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Purpose: Safety, efficacy, and patient comfort are the primary expectations during pulmonary vein isolation (PVI). We aimed to validate the combined advantages of pre-and periprocedural anticoagulation with non-vitamin K anticoagulants (NOACs) and rigorous left atrial appendage thrombus (LAAT) exclusion with computed tomography (CT). Moreover, we assessed the effect of pre-and periprocedural workups and the catheter ablation on the patients' quality of life. Methods: Consecutive patient population was collected between March 2018 and June 2020, who underwent cardiac CT within 24 hours before PVI to plan and guide the ablation and rule out LAAT. NOAC was omitted 24 hours before the ablation. If CT was inconclusive regarding the presence of a thrombus, transoesophageal echocargiography (TOE) was performed. All patients underwent PVI using point-by-point radiofrequency ablation. All patients had a routine follow up at 3 months. Quality of life questionnaires were obtained postprocedurally to evaluate the periprocedural discomfort of the patients. Results: 187 patients (63% male) underwent CT before PVI. TOE was used in 11 (6%) cases. None of the patients experienced stroke during or after the procedure. Based on the quality of life questionnaires, the worst patient discomfort was caused by atrial fibrillation itself, followed by the TOE, then the ablation procedure, hospital stay, and finally the CT. Complication rate was low, with no symptomatic thromboembolic event and 2.1% major bleeding event. Conclusion: Omitting NOAC 24 hours before the ablation might be safe. Moreover, patient comfort may be increased by replacing the TOE examination with CT.

Összefoglaló. A ritmuszavarok előfordulása gyakoribb a terhes nők esetén, mint a nem várandósok körében. A legtöbb esetben terápiás beavatkozás nélkül is kihordható a magzat. Hemodinamikai instabilitás és magzatkárosodáshoz vezető fetalis hypoperfusio jöhet létre, amennyiben tartós, magas kamrai frekvenciával járó epizódok jelentkeznek. Ezekben az esetekben a ritmuszavar megszüntetése indokolttá válhat. Az antiarrhythmiás gyógyszerek korlátozottan és nagy körültekintéssel alkalmazhatók a gyermeket várók körében, így a katéterablatio jelenthet biztonságos és használható alternatívát. Ezen beavatkozásokat hagyományosan röntgensugár segítségével végzik, ez azonban az ionizáló sugárzásnak a magzati fejlődésre gyakorolt hatása miatt magas rizikót jelentene. Több éve elérhető a szív-elektrofiziológiában az ún. zéró fluoroszkópiás ablatio, mely a pitvarfibrilláció kezelésében és más ritmuszavarok esetében egyaránt alkalmazható. A terheseknél alkalmazott eljárást két eseten keresztül mutatjuk be. A röntgensugár használatát, a jelen cikkben bemutatott beavatkozások esetén is, sikerült teljesen kiküszöbölnünk. Az első, 23 hetes gravid páciensnél recidív paroxysmalis supraventricularis tachycardia miatt végeztünk elektrofiziológiai vizsgálatot. E vizsgálat során atrioventricularis nodalis reentry tachycardiát igazoltunk és abláltunk sikerrel. Második esetbemutatásunkban egy anteroseptalis járulékos köteg katéterablatiós megoldását mutatjuk be. A terhesség során jelentkező, az anyára és/vagy magzatára veszélyt jelentő ritmuszavar esetén a háromdimenziós térképező rendszer (szükség esetén intracardialis ultrahangvizsgálattal kiegészítve) biztonságos és hatásos alternatívát jelent, olyan esetekben, ha röntgensugár nem használható. Orv Hetil. 2021; 162(41): 1643–1651. Summary. Arrhythmias are more common in pregnant women than in others. In most cases, the fetus can be delivered without therapeutic intervention. Hemodynamic instability and fetal hypoperfusion leading to fetal harm may occur if persistent episodes of high ventricular rate occur. In these cases, resolution of the arrhythmia may be advised. Antiarrhythmic drugs can be used with limitations and great caution in those expecting a child, so catheter ablation may be a safe and usable alternative. These interventions are traditionally performed using X-ray, however, due to the effect of ionizing radiation on fetal development, this would pose a high risk. Zero-fluoroscopic ablation has been available for several years in cardiac electrophysiology, which can be used both in the treatment of atrial fibrillation and in other arrhythmias. The procedure which we used in pregnant women is presented in two cases. We also managed to completely eliminate the use of X-ray during the interventions presented in this article. In the first case, a 23-week-old gravid patient underwent electrophysiological examination for recurrent paroxysmal supraventricular tachycardia. In the electrophysiological study, atrioventricular nodal reentry tachycardia was confirmed and successfully ablated. In our second case study, we present a catheter ablation for anteroseptal accessory pathway. Three-dimensional mapping system (supplemented with intracardiac ultrasound, if necessary), in the case of significant arrhythmia, is a safe and effective alternative where X-rays, which poses a risk to the mother and/or the fetus, cannot be used during pregnancy. Orv Hetil. 2021; 162(41): 1643–1651.

