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Background: The extravascular implantable cardioverter-defibrillator (ICD) has a single lead implanted substernally to enable pause-prevention pacing, antitachycardia pacing, and defibrillation energy similar to that of transvenous ICDs. The safety and efficacy of extravascular ICDs are not yet known.Methods: We conducted a prospective, single-group, nonrandomized, premarket global clinical study involving patients with a class I or IIa indication for an ICD, all of whom received an extravascular ICD system. The primary efficacy end point was successful defibrillation at implantation. The efficacy objective would be met if the lower boundary of the one-sided 97.5% confidence interval for the percentage of patients with successful defibrillation was greater than 88%. The primary safety end point was freedom from major system- or procedure-related complications at 6 months. The safety objective would be met if the lower boundary of the one-sided 97.5% confidence interval for the percentage of patients free from such complications was greater than 79%.Results: A total of 356 patients were enrolled, 316 of whom had an implantation attempt. Among the 302 patients in whom ventricular arrhythmia could be induced and who completed the defibrillation testing protocol, the percentage of patients with successful defibrillation was 98.7% (lower boundary of the one-sided 97.5% confidence interval [CI], 96.6%; P<0.001 for the comparison with the performance goal of 88%); 299 of 316 patients (94.6%) were discharged with a working ICD system. The Kaplan-Meier estimate of the percentage of patients free from major system- or procedure-related complications at 6 months was 92.6% (lower boundary of the one-sided 97.5% CI, 89.0%; P<0.001 for the comparison with the performance goal of 79%). No major intraprocedural complications were reported. At 6 months, 25 major complications were observed, in 23 of 316 patients (7.3%). The success rate of antitachycardia pacing, as assessed with generalized estimating equations, was 50.8% (95% CI, 23.3 to 77.8). A total of 29 patients received 118 inappropriate shocks for 81 arrhythmic episodes. Eight systems were explanted without extravascular ICD replacement over the 10.6-month mean follow-up period.Conclusions: In this prospective global study, we found that extravascular ICDs were implanted safely and were able to detect and terminate induced ventricular arrhythmias at the time of implantation. (Funded by Medtronic; ClinicalTrials.gov number, NCT04060680.). [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy with defibrillator function (CRT-D) along with an optimal medical therapy improves symptoms, cardiac efficiency, quality of life (QoL) and prognosis in patients with heart failure (CHF). The aim of the study was to assess effects of hospital-based and home-based/telemonitoring exercise training. Methods The prospective, randomized study was conducted in 52 patients (pts), aged 45–75 years (mean 62 ± 9.3), with CHF of ischemic or another etiology, NYHA class III and implanted CRT-D. Group CRT-Ex (n = 26) underwent initial exercise training in the hospital setting and continued training program at home with telemonitoring 5 times a week for 8 weeks. The CRT-control group (n = 26) consisted of patients who had hospital rehabilitation, but no training program after discharge. Results No differences between the groups in CHF etiology, comorbidities, medical therapy and in any of spiroergometry (CPX) parameters at baseline were observed. After 3–4 months the CRT-Ex group achieved better results in VO 2 peak, VCO 2 peak and treadmill test duration. But after 12 months the measurements returned to the baseline values. No significant differences were observed directly between two groups in distances of 6-MWT at baseline, at 3–4 months and at 12 months. Echocardiographic evaluation showed significant reduction of left ventricular dimensions and improvement in the left ventricular ejection fraction (EF), in both groups (25.3 ± 7.4% to 28.9 ± 9.1%, CRT-Ex group, p = 0.0213 and 24.9 ± 7.2% to 31.7 ± 10.6%, CRT-Control group, p = 0.0001). Significant improvement in all domains of QoL was observed in the CRT-Ex group, while the CRT-Control pts declared only higher energy levels and less pain. Intensity of telemonitoring guided home-based exercise training was low. In the 12- and 18-months follow-up there were no differences in the ICD-interventions, mortality or hospitalization rates between the groups. Conclusions A structured exercise training program in the hospital and home-based with telemonitoring was safe option of additional treatment and improved directly physical fitness and, quality of life in patients with NYHA III CHF and CRT-D. However these effects haven't been sustained in longer period of time and had no impact on prognosis. [ABSTRACT FROM AUTHOR]

Competing Interests: Maciej Bąk, Ewa Świerżyńska, Łukasz Szumowski—none, Artur Oręziak—has received speaker honoraria from Abbott Medical/St Jude Medical and Biotronik, Maciej Sterliński—investigator, proctoring or lecture fees from Abbott, Biotronik, HammerMed, Medtronic, Zoll.

