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IntroductionOne of the challenges of left bundle branch (LBB) pacing is to place the pacing lead deep enough in the septum to obtain capture of the LBB, yet not too deep to avoid perforation. We hypothesized that the occurrence of the ectopic beats of qR/rsR’ morphology in V1 lead (fixation beats) during the lead fixation would predict that the final desired intraseptal lead depth was just reached, while the lack of fixation beats would indicate too shallow position, and need for more lead rotations.MethodsConsecutive patients during LBB pacing device implantation were analyzed retrospectively and then prospectively with respect to the occurrence of the fixation beats during each episode of lead rotation. We compared the presence of fixation beats during the lead rotation event directly before the LBB capture area depth was reached versus during the events before intermediate/unsuccessful positions.ResultsA total of 339 patients and 1278 lead rotation events were analyzed. In the retrospective phase, the fixation beats were observed in 327/339 of final lead positions and in 9/939 of intermediate lead positions (pConclusionsMonitoring fixation beats during deep septal lead deployment can facilitate the procedure and possibly increase the safety of lead implantation.

Background: Transesophageal echocardiography (TEE) allows detailed characterization of atrial fibrillation (AF) substrate and could be valuable for predicting pulmonary vein isolation (PVI) procedure outcomes. Aims: We aimed at assessing the value of TEE-derived left atrial (LA) and LA appendage (LAA) features as prognostic markers for AF recurrence after cryoballoon-based ablation. Methods: Patients were enrolled using a prospective database of consecutive PVI procedures performed over a 7-year period. The following TEE-derived parameters were investigated: LAA emptying flow velocity (LAA-FV), the presence of patent foramen ovale (PFO), LA spontaneous echo contrast, and mitral regurgitation. Diagnosis of AF recurrence was based on scheduled and symptoms triggered ECG monitoring. The Cox’s regression model and Kaplan-Meier survival curves were applied for statistical analysis. Results: A total of 417 consecutive patients who underwent their first PVI using cryoballoon were analyzed (mean age: 59 years). AF recurrence was noted in 25.7% of patients (median follow-up of 24 months). Four TEE-derived variables had predictive values for AF recurrence: LAA-FV

Introduction Permanent deep septal stimulation with capture of the left bundle branch (LBB) enables maintenance/restoration of the physiological activation of the left ventricle. However, it is almost always accompanied by the simultaneous engagement of the local septal myocardium, resulting in a fused (nonselective) QRS complex, therefore, confirmation of LBB capture remains difficult. Methods We hypothesized that programmed extrastimulus technique can differentiate nonselective LBB capture from myocardial-only capture as the effective refractory period (ERP) of the myocardium is different from the ERP of the LBB. Consecutive patients undergoing pacemaker implantation underwent programmed stimulation delivered from the lead implanted in a deep septal position. Responses to programmed stimulation were categorized on the basis of sudden change in the QRS morphology of the extrastimuli, observed when ERP of LBB or myocardium was encroached upon, as: "myocardial," "selective LBB," or nondiagnostic (unequivocal change of QRS morphology). Results Programmed deep septal stimulation was performed 269 times in 143 patients; in every patient with the use of a basic drive train of 600 milliseconds and in 126 patients also during intrinsic rhythm. The average septal-myocardial refractory period was shorter than the LBB refractory period: 263.0 ± 34.4 vs 318.0 ± 37.4 milliseconds. Responses diagnostic for LBB capture ("myocardial" or "selective LBB") were observed in 114 (79.7%) of patients. Conclusions A novel maneuver for the confirmation of LBB capture during deep septal stimulation was developed and found to enable definitive diagnosis by visualization of both components of the paced QRS complex: selective paced LBB QRS and myocardial-only paced QRS.