Aims Controversial results have been published regarding the influence of pulmonary vein (PV) anatomical variations on outcomes after pulmonary vein isolation (PVI). However, no data are available on the impact of PV orientation on the long-term success rates of point-by-point PVI. We sought to determine the impact of PV anatomy and orientation on atrial fibrillation (AF)-free survival in patients undergoing PVI using the radiofrequency point-by-point technique. Methods and results We retrospectively included 448 patients who underwent initial point-by-point radiofrequency ablation for AF at our department. Left atrial computed tomography angiography was performed before each procedure. PV anatomical variations, ostial parameters (area, effective diameter, and eccentricity), orientation, and their associations with 24-month AF-free survival were analysed. PV anatomical variations and ostial parameters were not predictive for AF-free survival (all P > 0.05). Univariate analysis showed that female sex (P = 0.025) was associated with higher rates of AF recurrence, ventral-caudal (P = 0.002), dorsal-cranial (P = 0.034), and dorsal-caudal (P = 0.042) orientation of the right superior PV (RSPV), on the other hand, showed an association with lower rates of AF recurrence, when compared with the reference ventral-cranial orientation. On multivariate analysis, both female sex [odds ratio (OR) 1.83, 95% CI 1.15–2.93, P = 0.011] and ventral-caudal RSPV orientation, compared with ventral-cranial orientation, proved to be independent predictors of 24-month AF recurrence (OR 0.37, 95% CI 0.19–0.71, P = 0.003). Conclusion Female sex and ventral-caudal RSPV orientation have an impact on long-term arrhythmia-free survival. Assessment of PV orientation may be a useful tool in predicting AF-free survival and may contribute to a more personalized management of AF.

Aims Unlike in atrial fibrillation ablation, there is a lack of appropriately sized and properly designed studies regarding outflow tract (OT) premature ventricular complex (PVC) ablation outcomes with contact force sensing (CFS) catheters. We aimed to compare the acute success-, complication-, and long-term recurrence rates of manual CFS catheters with traditional irrigated catheters (T) in OT PVC ablation. Methods and results Single-centre, propensity-matched data of 75–75 patients ablated for right-sided OT (RVOT) or left-sided OT (LVOT) PVCs in 2015–17 with CFS or T catheters were compared. Acute success rate, peri-procedural complications, post-procedural daily PVC burden, and long-term recurrence rates were compared on intention-to-treat basis. Acute success rate equalled 80% in both groups, with no difference in force values in the CFS group comparing successful or failed cases [12.0 (8.75–17.0) vs. 16.0 (10.25–22.25) g, P = 0.21]. There were three cases of pseudo-aneurysm and one cardiac tamponade. PVC burden fell significantly from baseline 22 (15–30)% to 2 (0–10)% (P Conclusion Both types of catheters can effectively reduce OT PVC burden with minimal serious complication rates. Ablation with CFS or T catheters gives similar acute- and long-term results.

Implantation numbers of conventional antibradycardia pacemakers (PM), implantable cardioverter defibrillators (ICD) and cardiac resynchronisation therapy PMs and ICDs (CRT-P and D) have shown a minimal increase till 2017. Between 2017–2019 the implantation numbers have remained on a steady state level, the numbers of ILR, CRT-D and conventional ICDs have shown a slight increase, moreover the ratio of CRT-P against CRT-D has decreased. Year of 2020 was a special year due to the SARS-CoV2 pandemic, since the primary implantations without urgent indication have been limited and been postponed. In the last 2 years close speciality cooperation between the National Health Fund and the Board of the Hungarian Society of Cardiology Working Group of Cardiac Pacing and Electrophysiology established the reimbursement of implantation of leadless pacemakers and subcutaneous ICDs. Since 2020 a new special reimbursement possibility for His-bundle pacing modality for chronic heart failure patients without LBBB.

