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AIMS: Therapy with an implantable cardioverter defibrillator (ICD) is established for the prevention of sudden cardiac death (SCD) in high risk patients. We aimed to determine the effectiveness of primary prevention ICD therapy by analysing registry data from 14 centres in 11 European countries compiled between 2002 and 2014, with emphasis on outcomes in women who have been underrepresented in all trials. METHODS AND RESULTS: Retrospective data of 14 local registries of primary prevention ICD implantations between 2002 and 2014 were compiled in a central database. Predefined primary outcome measures were overall mortality and first appropriate and first inappropriate shocks. A multivariable model enforcing a common hazard ratio for sex category across the centres, but allowing for centre-specific baseline hazards and centre specific effects of other covariates, was adjusted for age, the presence of ischaemic cardiomyopathy or a CRT-D, and left ventricular ejection fraction ≤25%. Of the 5033 patients, 957 (19%) were women. During a median follow-up of 33 months (IQR 16-55 months) 129 women (13%) and 807 men (20%) died (HR 0.65; 95% CI: [0.53, 0.79], P-value

Background:Previous studies have demonstrated a high incidence of atrial tachyarrhythmias (ATs) in patients with Brugada syndrome (BS). The present study aimed to investigate whether various 12-lead electrocardiogram (ECG) and electrophysiological parameters may help to differentiate subjects with a high probability to develop ATs. Methods and Results:The clinical records of 38 individuals (31 males, age 44.4 ± 13.9) with spontaneous (n = 15) or ajmaline-induced (n = 23) type 1 ECG pattern of BS were analyzed. During a mean follow-up period of 4.6 ± 2.2 years, nine subjects suffered ATs (24%). Six subjects displayed paroxysmal atrial fibrillation and three typical atrial flutter. Among the studied 12-lead ECG parameters, subjects with ATs exhibited increased values of P-wave duration in lead II, P-wave dispersion, PR interval in leads II, QRS duration in leads II and V2, Tpeak-end interval in lead II, and Tpeak-end dispersion of the 12 leads in relation to those without ATs (P < 0.05). Among the assessed electrophysiological parameters, atrial-His (AH) and His-ventricular (HV) intervals were significantly prolonged in subjects with ATs (P < 0.05). Multiple Cox proportional hazards analysis revealed that P-wave duration in lead II, P-wave dispersion, Tpeak-end in lead II, Tpeak-end dispersion of the 12 leads, as well as AH and HV intervals are independent predictors of ATs in subjects with BS (P < 0.05). Cut-off point analysis showed that an HV interval≥56 ms displayed the highest predictive ability (P < 0.01). Conclusion:Our findings demonstrate that simple 12-lead ECG and electrophysiological parameters may easily be applied to identify high-risk subjects with BS ECG phenotype to develop ATs.

Aims Iatrogenic pulmonary vein (PV) stenosis after radiofrequency catheter ablation for atrial fibrillation (AF) is a new pathology in cardiology. The effects of PV stenosis on the pulmonary circulation are not yet known. We provide long-term follow-up data in patients with significant PV stenosis including magnetic resonance imaging (MRI) and Swan Ganz (SG) right heart catheterization. Methods and results One hundred and seventeen patients had MRI 12–24 months after the AF ablation procedure. Eleven patients (58±7 years, nine males) with significant stenosis ( n =9) or occlusion of the proximal PV ( n =5) at this follow-up were re-examined using MRI and SG right heart catheterization at rest and during exercise (follow-up time since PV ablation 50±15 months). None of these underwent previous PV angioplasty. When compared with prior MRI studies, no significant changes were noted. At rest, no patient had pulmonary hypertension. At 100 W, seven patients had elevated pulmonary artery pressures, three of them probably caused, in part, by left ventricular dysfunction. Conclusion Significant stenosis/occlusions of one or two PV do not create pulmonary hypertension at rest during long-term follow-up. However, seven of the 11 patients develop pulmonary hypertension during exercise. All three patients with stenosis/occlusions of two PV were affected.