BackgroundDuring permanent deep septal pacing, it is important to confirm left bundle branch (LBB) capture.ObjectiveThe effective refractory period (ERP) of the working myocardium is different than the ERP of the LBB; we hypothesized that it should be possible to differentiate LBB capture from septal myocardial capture using programmed extra-stimulus technique.MethodsIn consecutive patients undergoing pacemaker implantation who received pacing lead in a deep septal position programmed pacing was delivered from this lead. Responses to programmed pacing were categorized on the basis of QRS morphology of the extrastimuli as: myocardial (broader QRS, often slurred), selective (narrower QRS, preceded by an isoelectric interval) or non-diagnostic (unequivocal change).ResultsProgrammed deep septal pacing was performed 269 times in 143 patients; in every patient with the use of an 8-beat basic drive train of 600 ms and when possible also during supraventricular rhythm. Responses diagnostic for LBB capture were observed in 114 (79.7%) of patients. Selective LBB paced QRS was more often seen when premature beats were introduced during the intrinsic rhythm rather than after the basic drive train. The average septal-myocardial refractory period was significantly shorter than the LBB refractory period: 263.0±34.4 ms vs. 318.0±37.4 ms.ConclusionsA novel maneuver for the diagnosis of LBB capture during deep septal pacing, was formulated, assessed and found as diagnostically valuable. This method, based on the differences in refractoriness between LBB and the septal myocardium is unique in enabling the visualization of components of the usually fused, non-selective LBB paced QRS complex.Graphical abstract

Background Due to limited data, implantable loop recorders (ILR) are not currently recommended by the guidelines to routinely monitor patients after atrial fibrillation (AF) ablation. Aims To validate the diagnostic value of ILR after AF ablation, modern generation ILRs (LINQ) were implanted in patients scheduled for cryoballoon ablation of AF (CBA). Methods We included 29 patients with frequent and symptomatic episodes of paroxysmal AF. ILR was implanted 3 months prior to CBA, and data were collected before and for 6 months after the procedure. The device was programmed to maximize sensitivity of AF/ atrial tachycardia (AT) detection. All EGM recordings were "manually" assessed and annotated as true AF, pseudo AF, unrecognized AF, and episodes with no EGM available. Duration and episode-based standard performance metrics were evaluated. Results A total number of 5,842 episodes were recorded. A total of 4,403 episodes were true AF, 453 episodes were pseudo AF, and 986 episodes had no EGM available. The device did not recognize 144 episodes of AF. Duration-based sensitivity was 95.2%, duration-based specificity 99.9%, duration-based PPV 99.2%, duration-based NPV 99.9%, episode-based sensitivity 98.0%, and episode-based PPV 91.0%. Misdiagnosis happened in 1 in 10 episodes. Total data review time was 166 hr. Conclusions Implantable loop recorders is a valuable tool in evaluation of AF episodes in patients undergoing CBA. However, for high precision all recorded episodes need to be evaluated "manually." The memory storage space is too low for frequent AF episodes, resulting in overwriting of stored EGMs and data loss.

Cancer appears to be a major noncardiovascular factor affecting morbidity and mortality of heart failure (HF) patients. Risk of developing cancer seems to increase over time. It is well documented that patients with cancer treated with chemiotherapy are at risk of developing HF and therefore they should be screened for HF on regular basis. There is limited data whether the opposite should be done, namely routinely screen each HF patient for cancer.We hypothesized that in HF patients cancer might be responsible for some symptoms that are incorrectly diagnose as HF related.The data from “Renal Denervation in Patients With Chronic Heart Failure and Resynchronization Therapy” study of 18 patients (22% women) aged 73.2 (±9.1 years) with HF in NYHA Class II-IV and resynchronization pacemaker implanted according to current ESC guideliness at least 6 months earlier were analyzed. Patients had symptoms of heart failure despite optimal HF therapy including pharmacotherapy and CRT. Medical history including current symptoms of HF was taken, patients’ demographics and vital signs were assessed. Diagnostic tests in the study group included echocardiography, abdominal CT scan and laboratory tests.Only in 5 patients CT scan did not show any abnormalities. Renal cysts were present in 5 patients, adrenal glands adenomas were observed in 3 patients and both changes were present in 1 patient. Tumors suspected of malignancy were diagnosed in 4 patients - 2 had a tumor in adrenal glands, 1 had kidney tumor and 1 had tumors both in kidney and adrenal gland. All patients with malignancy were directed for further oncological evaluation.Considering the complex physiology of HF, there is possibility that some HF related mechanisms might trigger cancer development and presence of cancer may aggrevate the symptoms of HF. One should consider evaluation of HF patients on optimal medical therapy, yet still symptomatic to identify some common forms of cancer.