A leggyakoribb tartós ritmuszavar, a pitvarfibrilláció (PF) prevalenciája a 4%-ot is elérheti a 20 évnél idősebb populációban. A PF emeli a halálozás, a szívelégtelenség, a depresszió és a demencia kialakulásának a kockázatát, rontja az életminőséget, így mindezek által jelentős terhet ró a betegekre, orvosokra és az egészségügyi rendszerre egyaránt. Jelen közlemény az Európai Kardiológus Társaság (ESC) 2020-ban publikált irányelveit foglalja össze a PF ellátására vonatkozóan.

Absztrakt: A szívműtét utáni pacemaker-terápiát igénylő ritmuszavarok kérdésköre jól ismert és tanulmányozott, problematikája komoly kihívások elé állítja a szakmát. Írásunk célja összefoglalni a jelenleg érvényes nemzetközi ajánlásokat és a jelentős tanulmányok eredményeit, valamint ismertetni kórházunk ez irányú tapasztalatait. Bemutatjuk a lényeges európai és amerikai iránymutatásokat és az eddigi meghatározó tanulmányok főbb eredményeit. Közreadjuk a Zala Megyei Szent Rafael Kórházban 2014. 01. 01. és 2018. 12. 31. között operált 2735 beteg közül a műtét utáni egy hónapon belül végleges pacemaker-implantáción átesettek adatait, és összevetjük azokat a nemzetközi eredményekkel. A nemzetközi irodalom adatai alapján a korai posztoperatív időszakban a végleges pacemaker-beültetés aránya átlagosan 1,5–5% körül mozog a szívsebészetben, és ez az arány a későbbiekben tovább nő. Az ingerületvezetési zavarok kialakulásáról részletes információkkal rendelkezünk, számos prediktív tényező került azonosításra, az aktuális guideline-ok mégis csak hozzávetőleges iránymutatást kínálnak a kérdésben. A korai perioperatív időszak (1 hónap) során osztályunkon 15 esetben (0,55%) volt szükség végleges pacemaker implantációjára, és a késői utánkövetés során 6 beteg bírt továbbra is pacemakerdependens ritmuszavarral. A perioperatív ritmuszavarok gyakori és komoly következményekkel járó szövődmények a szívsebészetben, nehezítik a betegek gyors felépülését, terhet rónak a betegellátásra, és költségtöbbletet jelentenek. A végleges pacemaker-beültetés aránya a Zala Megyei Szent Rafael Kórházban alacsonynak mondható. A késői utánkövetés alapján a betegeknek így is csak töredéke pacemakerdependens. Az eddig rendelkezésre álló információk és egy hazai, nagy esetszámú, prospektív vizsgálat segítségével szükséges lenne standardizált protokoll kialakítása a témában, mely mérvadó lenne a szakma számára. Orv Hetil. 2020; 161(31): 1271–1280.

Comparative data are virtually missing about the performance of different electro-anatomical mapping (EAM) system platforms on outflow tract (OT) premature ventricular complex (PVC) ablation outcomes with manual ablation catheters. We aimed to compare the acute success-, complication-, and long-term recurrence rates of impedance-based (IMP) and magnetic field-based (MAG) EAM platforms in manual OT PVC ablation. Single-centre, propensity score matched data of 39–39 patients ablated for OT PVCs in 2015–17 with IMP or MAG platforms were analysed. Acute success rate, peri-procedural complications, post-ablation daily PVC burden, and long-term recurrence rates were compared on intention-to-treat basis. Acute success rate was similar in the IMP and MAG group (77 vs. 82%, p = 0.78). There was a single case of femoral pseudo-aneurysm and no cardiac tamponade occurred. PVC burden fell significantly from baseline 24.0% [15.0–30.0%] to 3.3% [0.25–10.5%] (p p = 0.60). There was no significant difference in recurrence-free survival of the intention-to-treat cohort of the IMP and MAG groups (54 vs. 60%, p = 0.82, respectively) during 12 months of follow-up. Ablation with the aid of both impedance- and magnetic field-based EAM platforms can considerably reduce OT PVC burden and give similar acute- and long-term freedom from arrhythmia.

