. Coronary angiography was performed revealing severe aneurysmal coronary artery disease. The right …

Fur rechtsatrial laterale, atrial septale und bifokal rechtsatriale Stimulation finden sich typische P-Wellen-Morphologien.

Patienten mit fortgeschrittener Herzinsuffizienz, vor orthotoper Herztransplantation, welchen aufgrund einer lebensbedrohlichen ventrikularen Tachyaarrhythmie ein ICD implantiert wurde, erfahren fruhzeitig eine adaquate antitachykarde ICD-Therapie. Durch die Bewahrung dieser Untergruppe mit hohem Risiko vor dem plotzlichen Herztod durch die ICD-Therapie kann die Gesamtmortalitat auf das Niveau eines Vergleichskollektives ohne ICD verringert werden. Die Anwesenheit von Vorhoftachyarrhythmien korreliert mit einer fruhzeitigeren Abgabe einer adaquaten ICD Therapie Hamodynamische oder echokardiographische Messungen lassen sich retrospektiv nicht zur Risikostratifizierung heranziehen. Es bedarf jedoch weiterer Studien zur Evaluierung der Assoziation hamodynamischer Veranderungen und arrhythmischen Ereignisse in nicht selektierten Untersuchungsgruppen zur Definition von Untergruppen, die vor Herztransplantation von einer prophylaktischen ICD Implantation profitieren konnten.