Introduction The aim of this study was to determine whether baseline right ventricular (RV) function assessed by standard echocardiography may indicate patients who will respond to cardiac resynchronization therapy (CRT).

This editorial refers to ‘Transvenous phrenic nerve stimulation for the treatment of central sleep apnoea in heart failure’, by P. Ponikowski et al. , doi:10.1093/eurheartj/ehr298 The prevalence of central sleep apnoea (CSA) is 100-fold greater in chronic heart failure (HF) due to impaired systolic function than in the general population.1 It afflicts principally elderly male patients who have atrial fibrillation, implanted pacemakers, low arterial PCO2 when awake, or high diuretic requirements.1 Its presence identifies HF patients with higher night- and day-time sympathetic nervous system activity,2 at increased of risk of malignant ventricular arrhythmias,3 whose survival is foreshortened.4 The primary abnormality in CSA is neither the upper airway collapse of obstructive sleep apnoea (OSA), which can be treated quite effectively with continuous positive airway pressure (CPAP), nor a paucity of ventilation, but rather the compromise of mechanisms that normally stabilize breathing due to the confluence of pulmonary congestion, circulatory delay, altered cerebrovascular blood flow, and enhanced central sensitivity to CO2, all predisposing to hyperventilation.4 Although the reality is more complex, to simplify, in HF the cyclical oscillations between hyperpnoea and apnoea, known commonly as Cheyne–Stokes respiration, are initiated by the hyperpnoea, which can be stimulated by spontaneous arousal from sleep, or by pulmonary congestion. During sleep, the latter is exacerbated both by fluid shifts from the periphery to the cardiopulmonary reservoir,5 and by pre-existing pulmonary–cardiac–chemoreceptor circulatory delay. Thus, when increases in pulmonary capillary and venous pressures stimulate pulmonary irritant receptors, triggering a bout of hyperpnoea, the already low PaCO2 is driven below the patient's apnoeic threshold. Central drive to the muscles of breathing pauses until the rising PaCO2 and falling PaO2 are sensed, eventually, by chemoreceptors, which then initiate a new cycle of hyperpnoea, hypocapnia, and apnoea. CSA is …

The aim of the study was to appraise time domain heart rate variability (HRV) parameters in patients with ST-segment elevation myocardial infarction (STEMI) in different age groups.Retrospective analysis included 357 consecutive patients in sinus rhythm without diabetes, aged 27-87 years (mean age--63.0 +/- 11.8 years, 243 men) treated with primary percutaneous transluminal coronary angioplasty (PTCA) due to first in their life STEMI. Each patient had an echocardiographic examination and 24-hour ECG monitoring results interpreted. Participants were divided in the analysis applying the WHO old age criterion into two groups: group A65 years old (n = 188) and B agedor = 65 years (n = 169).In the whole study group age negatively correlated with SDNN, SDANNI, SDNNI and EF, whereas positive correlation between EF and SDANN, and EF and SDNNI was observed. Elderly patients as compared to the younger individuals had significantly diminished SDNN, SDANN, SDNNI and more often SDNN70 ms (33.7% vs 20.7%, p0.0001). When the circumflex artery lesion was the cause of myocardial infarction SDNN and SDANN were significantly lower in the group B, whereas in case of PTCA of RCA, apart from decreased SDNN and SDANN, EF was also compromised in this group.Elderly patients with myocardial infarction with ST-segment elevation treated with primary PTCA, compared to the younger age group, are characterized by increased sympathetic activation assessed by heart rate variability and heart rate in 24-hour ECG monitoring.