Vorhofflimmern wird uberwiegend durch Trigger in den Pulmonalvenen induziert und unterhalten. In der vorliegenden Studie wurde die elektrische Aktivierung der Pulmonalvenen bei 65 Patienten (43 Manner, 22 Frauen, mittleres Alter 54 ± 12 Jahre) mit therapieresistentem Vorhofflimmern (paroxysmal n = 42, persistierend n = 23) mit Hilfe eines 64-poligen Basketkatheters untersucht. 75% der arrhythmogenen Pulmonalvenen zeigten bei ektopen Entladungen ein stabiles und fur die einzelne Vene spezifisches Aktivierungsmuster. Durch die gezielte ostiale Hochfrequenzkatheterablation von im Mittel 2,3 ± 1,1 separierten Leitungswegen konnten 187 von 190 Pulmonalvenen erfolgreich elektrisch vom Vorhof aus isoliert werden. 55% (36/65) der Patienten sind nach 12 Monaten ohne Antiarrhythmika im Sinusrhythmus, 67% (28/42) der Patienten mit paroxysmalem Vorhofflimmern. Mittels Kernspintomographie fand sich nach 1 Jahr nur eine bedeutsame Pulmonalvenenstenose von > 50%. Pulmonalvenen zeigen sowohl bei ektopen Entladungen als auch im Sinusrhythmus ein spezifisches Aktivierungsmuster. Durch die gezielte Ablation von im Mittel 2,3 ± 1,1 separierten Leitungsbahnen konnten 187 von 190 Pulmonalvenen erfolgreich ostial isoliert werden.

Background— Ostial pulmonary vein (PV) isolation by radiofrequency (RF) catheter ablation can cure patients with atrial fibrillation (AF); however, this procedure carries the risk of PV stenosis. The aim of this study was to assess the feasibility of a new mapping and navigation technique using a multipolar basket catheter (BC) for PV isolation in patients with refractory AF and to analyze its safety with regard to PV stenosis at long-term follow-up. Methods and Results— We studied 55 patients (mean age, 53±11 years; 40 male) with drug-refractory AF (paroxysmal, n=37; persistent, n=18). A 64-pole BC was placed transseptally into each of the accessible PVs. By use of a nonfluoroscopic navigation system, the ablation catheter was guided to the BC electrodes at the PV ostium, with earliest activation during sinus rhythm. RF was delivered by use of maximum settings of temperature at 50°C and power at 30 W. The end point of the procedure was the complete elimination of all distal and fragmented ostial PV potentials. Of 165 targeted veins, 163 were successfully isolated with a mean RF duration of 720±301 seconds per vein. At 1-year follow-up, 62% of the patients were in sinus rhythm without antiarrhythmic drugs. Contrast-enhanced magnetic resonance angiography revealed 2 PV stenoses of >25% out of 165 treated vessels. Conclusions— The use of a multipolar BC allowed effective and safe PV isolation by combining 3D mapping and navigation. At 1-year follow-up, 62% of the patients were in sinus rhythm without antiarrhythmic drugs, and the incidence of relevant diameter reduction of the treated PVs was 1.2%.

AIMS: Cardiac resynchronization therapy (CRT) is sometimes complicated by elevated pacing thresholds and phrenic nerve stimulation (PNS), both of which may require that the coronary sinus lead be repositioned. The purpose of this study was to evaluate the performance of a novel quadripolar electrode lead and cardiac resynchronization therapy-defibrillator (CRT-D) device that enables electrical repositioning, potentially obviating a lead reposition procedure. METHODS AND RESULTS: Patients indicated for CRT were enrolled and received a quadripolar electrode lead and CRT-D device (Quartetmodel 1458Q and Promote Q; St Jude Medical, Sylmar, CA, USA). Electrical data, and the presence of PNS during pacing from each left ventricular (LV) configuration, were documented at pre-hospital discharge and at 1 month. Seventy-five patients were enrolled and 71 were successfully implanted with a Quartetlead. Electrical measurements were stable over the follow-up period. Ninety-seven per cent (64 of 66) of patients had one or more programmable configurations with a threshold < 2.5 V and no PNS vs. 86% (57 of 66) if only conventional bipolar configurations were considered. Physicians were able to use the increased programming options to manage threshold changes and PNS. CONCLUSION: The new quadripolar electrode LV lead provides more programming options to address common problems faced when managing CRT patients. Electrical measurements from new vectors are comparable with conventional configurations. Furthermore, 11% of patients in the study suffered PNS on all conventional bipolar vectors