Competing Interests: Disclosures The authors have no conflicts of interest to disclose.

Background: Substernal lead placement of the extravascular implantable cardioverter defibrillator (EV ICD) permits both defibrillation at thresholds similar to those seen with transvenous implantable cardioverter defibrillators and effective anti-tachycardia pacing (ATP) while avoiding the vasculature and associated complications. The global Pivotal study has shown the EV ICD system to be safe and effective through 6 months, but long-term experience has yet to be published. Our aim was to report the performance and safety of the EV ICD system throughout the study., Methods: The EV ICD Pivotal study was a prospective, global, single-arm, premarket clinical study. Individuals with a Class I or IIa indication for a single-chamber implantable cardioverter defibrillator per guidelines were enrolled. Freedom from major system- or procedure-related complications and appropriate and inappropriate therapy rates were assessed through 3 years with the Kaplan-Meier method. ATP success was calculated from simple proportions., Results: An implantation was attempted in 316 patients (25.3% female; 53.8±13.1 years of age; 81.6% primary prevention; left ventricular ejection fraction, 38.9±15.4%). Of 299 patients with a successful implantation, 24 experienced 82 spontaneous arrhythmic episodes that were appropriately treated with ATP only (38, 46.3%), shock only (34, 41.5%), or both (10, 12.2%) for a Kaplan-Meier-estimated rate of first any appropriate therapy of 9.2% at 3 years. ATP was successful in 77.1% (37/48) of episodes, and ATP use significantly increased from discharge to last follow-up visit ( P <0.0001). Shock therapy was successful in 100% (27/27) of discrete, spontaneous ventricular arrhythmias. The inappropriate shock rates at 1 and 3 years were 9.8% and 17.5%, respectively, with P-wave oversensing the predominant cause. No major intraprocedural complications were reported, and the estimated freedom from system- or procedure-related major complications was 91.9% at 1 year and 89.0% at 3 years. The most common major complications were lead dislodgement (10 events; n=9 patients, 2.8%), postoperative wound or device pocket infection (n=8, 2.5%), and device inappropriate shock delivery (n=4, 1.3%). Twenty-four system revisions were performed as a result of major complications related to the EV ICD system or procedure., Conclusions: From implantation to study completion, the EV ICD Pivotal study demonstrated that a single integrated system with an extravascular lead placed in the substernal space maintains high ATP success, effective defibrillation, and a consistent safety profile., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04060680., Competing Interests: Dr Friedman reports receiving EV ICD Pivotal study participation support, paid to their institution, from Medtronic; licenses and patents with Anumana, Eko Health, Alive Cor, and Marani Health; advisory board participation at Anumana; a leadership position with xAI.health and MediCool; steering committee participation and advisory group participation at Boston Scientific, funds paid to their institution; and stock from MediCool, Marani Health, and xAI.health. Dr Murgatroyd reports receiving EV ICD Pivotal study participation support, paid to their institution, from Medtronic; consulting fees from Medtronic for advisory board and steering committee participation, consulting fees from Boston Scientific for steering committee participation; and speaker fees from Medtronic. Dr Boersma reports receiving EV ICD Pivotal study participation support, paid to their institution, from Medtronic and consulting fees from Medtronic and Adagio, paid to the cardiology department at their institution. Dr Manlucu reports receiving EV ICD Pivotal study participation support, paid to their institution, from Medtronic; consulting fees from Medtronic for advisory board and steering committee participation; and speaker fees from Medtronic. Dr Knight reports receiving EV ICD Pivotal study participation support, paid to their institution, from Medtronic; consulting fees from Medtronic for advisory board and steering committee participation; consulting fees from Boston Scientific for advisory board participation; and speaker fees from Medtronic and Boston Scientific. Dr Clémenty reports receiving consulting fees, honoraria fees, travel support, and advisory board participation from Medtronic. Dr Leclercq reports receiving consulting fees and honoraria from Medtronic, Boston Scientific, and Abbott for steering committee participation and speaker fees from Medtronic. Dr Amin reports receiving EV ICD Pivotal study participation support from Medtronic; an institutional grant from Biosense Webster; consulting fees from Medtronic, Boston Scientific, Biosense Webster, Atricure, and Philips; honoraria from Medtronic, Boston Scientific, Biosense Webster, Atricure, and Philips; travel support from Boston Scientific, Medtronic, and Philips; and advisory board participation at Boston Scientific, Medtronic, Atricure, and Philips. Dr Merkely reports receiving institutional grants from Medtronic and Boston Scientific and lecture fees from Medtronic, Biotronik, and Abbott. Dr Birgersdotter-Green reports receiving honoraria from Medtronic, Boston Scientific, Abbott, and Biotronik; advisory board participation at Biotronik; and stock ownership in Vektor Medical. Dr Chan reports receiving honoraria for lectures from Medtronic. Dr Biffi receiving EV ICD Pivotal study participation support, paid to their institution, from Medtronic and grants from Medtronic, paid to their institution. Dr Knops reports receiving EV ICD Pivotal study participation support from Medtronic for trial funding; grants from Boston Scientific and Abbott for trial funding; institutional and private consulting fees from Abbott and Boston Scientific; honoraria from Medtronic, Boston Scientific, and Abbott; advisory board participation at Boston Scientific, Atacor, and Kestra; participation on the ESC pacing guideline committee; and stock ownership from Atacor. Dr Engel reports consulting fees from Medtronic. Dr Epstein reports institutional support for the EV ICD Pivotal study, consulting fees from Medtronic, and honoraria from Medtronic. Dr Johansen reports honoraria paid to their institution from Merit Medical, Education course and advisory board participation at Medtronic and Biotronik. Dr Sterliński reports receiving EV ICD Pivotal study participation support, paid to their institution, from Medtronic; grants from Biotronik and HammerMed; consulting fees from Abbott, Biotronik, HammerMed, and Medtronic; honoraria from Abbott, Biotronik, Medtronic, and Zoll; and advisory board participation at Medtronic. Dr Hounshell reports consulting fees from Medtronic, lecture fees from Medtronic, and advisory board participation at Medtronic. Dr Abben reports consulting fees and honoraria from Medtronic. A. Thompson, Y. Zhang, Dr Wiggenhorn, and S. Willey report employment by Medtronic. Dr Crozier reports receiving research funding for the EV ICD Pivotal study from Medtronic, grants from Medtronic for fellowship funding, and consulting fees from Medtronic. The other authors report no conflicts.