The choice of an attested blood pressure (BP) monitor with an adequate arm cuff size and its proper maintenance are crucial for obtaining reliable results in Self-Blood Pressure Monitoring (SBPM) practice. The aim of the study was to assess the factors determining the BP monitor selection, its purchase place and technical use aspects.Two hun. dred consecutive patients with arte. rial hypertension regularly performing SBPM (100 individuals from a munici. pal primary health care centre and 100 from a specialized hypertension office at a university cardiology clinic, aged 57.7 +/-12.4 years, 54.0% female) have undergone an inquiry study based on the European Society of Hyperten. sion (ESH) guidelines for home BP monitoring.Almost half of the re. spondents are utilizing BP monitors that are not routinely recommended for SBPM: wrist devices - 22.0%, aneroid appliances -15.0%, mercury monitors - 7.0% and finger monitors - 1.0%. Only 45.0% of the study participants have checked if the cuff size is ap. propriate, whereas arm circumference in 26.0% of the patients exceeded 34 cm and in 3.5% of the individuals was below 24 cm. As few as 2.5% of SBPM practitioners perform regular techni. cal checkups of their BP monitors. Patients of a specialized hypertension office have significantly more often chosen their BP apparatus according to the doctor's recommendation than primary health care patients (27.0% vs 12.0%, p=0.007, respectively).Sphygmomanometer type and appropriate arm cuff size selections for SBPM is random. The aspects of BP monitor attest and its proper maintenance are neglected. Physicians recommend an adequate BP apparatus choice too rarely.

The aim of this study was to evaluate the short term effect of cardiac resynchronisation therapy (CRT) on right ventricular (RV) function assessed by standard echocardiography.Data from 57 patients (54 men, 95%; three women, 5%), aged 66.4 ± 8.7 years with heart failure (HF) was analysed. All patients were in NYHA III-IV functional classes, despite optimal pharmacological treatment according to the current guidelines, had left ventricular ejection fraction ≤ 35% and QRS complex ≥ 120 ms in a standard electrocardiogram. At baseline and three months after CRT implantation the patients' histories were taken, an anthropometrical examination was made, laboratory tests including the level of NT-proBNP and electrocardiogram were performed, and echocardiographic examination was extended by tissue Doppler imaging techniques and complex RV evaluation.Three months after CRT implantation in the whole study group, the average NYHA functional class had decreased from 3.11 ± 0.28 to 2.25 ± 0.68 (p0.001), and the six-minute walk test distance had increased from 298.04 ± 107.42 m to 373.12 ± 127.15 m (p0.001). CRT improved RV systolic function in the whole study group. Tricuspid annular plane systolic excursion had increased from 13.95 ± 2.80 to 15.79 ± 2.33 mm (p0.001), and so likewise had systolic excursion velocity (S'), which rose from 8.84 ± 3.45 to 11.00 ± 3.43 cm/s (p0.001). Tricuspid regurgitation grade decreased from 2.02 ± 0.95 to 1.86 ± 0.91 (p = 0.013). RV systolic pressure decreased from 31.07 ± 20.43 to 27.75 ± 17.35 mm Hg (p0.001). RV fractional area change rose from 31.35 ± 10.30% to 35.40 ± 10.51% (p0.001).This study showed that CRT improved RV systolic function evaluated with parameters assessed in standard echocardiographic examination three months after therapy initiation. The observed improvement was consistent among all applied echocardiographic parameters reflecting RV systolic function.