To evaluate the acute hemodynamic effects of different right (RV) and left ventricular (LV) pacing sites in patients undergoing the implantation of a cardiac resynchronization therapy defibrillator (CRT-D).Stroke volume index (SVI), assessed via pulse contour analysis, and dp/dt max, obtained in the abdominal aorta, were analyzed in 21 patients with New York Heart Association class III heart failure and left bundle branch block (mean ejection fraction of 24 ± 6%), scheduled for CRT-D implantation under general anesthesia. We compared the hemodynamic effects of RV apical (A), RV septal (B), and biventricular pacing using the worst (lowest SVI; C) and best (highest SVI; D) coronary sinus lead positions.Mean arterial pressure, SVI, and dp/dt max did not differ significantly between RV apical and septal pacing. Dp/dt max and SVI increased significantly during biventricular pacing (dp/dt max: B, 588 ± 160 mmHg/s; C, 651 ± 218 mmHg/s, P = 0.03 vs B; D, 690 ± 220 mmHg/s, P = 0.02 vs C; SVI: B, 33.6 ± 5.5 mL/m², C, 34.8 ± 6.1 mL/m², P = 0.08 vs B, D 36.0 ± 6.0 mL/m², P0.001 vs C). The best hemodynamic response was associated with lateral or inferior lead positions in 15 patients. Other LV lead positions were most effective in six patients.The optimal LV lead position varies significantly among patients and should be individually determined during CRT-D implantation. The impact of the RV stimulation site in patients with intraventricular conduction delay, undergoing CRT-D implantation, has to be investigated in further studies.

Objective - The present study aimed to evaluate the diagnostic value of specific ECG markers in the differentiation of common type atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) via a concealed accessory pathway. Methods — One hundred and ten ECGs with paroxysmal narrow QRS complex, short RP tachycardia were evaluated. Subjects with overt ventricular pre-excitation during sinus rhythm were excluded from the study. The mechanism of arrhythmia was established during the electrophysiological study and confirmed by the efficacy of radiofrequency ablation. Results - Of the 110 patients, 74 displayed common type AVNRT and 36 AVRT. Predictors of AVNRT were the presence of pseudo r'-waves in lead V 1 [sensitivity 39.19%; specificity 97.14%; positive predictive value (PPV) 96.67%; negative predictive value (NPV) 43.04%] and pseudo S-waves in inferior leads (sensitivity 28.38%; specificity 94.29%; PPV 91.30%; NPV 38.37%). In the setting of visible P-waves, an RP intervals ≤ 90 ms favoured the diagnosis of AVNRT (sensitivity 57.14%; specificity 80.65%). Predictors of AVRT were QRS alternans (sensitivity 50%; specificity 89.19%; PPV 69.23%; NPV 78.57%) as well as ST-segment alterations during tachycardia. The overall sensitivity, specificity, PPV and NPV of ST-segment depression for discriminating AVRT from AVNRT were 97.22%, 58.11%, 53.03%, 97.73%, respectively. Similarly, the sensitivity, specificity, PPV and NPV of ST-segment elevation in lead aVR were 94.44%, 58.11%, 52.31%, and 95.56%, respectively. Multiple logistic regression analysis showed that ST-segment depression [(odds ratio (OR): 12.67, 95% confidence interval (CI): 1.77-90.81, P=0.011)] and QRS alternans (OR: 9.43, 95% CI: 1.38-64.37, P = 0.022) displayed the highest predictive ability favouring the diagnosis of AVRT. Conclusions - Twelve-lead ECG parameters may help to differentiate the mechanism of supraventricular tachycardia prior to the ablation procedure.

In their letter regarding our article,1 Drs Kriatselis and Roser suggest that large isolation during circumferential ablation can only be proved using 2 circumferential mapping catheters, 1 in each ipsilateral …