Background: Transvenous lead extraction (TLE) has become an essential component of lead management strategies, but it carries the risk of severe complications, including damage to the tricuspid valve. Currently, there are no established predictors that can help prevent these complications., Case Summary: An 84-year-old male with a dual-chamber pacemaker was admitted to the hospital due to a pocket fistula resulting from a local infection. Approximately 1 year prior, he underwent the implantation of a new ventricular lead and pacemaker replacement due to lead damage and battery depletion. Another lead had been abandoned. The patient underwent a procedure to remove the entire pacing system, which was complicated by tricuspid leaflet avulsion, resulting in acute and severe tricuspid regurgitation. A biological valve was successfully implanted to replace the damaged valve. Twenty days later, a new pacing system was implanted, which included one atrial lead and another positioned in the posterolateral coronary vein of the left ventricle. Post-procedural transthoracic echocardiography (TTE) showed the biological valve in place at the tricuspid orifice, with no regurgitation and preserved ejection fraction. Following recovery, the patient was discharged in good condition., Discussion: While pre-procedural TTE and intra-procedural transesophageal echocardiography are commonly used to identify lead-induced tricuspid insufficiency, they often do not clarify the underlying mechanisms or predict potential complications during TLE. To address this issue safely, further research into new imaging techniques is necessary, as some existing methods may not be adequate in certain situations., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Atrial fibrillation (AF) is common in cardiac resynchronization therapy (CRT) recipients. It is a marker of impaired CRT response mainly mediated by the reduction of effectively captured biventricular paced beats (BiVp). There are no randomized trials comparing strategies to maintain high BiVp percentage., Objective: To compare the efficacy of rhythm vs rate control strategies in CRT recipients with long-standing persistent AF., Methods: We performed a randomized trial including CRT recipients with persistent AF resulting in low BiVp%. All patients received amiodarone, the rhythm control group received external electrical cardioversion (EC), and the rate control group received atrioventricular node ablation, if needed. The primary end-point was 12-month BiVp% (NCT)., Results: 43 patients were included in the analysis. The mean age was 68.4 (SD: ± 8.3) years and the mean BiVp% 82.4% ± 9.7%. AF lasted 25 ± 19 months. The mean baseline left ventricular ejection fraction (LVEF), left atrium area, and the maximal oxygen uptake (VO2max) were: 30 ± 8%, 33 ± 7 cm 2 , and 14 ± 5 mL/(kg*min), respectively. The EC success rate was 58%. 38% patients remained in sinus rhythm (SR) after 12 months. BiVp% increased similarly in both arms reaching 99% [95% CI 97.3-99.8] and 98% [94.0-99.0], P = 0.14 in rhythm and rate control groups, respectively. LVEF raised significantly only in the rhythm control group (ΔLVEF 4.1 (± 7.3), P = 0,018) which was driven by the patients who maintained SR. No differences in VO2max, QoL, clinical and safety end-points were observed., Conclusion: Despite comparable BiVp% in both groups, only restoration of SR led to improved left ventricular ejection fraction in CRT patients with long-standing AF., Trial Registration: NCT01850277 registered on 22/04/2013., (© 2024. The Author(s).)