The aim of the study was to assess the influence of cardiac resynchronization therapy(CRT) on a series of humoral parameters crucial for the pathophysiology of chronic heart failure such as aldosterone or the inflammatory markers. Thirty eight consecutive patients (aged 66.3 +/- 9.6 years, 31 men - 82% ) with chronic heart failure (57.9% with ischaemic background and 42.1% of non-ischaemic etiology) in stable for at least 3 months, NYHA class III - IV despite optimized pharmacotherapy, with left ventricular ejection fraction (LVEF)or = 35% and wide QRS complex (or = 120 ms) had the blood serum tested for the concentrations of interleukin-6 (IL-6), interleukin-18 (IL-18), C-reactive protein (CRP) and aldosterone before and 12-16 weeks after CRT introduction. In the study group aldosterone concentrations were significantly reduced. Among the inflammatory markers the level of IL-6 decreased, IL-18 concentrations showed a falling trend (445.1 +/- 225.7 pg/ml vs 418.4 +/- 229.6 pg/ml, p = 0.052), whereas no change of CRP serum contain was noted. It was showed that cardiac resynchronization therapy had an impact on systemic inflammation and hormonal status in patients with chronic heart failure during short-term observation.

Sleep-related breathing disorders are common in patients with chronic heart failure (CHF) and contribute to exacerbation of CHF. The effects of biventricular stimulation (CRT) seem to exceed the improvement of mechanical heart performance and are likely to affect other aspects of CHF pathophysiology. The aim of the study was to assess the influence of CRT on subjective and objective sleep features.Twenty seven consecutive patients (aged 67.7 +/- 8.7 years, 23 men - 85%) with chronic heart failure (62.9% with ischaemic background and 37.1% of non-ischaemic etiology) in stable for at least 3 months NYHA class III - IV despite optimized pharmacotherapy, with left ventricular end-diastolic diameter (LVEDd)55 mm, left ventricular ejection fraction (LVEF)or = 35% and wide QRS complex (or = 120 ms) were appraised before and 12-16 weeks after CRT introduction clinically (including 6-minute walk test--6-MWT), echocardiographically and in polisomnography. The apnea-hypopnea index (AHI) and apnea indexes (AI) of central, obstructive and mixed types were calculated. The sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), daytime sleepiness with the Epworth Sleepiness Scale (ESS).LVEF increased, 6-MWT distance rose. Left ventricular diameters and left ventricular end-systolic volume decreased. PQSI and ESS fell (9.3 +/- 4.2 vs 6.2 +/- 3.2, p0.001 and 8.4 +/- 4.1 vs 7.0 +/- 3.4, p0.001, respectively). AHI, obstructive AL and mixed AL did not alter but significant reduction of central AL was noted (9.6 +/- 13.0 vs 3.7 +/- 6.2, p = 0.023).CRT decreases central sleep apnea and improves quality of sleep and daytime sleepiness in patients with CHF.

Introduction: The aim of the study was to assess the relation of baseline mechanical dyssynchrony with the left ventricular end-systolic volume (LVESV) decrease following cardiac resynchronization (CRT) therapy introduction. Material and methods: Sixty consecutive patients (aged 66.3 ±8.7 years; 57 men) with chronic heart failure (71.7% of ischaemic and 28.3% of non-ischaemic origin) and current indications for CRT were assessed before and 3 months after biventricular heart stimulator implantation. Longitudinal movements of twelve segments of the left ventricle (LV) (6 basal and 6 midlevel) and two segments of the right ventricle (RV) were analysed using tissue Doppler imaging (TDI) techniques with time from onset of Q wave in ECG to peak systolic velocity in colour-coded TDI (TTDI ), time to peak strain (Tstrain) and time to peak strain rate (Tstrain rate). Minimal and maximal time differences within LV and between LV and RV walls were calculated. Results: In the study group LVEF and 6-min walk test distance increased, while NYHA class, NT-proBNP level, left ventricular end-diastolic volume and LVESV decreased. Significant correlations between the magnitude of LVESV reduction with maximal time differences between Tstrain of 12 LV segments (r = 0.34, p = 0.017) and time differences between TTDI basal LV-RV segments (r = –0.29, p = 0.041) were found. Conclusions: Only a few TDI-derived parameters such as maximal time differences between Tstrain of 12 LV segments and TTDI difference of LV-RV basal segments can be useful to predict the magnitude of left ventricle reverse remodelling after CRT introduction.