Background— Pulmonary vein (PV) isolation is a promising new treatment for atrial fibrillation (AF). We hypothesized that isolation of large areas around both ipsilateral PVs with verification of conduction block is more effective than the isolation of each individual PV. Methods and Results— A total of 110 patients, 67 with paroxysmal AF and 43 with persistent AF, were randomly assigned to undergo either isolation of each individual PV or isolation of large areas around both ipsilateral PVs. The isolation of each individual PV was an electrophysiologically guided, ostial segmental ablation with a 64-pole basket catheter or a 20-pole circular mapping catheter (group I). Isolation of large areas was performed around the 2 ipsilateral veins with a nonfluoroscopic navigation system and a circular 20-pole mapping catheter for verification of conduction block (group II). In both groups, an irrigated-tip ablation catheter (25 to 35 W) was used to achieve complete isolation. Procedure and ablation times were longer in group II, whereas fluoroscopic time was significantly shorter ( P ≤0.001). After a follow-up period of 15±4 months, 27 patients in group I (49%) and 37 patients in group II (67%) remained free of symptoms of AF and had no AF or atrial flutter during repetitive Holter monitoring without antiarrhythmic drug treatment after a single procedure ( P ≤0.05). Conclusions— The rate of success was significantly higher and fluoroscopy times were significantly lower in the group with large isolation areas around both ipsilateral PVs than in those who underwent individual PV isolation.

Aims Lower platelet activation by cryoenergy compared with radiofrequency (RF) energy was recently demonstrated immediately following ablation procedures of cardiac arrhythmias. Due to the delayed occurrence of cryolesions it is currently unknown, if cryoenergy and RF energy are associated with similar platelet activation and myocardial necrosis in the days after the procedure. Methods and results We enrolled 38 patients with common atrial flutter undergoing cavotricuspid isthmus ablation with either RF energy (n ¼ 23) or cryoenergy (n ¼ 13). Ten patients undergoing RF ablation and receiving aspirin served as antiplatelet control group. Troponin T and platelet surface protein expression of P-selectin were determined before and immediately after ablation as well as on day 1 and 2 thereafter. Rise in troponin T was amplified after RF ablation (0.50 + 0.37 mg/L) when compared with cryoablation (0.24 + 0.20 mg/L; P ¼ 0.024). In patients without aspirin, a significant increase in P-selectin expression was observed on day 1 after intervention in RF ablation compared with cryoablation (80 + 26 vs. 63 + 16 arbitrary units; P ¼ 0.048). Platelet activation was attenuated in patients receiving aspirin. Conclusion Successful ablation of atrial flutter with cryoenergy is associated with less myocardial necrosis and platelet activation compared with ablation with RF energy. Increased platelet activation following RF ablation can be attenuated by concomitant treatment with aspirin.

Effects of Circumferential Ostial Lesions. Aims: Two different ablation procedures are performed to cure patients of atrial fibrillation (AF): (1) the electrophysiological pulmonary vein (PV) isolation, and (2) the anatomical circumferential ablation of all four PV ostia. The aim of this study was to determine the effects of circumferential radiofrequency lesions around the ostia on PV activation. Methods and Results: In 34 patients with drug refractory paroxysmal (N = 22) or persistent (N = 12) AF a 31-mm basket catheter (BC) was introduced transseptally in the PVs. After creating a circumferential ablation line around the PV ostia using a nonfluoroscopic 3D-navigation system, electrical isolation was achieved in 46% of the PVs, and prolongation of conduction time (+39 ′ 34 ms) was observed in 30%. PVs with persistent conduction (54%) were isolated by ablating the remaining conduction pathways using the BC. At 12 months follow-up, 62% of the patients were in stable sinus rhythm without antiarrhythmic drug therapy. Six patients had developed left atrial flutter. Conclusions: Anatomically guided, circumferential lesions around the PV ostia resulted in isolation in only 46% of the veins. At 12 months, 62% of the patients were free of AF without antiarrrhythmic drug treatment, however, 6 patients (18%) developed left atrial flutter.

Nicht-medikamentose Therapieverfahren haben in den vergangenen 20 Jahren einen zunehmenden Stellenwert bei der Behandlung von Herzrhythmusstorungen erlangt, z.T. haben sie die medikamentose Therapie vollstandig verdrangt. Das gilt z. B. fur die Behandlung symptomatischer Bradykardien mittels Herzschrittmacher. Aber auch im Bereich tachykarder Herzrhythmusstorungen sind sie z.T. nicht nur eine Alternative zur medikamentosen Therapie, sondern durfen schon heute als Therapie I.Wahl gelten. Das gilt insbesondere fur die Katheterablationsbehandlungen supraventrikularerTachykardien, aber auch fur die Implantation automatischer Kardioverter/Defibrillatoren in der Sekundarprophylaxe des plotzlichen Herztodes oder als primar prophylaktische Therapie bei ausgewahlten Hochrisikopatienten.