Aims: The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial., Methods and Results: STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022-23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers., Conclusion: The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care., Clinical Trial Registration: Clinicaltrials.gov, NCT04396418., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Left ventricular assist devices (LVAD) are used in the treatment of advanced left ventricular heart failure. LVAD can serve as a bridge to orthotopic heart transplantation or as a destination therapy in cases where orthotopic heart transplantation is contraindicated. Ventricular arrhythmias are frequently observed in patients with LVAD. This problem is further compounded as a result of diagnostic difficulties arising from presently available electrocardiographic methods. Due to artifacts from LVAD-generated electromagnetic fields, it can be challenging to assess the origin of arrhythmias in standard ECG tracings. In this article, we will review and discuss common mechanisms, diagnostics methods, and therapeutic strategies for ventricular arrhythmia treatment, as well as numerous problems we face in LVAD implant patients.

The year 2023 marks 60 years since the first pacemaker was implanted in Poland. The number of implantable cardiac electrotherapy devices (CIEDs), including pacemakers, cardioverter-defibrillators, and resynchronization therapy systems, has been systematically increasing in the subsequent decades. It is estimated that nearly 500,000 Poles have an implanted cardiac electrotherapy device, making optimal diagnostic imaging with the use of magnetic resonance imaging (MRI) a clinically and epidemiologically important issue. MRI has become a gold diagnostic standard in many disease states. In this situation, it is believed that 50-70% of patients who have a cardiac electrotherapy device may have indications for an MRI examination later in life. For many years, an implanted cardiac electrotherapy device was considered a definite contraindication to MRI. However, MRI has become possible in most patients with CIED if certain procedures and precautions are followed. In these guidelines, we describe the basic rules that should be followed in order to perform a safe MRI examination in patients with different CIEDs. Despite all the risks and organizational factors described in the text, it seems that for many MRI departments, MRI in patients with CIEDs is achievable and should be implemented immediately. A second important issue is the need for dedicated financial support for these procedures from public health insurance., Competing Interests: The authors report no conflict of interest., (© Pol J Radiol 2024.)

Cardiomyopathies (CMs) are a very broad group of diseases, including genetically determined and acquired, and their classification is based on phenotypic characteristics. There is always a need to search for the etiology (often also to try to identify the genetic cause), which may determine the appropriate choice of clinical management. The geographical distribution of genetic variants varies as does the prevalence across populations, ethnic groups, regions, and countries. The most reliable data on the distribution of individual genetic variants come from developed countries. The phenotypic classification includes 5 main types of CM, i.e., dilated CM, hypertrophic, restrictive, arrhythmogenic right ventricular CM, and non-dilated left ventricular (LV) CM. Individual CMs are characterized by a variety of causes and different phenotypic pictures, which affect their presentation, diagnosis, and response to treatment. Within each type of CM, there are both familial and sporadic (acquired) forms. The complex presentation of CM, as well as the limited availability of screening and diagnostic tests, causes CMs to be diagnosed late, often at an advanced stage of the disease. Therapeutic management of CM is strictly determined by its type and clinical picture. Diagnostics include the assessment of symptoms, the results of imaging and genetic tests, as well as morphological, functional, and often histological assessment. This allows for personalized and dedicated clinical management. To optimize thediagnosis, treatment, and care of patients with CMs, an individualized, expert, systemic, coordinated, and often multidisciplinary structure of care is necessary. Hence, it is important to create multidisciplinary teams for CM management. We present examples of existing systemic solutions for the care of CM patients in Europe (France and Spain). Not all of these options are available to patients in our country. This article presents issues related to CM and may be the basis for developing a diagnostic and therapeutic model allowing for earlier detection of CM in Polish patients and their effective treatment.