Focal discharges from pulmonary veins are the major sources of paroxysmal atrial fibrillation. The aim of this study was to analyze the activation pattern of pulmonary veins during sinus rhythm and ectopy with the help of a multipolar basket catheter and to disconnect them from the left atrium by localized radiofrequency catheter ablation.We studied 65 patients (43 male, 22 female, mean age 54 +/- 12 years) with drug-refractory atrial fibrillation (paroxysmal n = 42, persistent n = 23). A 64-pole basket catheter (Figure 1) with a diameter of 31 or 38 mm (Constellation, Boston Scientific) was placed transseptally into the pulmonary veins to record its activation during ectopic beats and during sinus rhythm or coronary sinus pacing (Figure 2). The ablation catheter was placed as ostial as possible next to the electrodes showing the earliest pulmonary vein activation during sinus rhythm or coronary sinus pacing (Figures 3 and 4a). The radiofrequency energy was delivered with a maximum temperature of 50 degrees C and a maximum power of 30 W. In 32 patients, an irrigated-tip catheter (Thermocool, Biosense-Webster) was used. Endpoint of the procedure was the complete elimination of all distal pulmonary vein potentials during sinus rhythm (Figure 4b).The mean number of procedures per patients was 1.25, mean procedure time 236 +/- 79 min, and mean fluoroscopy time 40 +/- 17 min, respectively. In 16 veins, repetitive discharges (more than three) could be recorded under stable conditions (Figures 2 and 5). In twelve of these 16 pulmonary veins (75%), the activation pattern during ectopic beats was identical in the same vein, but different from one vein to another (Figure 2). In four veins, changing activation patterns were observed in the same vein. Focal atrial fibrillation was recorded in four pulmonary veins (Figures 6 and 7). A total of 187 out of 190 mapped veins were successfully isolated at the ostium by ablating 2.3 +/- 1.1 separated conduction pathways. In 16 patients, a second EP study was performed for recurrence of atrial fibrillation. Recovery of conduction of a previously isolated pulmonary vein was identified as the primary reason for recurrence of atrial fibrillation. The second reason were ostial foci, localized proximal to the ablation line (Figure 8). COMPLICATIONS AND FOLLOW-UP: One pericardial tamponade occurred. Carbonization on the splines of the basket catheter-observed in twelve cases with use of a nonirrigated-tip catheter-was prevented by use of irrigated-tip catheters. At 12 months, 36 out of 65 patients (55%) are in sinus rhythm without antiarrhythmic drug use, 28 of 42 patients (67%) with paroxysmal atrial fibrillation. Only one pulmonary vein stenosis50% was detected by angiomagnetic resonance imaging 1 year after the procedure.75% of the arrhythmogenic pulmonary veins showed a stable and specific pattern during repetitive ectopic activity. Ostial ablation of 2.3 +/- 1.1 separated conduction pathways from the left atrium into the pulmonary veins resulted in complete conduction block in 187 of 190 veins.

BACKGROUND Modification of AV nodal conduction by means of radiofrequency catheter ablation has become the accepted mode of therapy for patients with symptomatic AV nodal re-entry tachycardias (AVN-RT). The published results demonstrate high success rates and a low incidence of severe complications. However, published series have primarily dealt with relatively young patient populations. Little is known about the efficacy and risks of radiofrequency catheter ablation of AVN-RT in the elderly. METHODS We retrospectively analysed our data of 404 patients who underwent a catheter ablation therapy for AVN-RT between 1992 and June 1997. Nine patients were excluded from further analysis because of presence of more than one tachycardia mechanism. The ablation procedure was performed at the time of the diagnostic electrophysiologic study. RESULTS The mean age of 395 patients undergoing catheter ablation for AVN-RT was 52.3 years (19-90 years); 85 patients were 65 years old or older. Compared with the younger subgroup, these elderly patients (mean age 70.4 years) more often had organic heart disease (coronary heart disease with or without myocardial infarction 19.3% versus 2.6%; P < 0.02), more often had syncopes or presyncopes with AVN-RT (43.2% versus 29.8%; P < 0.05), had more hospitalisations and emergency treatments because of their symptoms (56.8% versus 39.5%; P < 0.05) although the cycle length of the induced AVN-RT was significantly shorter in the younger patient group (325 ms versus 368 ms; P < 0.001). Slow pathway ablation was performed in 94% of the young and 82% of the elderly (P < 0.001). In 17.5% of the elderly patients versus 6.5% of the young (P < 0.05) the fast pathway approach was chosen as the first therapy or tried after an unsuccessful approach to the slow pathway. The overall success rate (96.8% in the young and 95.3% in the elderly) and the recurrence rate (5.8% in the elderly versus 4.9% in the young) were similar in both patient groups. There were no differences regarding the total procedure of fluoroscopy time, radiation exposure or the incidence of high-degree AV-block necessitating pacemaker implantation (2.3% in the elderly versus 1.6% in the young). CONCLUSIONS In patients older than 65 years, AVN-RT may lead to severe, sometimes life-threatening symptoms, despite the fact that the tachycardia is not as fast as in younger patients. Radiofrequency catheter ablation can be performed effectively and safely and should be offered to these patients as first-choice therapy.

Introduction The respiratory variation in pulse pressure (PP) has been established as a dynamic variable of cardiac preload which indicates fluid responsiveness in mechanically ventilated patients. The impact of acute changes in cardiac performance on respiratory fluctuations in PP has not been evaluated until now. We used cardiac resynchronization therapy as a model to assess the acute effects of changes in left ventricular performance on respiratory PP variability without the need of pharmacological intervention. Methods In 19 patients undergoing the implantation of a biventricular pacing/defibrillator device under general anesthesia, dynamic blood pressure regulation was assessed during right ventricular and biventricular pacing in the frequency domain (power spectral analysis) and in the time domain (PP variation: difference between the maximal and minimal PP values, normalized by the mean value). Results PP increased slightly during biventricular pacing but without statistical significance (right ventricular pacing, 33 ± 10 mm Hg; biventricular pacing, 35 ± 11 mm Hg). Respiratory PP fluctuations increased significantly (logarithmically transformed PP variability -1.27 ± 1.74 ln mm Hg2 versus -0.66 ± 1.48 ln mm Hg 2 ; p < 0.01); the geometric mean of respiratory PP variability increased 1.8-fold during cardiac resynchronization. PP variation, assessed in the time domain and expressed as a percentage, showed comparable changes, increasing from 5.3% (3.1%; 12.3%) during right ventricular pacing to 6.9% (4.7%; 16.4%) during biventricular pacing (median [25th percentile; 75th percentile]; p < 0.01). Conclusion Changes in cardiac performance have a significant impact on respiratory hemodynamic fluctuations in ventilated patients. This influence should be taken into consideration when interpreting PP variation.

To test the hypothesis that the timing of atrial contraction is essential to obtain optimal cardiac output (CO) in patients (pts) with heart failure we studied 15 pts (14 male) in whom DDD-pacemakers (PM) had been implanted for standard indications (sinus node disease 1, AV-block 3, both 11 pts.). Methods Assessment of LV-function by ECHO (enddiastolic and end systolic diameters: EDD/ESD; fractional shortening: FS; ejection fraction: EF); calculation of stroke volumes by measuring the time velocity integral (TVI) in the LV-outflow tract (PW-doppler); programming of 9 different AV-delays between 90 and 250 ms in each pt besides programming VVI-pacing; all measurements at a rate of 751min. [AV-sequential – or VVI-pacing] with the pt in a 60° supine position. Patients History of NYHA IV heart failure in all, but hemodynamically stable at the time of the study; age x 59 yrs (29–74); dilated CMP 13, coronary heart disease 2. LV-function EDD x ¯ 70.4 mm (59 – 82); FS x ¯ 14.1% (4 – 21); EF x ¯ 28.8% (10 – 40). SV/CO-calculations The mean value of the lowest TVI was 9.6 with 14.1 being the mean value of the highest obtained values. This corresponded to a difference in CO of x 31% (20 – 50%) depending on the programming of the AV-delay (p l 0.05). In 6/15 pts the optimal AV-delay was in the range of 150 to 170 ms; in 4 pts it was shorter ( x ¯ 130 ms), in 5 it was markedly longer ( x ¯ 193 ms). There was no pt whose SV could not be enhanced significantly by optimal programming of the PM. WI-pacing was constantly inferior to optimized DDD-pacing. Conclusions In pts with depressed LV-function and a dual-chamber PM CO can be optimized by searching for the best individual AV-delay by Doppler-Echo. The indication for DDD pacing might be considered in heart failure pts even if there is only a prolonged AV-interval WAV-Block) during sinus rhythm.