His-bundle pacing (HBP) is a relatively new method of cardiac pacing, with recent studies showing an association between HBP and a lower risk of developing right ventricular heart failure compared to classical pacing methods. However, HBP is also associated with a higher risk of lead dislodgement, undersensing, and loss of capture. As such, a detailed assessment of pacing effectiveness in pacemaker patients is vital. In the presented case, an electrocardiogram (ECG) recording seems to present successful selective His-bundle pacing, while pacemaker follow-up demonstrated the loss of ventricular capture. In conclusion, patients receiving HBP should undergo ECG alongside pacing parameter analysis and pacing electrograms, as differences in successful and unsuccessful pacing ECG can be very subtle., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023. Published by Elsevier Inc.)

Background: Transvenous lead extraction (TLE) is recommended in cases of local and systemic infections related to cardiac implantable electronic devices (CIEDs). Additionally, TLE is indicated in the event of lead damage or CIED malfunction. The extraction procedure is associated with a risk of life-threatening complications., Objectives: The aim of the EVO registry was to assess the safety and efficacy of birotational Evolution tool usage., Material and Methods: This registry study was prospectively conducted in 8 high-volume implantation centers in Poland. The study included 133 patients aged 63.5 ±15.1 years, and 76.69% were male. Indications for the procedure were: local or systemic infection (33.1%) and lead dysfunction (66.9%). The number of leads extracted varied from 1 (39.84%) to 3 (9.77%)., Results: Clinical procedural success was achieved in 99.1% of cases. A total of 226 leads were extracted, and 206 used the Evolution system. Two procedural strategies were identified while using the Evolution system: (1) usage of locking stylet, propylene sheaths and the Evolution system (118 leads, 52%) - group A; (2) usage of locking stylet and Evolution (88 leads, 39%) - group B. There were no differences in the number of complications between these 2 groups. The extraction time was significantly shorter (p = 0.02) in group B than in group A. Major complications occurred in 5.2% of cases with 2 intraprocedural deaths. Minor complications occurred in 1.5% of patients., Conclusions: The registry confirmed the efficacy and relative safety of the birotational Evolution sheath. Using the rotational sheath as a first attempt significantly reduces extraction time without compromising its safety.

A 36-year-old professional marathon runner reported sudden irregular palpitations occurring during competitions, with heart rates (HR) up to 230 bpm recorded on a sports HR monitor (HRM) over 4 years. These episodes subsided upon the cessation of exercise. Electrocardiograms, echocardiography, and cardiac magnetic resonance imaging results were borderline for athlete's heart. Because an electrophysiology study and standard exercise tests provoked no arrhythmia, doctors suspected Munchausen syndrome. Ultimately, an exercise test that simulated the physical effort of a competition provoked tachyarrhythmia consistent with the HRM readings. This case demonstrates the diagnostic difficulties related to exercise-induced arrhythmia and the diagnostic usefulness of sports HRMs.

Modern cardiac pacemakers are equipped with a function that allows the heart rate to adapt to the current needs of the patient in situations of increased demand related to exercise and stress ("rate-response" function). This function may be based on a variety of mechanisms, such as a built-in accelerometer responding to increased chest movement or algorithms sensing metabolic demand for oxygen, analysis of intrathoracic impedance, and analysis of the heart rhythm (Q-T interval). The latest technologies in the field of rate-response functionality relate to the use of an accelerometer in leadless endocavitary pacemakers; in these devices, the accelerometer enables mapping of the mechanical wave of the heart's work cycle, enabling the pacemaker to correctly sense native impulses and stimulate the ventricles in synchrony with the cycles of atria and heart valves. Another modern system for synchronizing pacing rate with the patient's real-time needs requires a closed-loop system that continuously monitors changes in the dynamics of heart contractions. This article discusses the technical details of various solutions for detecting and responding to situations related to increased oxygen demand (e.g., exercise or stress) in implantable pacemakers, and reviews the results of clinical trials regarding the use of these algorithms.

Background: Atrial fibrillation (AF) is the most common arrhythmia which places a significant bur-den on individuals as well as the healthcare system. AF management requires a multidisciplinary approach in which tackling comorbidities is an important aspect., Aims: This study aimed to evaluate how multimorbidity is currently assessed and managed and to determine if interdisciplinary care is undertaken., Methods: A 21-item online survey was undertaken over four weeks as part of the EHRA-PATHS study examining comorbidities in AF and distributed to European Heart Rhythm Association members in Europe., Results: A total of 341 eligible responses were received, of which 35 (10%) were from Polish physi-cians. Compared to other European locations, the rates of specialist services and referrals varied but were not significantly different. However, there were higher numbers of specialized services reported in Poland compared to the rest of Europe for hypertension (57% vs. 37%; P = 0.02) and palpita-tions/arrhythmias (63% vs. 41%; P = 0.01), whereas rates of sleep apnea services and comprehensive geriatric care tended to be lower (20% vs. 34%; P = 0.10 and 14% vs. 36%; P = 0.01, respectively). The only statistical difference in reasons for referral rates between Poland and the rest of Europe was the barrier relating to insurance and financial reasons (31% vs. 11%; P <0.01, respectively)., Conclusions: There is a clear need for an integrated approach to patients with AF and associated comorbidities. Preparedness of Polish physicians to deliver such care seems to be similar to other European countries but may be hampered by financial obstacles.

Cardiovascular diseases account for 43% of deaths in Poland. The COVID-19 pandemic increased the number of cardiovascular deaths by as much as 16.7%. Lipid metabolism disorders are observed in about 20 million Poles. Lipid disorders are usually asymptomatic, they cause a significant increase in the risk of cardiovascular diseases. Up to 20% of patients who experience an acute coronary syndrome (ACS) may experience a recurrence of a cardiovascular event within a year, and up to 40% of these patients may be re-hospitalized. Within 5 years after a myocardial infarction, 18% of patients suffer a second ACS and 13% have got a stroke. Lipid-lowering therapy is an extremely important element of comprehensive management, both in primary and secondary prevention, and its main goal is to prevent or extend the time to the onset of heart or vascular disease and reduce the risk of cardiovascular events. A patient with a history of ACS belongs to the group of a very high risk of a cardiovascular event due to atherosclerosis. In this group of patients, low-density lipoprotein cholesterol levels should be aimed below 55 mg/dl (1.4 mmol/l). Many scientific guidelines define the extreme risk group, which includes not only patients with two cardiovascular events within two years, but also patients with a history of ACS and additional clinical factors: peripheral vascular disease, multivessel disease (multilevel atherosclerosis), or multivessel coronary disease, or familial hypercholesterolemia, or diabetes with at least one additional risk factor: elevated Lp(a) >50 mg/dl or hsCRP >3 mg/l, or chronic kidney disease (eGFR <60 ml/min/1.73 m²). In this group of patients, the LDL-C level should be aimed at below 40 mg/dl (1.0 mmol/l). Achieving therapeutic goals in patients after ACS should occur as soon as possible. For this purpose, a high-dose potent statin should be added to the therapy at the time of diagnosis, and ezetimibe should be added if the goal is not achieved after 4-6 weeks. Combination therapy may be considered in selected patients from the beginning. After 4-6 weeks of combination therapy, if the goal is still not achieved, adding a proprotein convertase subtilisin/kexin type 9 protein inhibitor or inclisiran should be considered. In order to increase compliance with the recommendations, Polish Cardiac Society and Polish Lipid Society propose to attach in the patient's discharge letter a statement clearly specifying what drugs should be used and what LDL-C values should be achieved. It is necessary to cooperate between the patient and the doctor, to follow the recommendations and take medicines regularly, to achieve and maintain therapeutic goals.

Flecainide, similar to encainide and propafenone, is IC class antiarrhythmic, inhibiting Nav1.5 sodium channels in heart muscle cells and modulates cardiac conduction. Despite its over 40-year presence in clinical practice, strong evidence and well-known safety profile, flecainide distribution in Europe has not always been equal. In Poland, the drug has been available in pharmacies only since October this year, and previously it had to be imported on request. Flecainide can be used successfully in both the acute and chronic treatment of cardiac arrhythmias. The main indication for flecainide is the treatment of paroxysmal supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, atrioventricular re-entrant tachycardia and ventricular arrhythmias in patients without structural heart disease. Beyond that, it may be used in some supraventricular tachycardia in children and for sustained fetal tachycardia. Many studies indicate its efficacy comparable to or better than previously used drugs such as propafenone and amiodarone, depending on the indication. This review aims to highlight the most important clinical uses of flecainide in the light of the latest scientific evidence and to provide an overview of the practical aspects of treatment, including indications, off-label use, contraindications, areas of use, monitoring of treatment and most common complications, taking into account special populations: children and pregnant women.

There are reports documenting that electromagnetic waves generated by deep brain stimulation devices can interfere with cardiac pacemakers. This might be even a life-threatening problem in cardiac pacemaker-dependent patients. Herein, we present a case report on a patient with bilaterally implanted deep brain stimulation devices, who concomitantly had the indications for permanent cardiac pacing. The report shows that a leadless AV pacemaker may be a safe and reasonable option in these cases.

Study Objectives: The aim of the study was to evaluate of the quality of life, depression, anxiety levels, and physical activity in the groups after the implantation of an ICD or CRT-D., Methods: All subjects (111 CHF patients) underwent tests to assess the quality of life (NHP), the level of physical activity (IPAQ), the level of perceived stress (PSS), and the incidence of depression (BDI)., Results: After the implantation, physical activity (PA) of the patients from the primary prevention (PP) group remains unchanged, whereas in the secondary prevention (SP) group, it decreases noticeably. Physical activity is lower in the SP group in comparison with the PP group. There are no statistically significant differences in the level of depression. The scores in the second part of the NHP questionnaire indicate that the SP group significantly more often declare problems with housework and with social life than the PP group., Conclusions: 1. The type of prevention does not have an influence on the level of anxiety, stress, or depression. 2. The patients after implantation as SP are physically less active; lower PA is associated additionally with the higher NYHA class and chronic kidney disease. 3. The quality of life of the patients from SP group is at a lower level than patients from PP group.

Offering cardiac rehabilitation to people who can benefit most could improve the outcomes in the context of limited availability. We used cluster analysis to distinguish three patient groups based on clinical and laboratory variables and then compared the outcomes of 6-month outpatient cardiac rehabilitation between these groups. The outcomes included blood pressure, blood lipids, fasting blood glucose, and uric acid concertation in serum. Group 1 consisted primarily of men with obesity, increased blood pressure, favourable lipid profiles and increased fasting glucose. Group 2 consisted of men or women with normal weight, normal blood pressure, favourable lipid profiles, and normal fasting glucose. Group 3 consisted primarily of women with overweight, normal blood pressure, unfavourable lipid profiles, and normal fasting glucose. After 6 months of cardiac rehabilitation, blood lipids improved in group 3, whereas blood pressure improved in groups 1 and 3, but the outcomes did not change significantly in group 2. We did not see any effect of cardiac rehabilitation on fasting blood glucose and serum uric acid concentration in any group. Concentrations of glucose and uric acid did not change significantly in any group. In conclusion, an adequate selection of patients should maximise the benefits of cardiac rehabilitation.

Introduction: The impact of antibodies against Borrelia burgdorferi (BB) on the occurrence of cardiac arrhythmias in patients without typical symptoms of Lyme disease (LD) is largely unknown., Objectives: We aimed to assess the risk of atrial fibrillation (AF) and other atrial arrhythmias (AAs) in patients who tested positive for anti-LD antibodies., Patients and Methods: We included consecutive patients referred for the diagnosis and treatment of AAs who had no history of erythema migrans or other symptoms of LD. The presence of anti-BB antibodies (immunoglobulin [Ig] M and IgG) was assessed in each patient, and the diagnostic workup of cardiac arrhythmias was performed., Results: Of the 527 patients enrolled in the study, 292 (55%) were diagnosed with AAs, and we detected BB antibodies in 131 individuals (24.8%). The patients with a serological history of Borrelia infection were older (mean [SD], 55.6 [15.7] vs 50.3 [18.6] years; P = 0.01), had a higher probability of developing AF or other supraventricular arrhythmias (SAs) (66.4% vs 51.8%; P = 0.03), and had elevated levels of N‑terminal pro-B ‑type natriuretic peptide (NT‑proBNP) (58% vs 47.5%; P = 0.04). We also found an as-sociation between the occurrence of AF and other SAs in patients with anti-BB antibodies and elevated NT‑proBNP values, and the risk of AAs in these patients increased almost 3‑fold (P = 0.01)., Conclusion: Our data indicated an association between the exposure to Borrelia infection and the risk for AF and other AAs in the patients with elevated levels of NT‑proBNP, suggesting the need for a more efficacious diagnostic approach to patients with SAs, especially in LD‑endemic regions.

The aim of the SYNSEQ (Left Ventricular Synchronous vs. Sequential MultiSpot Pacing for CRT) study was to evaluate the acute hemodynamic response (AHR) of simultaneous (3P-MPP syn ) or sequential (3P-MPP seq ) multi-3-point-left-ventricular (LV) pacing vs. single point pacing (SPP) in a group of patients at risk of a suboptimal response to cardiac resynchronization therapy (CRT). Twenty five patients with myocardial scar or QRS ≤ 150 or the absence of LBBB (age: 66 ± 12 years, QRS: 159 ± 12 ms, NYHA class II/III, LVEF ≤ 35%) underwent acute hemodynamic assessment by LV + dP/dt max with a variety of LV pacing configurations at an optimized AV delay. The change in LV + dP/dt max (%ΔLV + dP/dt max ) with 3P-MPP syn (15.6%, 95% CI: 8.8%-22.5%) was neither statistically significantly different to 3P-MPP seq (11.8%, 95% CI: 7.6-16.0%) nor to SPP basal (11.5%, 95% CI:7.1-15.9%) or SPP mid (12.2%, 95% CI:7.9-16.5%), but higher than SPP apical (10.6%, 95% CI:5.3-15.9%, p = 0.03). AHR (defined as a %ΔLV + dP/dt max ≥ 10%) varied between pacing configurations: 36% (9/25) for SPP apical , 44% (11/25) for SPP basal , 54% (13/24) for SPP mid , 56% (14/25) for 3P-MPP syn and 48% (11/23) for 3P-MPP seq.Fifteen patients (15/25, 60%) had an AHR in at least one pacing configuration. AHR was observed in 10/13 (77%) patients with a LBBB but only in 5/12 (42%) patients with a non-LBBB ( p = 0.11). To conclude, simultaneous or sequential multipoint pacing compared to single point pacing did not improve the acute hemodynamic effect in a suboptimal CRT response population., Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT02914457., Competing Interests: VS, FLem, and BS were employed by the company Medtronic Inc. BM and RC were an employee of Medtronic and holds Medtronic stocks. MS, AM, AS, and FLey they received fees from commercial companies. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sterliński, Zakrzewska-Koperska, Maciąg, Sokal, Osca-Asensi, Wang, Spyropoulou, Maus, Lemme, Okafor, Stegemann, Cornelussen and Leyva.)

Background: Left atrial enlargement (LAE) predicts atrial fibrillation (AF) recurrence after cryoballoon-based pulmonary vein isolation (CB). Increased left ventricular wall thickness (LVWT) is pathophysiologically associated with LAE and atrial arrhythmias., Aims: To assess effect of increased LVWT on long-term outcomes of CB depending on coexistence of LAE., Methods: LAE was defined using either echocardiography ( > 48 cm³/m²) or multislice computer tomography (MSCT, ≥63 cm³/m²). Increased LVWT was echocardiographic septal/posterior wall thickness > 10 mm in males and > 9 mm in females. All patients achieved 2-year follow-up., Results: Of 250 patients (median [interquartile range, IQR] age of 61 [49.0-67.3] years; 30% female) with AF (40% non-paroxysmal), 66.5% had hypertension, and 27.2% underwent redo procedure. MSCT was done in 76%. During follow-up of 24.5 (IQR, 6.0-31.00) months the clinical success rate was 72%, despite 46% of patients having arrhythmia recurrence. Arrhythmia recurrence risk was increased by LAE and increased LVWT (hazard ratio [HR], 1.801; P = 0.002 and HR, 1.495; P = 0.036; respectively). The highest arrhythmia recurrence (61.9% at 2 years) was among patients with LAE and increased LVWT (33.6% of patients); intermediate (41.8%) among patients with isolated LAE; and lowest among patients with isolated increased LVWT or patients without LAE or increased LVWT (36.8% and 35.2% respectively, P = 0.004). After adjustment for body mass index (BMI), paroxysmal AF, CHA₂DS₂-VASc score, clinically-significant valvular heart disease, and cardiomyopathy, patients with LAE and concomitant increased LVWT diagnosis had a 1.8-times increased risk of arrhythmia recurrence (HR, 1.784; 95% confidence interval [CI], 1.017-3.130; P = 0.043)., Conclusion: Joint occurrence of LAE and increased LVWT is associated with the highest rate of arrhythmia recurrence after CB for AF.