Introduction Catheter ablation is an established therapy for rhythm control in patients with drug-refractory atrial fibrillation (AF), however, recurrence is frequent particularly in persistent AF. There are no consistently confirmed predictors of AF recurrence after catheter ablation. Therefore, we aimed to study whether LAA volume (LAAV) and function influence the long-term recurrence of AF after catheter ablation, depending on AF type. Methods AF patients who underwent point-by-point radiofrequency catheter ablation after cardiac computed tomography (CT) were included in this analysis. LAAV and LAA orifice area were measured by CT. Uni- and multivariable Cox proportional hazard regression models were performed to determine the predictors of AF recurrence. Results In total, 561 AF patients (61.910.2 years, 34.9% females) were included in the study. Recurrence of AF was detected in 40.8% of the cases (34.6% in patients with paroxysmal and 53.5% in those with persistent AF) with a median recurrence-free time of 22.7 9.3-43.1 months. Patients with persistent AF had significantly higher iLAV, LAAV, LAA orifice area and lower LAA flow velocity, than those with paroxysmal AF. After adjustment left ventricular ejection fraction (LVEF)

Background and Aims. Resynchronization therapy (CRT) improves mortality and induces reverse remodeling in heart failure (HF) patients with reduced ejection fraction and wide QRS. Nonetheless, some patients do not improve despite the optimal medical therapy and right indications for device implantation. Therefore, finding biomarkers suitable for identification of those patients is crucial. Vitamin D plays a classic hormonal role in the regulation of bone metabolism and also has physiological functions in wide range of nonskeletal tissues. Based on recent studies, low levels of vitamin D seem to directly contribute to pathogenesis and worsening of HF. We planned to assess the role of vitamin D levels on clinical outcomes of HF patients undergoing CRT. Methods and Results. We enrolled 136 HF patients undergoing CRT. Total plasma vitamin D levels were measured at baseline and 6 months later. Primary endpoint was 5-year all-cause mortality; secondary endpoint was lack of good clinical response, defined as less than 15% increase of left ventricular ejection fraction after six months. During follow-up, 58 patients reached the primary, and 45 patients reached the secondary endpoint. Vitamin D levels less than 24.13 ng/mL predicted 5-year mortality (p=0.045) and poor clinical response (p=0.03) after adjusting to all significant baseline predictors. Conclusion. Our study showed that vitamin D deficiency has a significant impact in heart failure patients; it is an independent predictor of lack of midterm clinical response and long-term mortality in patients undergoing CRT. Therefore, monitoring vitamin D status of heart failure patients could be of clinical significance.

Abstract: Introduction: Levels of cardiac necroenzymes, high-sensitive troponin (hsTnT) and creatine kinase muscle-brain (CKMB) increase as a result of a myocardial damage following catheter ablation. Aim: To analyze the mid-term alteration of hsTnT and CKMB levels following radiofrequency ablation (RFCA) for atrial fibrillation (AF), atrial flutter (AFlu), AV-nodal reentry tachycardia (AVNRT) and electrophysiological studies (EPS) without ablation. Method: Patients undergoing RFCA for various indications and EPS were consecutively enrolled in our prospective study. Concentrations of hsTnT and CKMB were measured from serial blood samples directly before and after the procedure, 4 and 20 hours later and at 3 months follow-up. Results: Forty-seven patients (10 EPS, 12 AVNRT, 13 AFlu, 12 AF) with mean age of 55 ± 13 were included. hsTnT levels increased significantly in all groups after the procedures, while CKMB changed only in the AF group. hsTnT exceeded the reference value in all patients with ablation and in 80% of patients with EPS 4 hours post-ablation. Peak average hsTnT levels for EPS, AVNRT, AFlu were 24 ± 11, 260 ± 218 and 541 ± 233 ng/L, respectively. The highest hsTnT level was measured in the AF group (799 ± 433 ng/L). We found a positive correlation between hsTnT levels and ablation time after RFCA. Conclusions: The hsTnT levels significantly change after EPS and RFCA, in all patients who underwent ablation, and in 80% of those with EPS had hsTnT positivity in the early post-procedural phase. hsTnT levels depended significantly on the type of the subgroups and correlated with the ablation time. Awareness of those observations is essential to correctly interpret elevated hsTnT levels following RFCA. Orv Hetil. 2019; 160(14): 540–548.

Aims Atrial fibrillation (AF) ablation has made huge progress with respect to innovation, efficacy, and safety, however, complications are still present. Recent studies examined various predictors of complications. However, limited data exist regarding the role of a repeat procedure. Our aim was the prospective evaluation of the incidence and predictors of complications related to AF ablation procedures in consecutive patients, including repeat procedures. Methods and results All ablation procedures for AF between January 2013 and December 2015 were analysed in our electrophysiology laboratory. During the study period 1243 procedures were analysed [394 female, median age 62 (55–69)]. Overall complication rate was 6.84%, major complication rate was 2.82%. Major complications were the following: 18 pericardial tamponades; 5 pseudoaneurysms; 1 arteriovenous fistula; 6 thromboembolic cerebrovascular events; 3 pulmonary vein stenosis; and 2 atrioventricular blocks. No atrio-oesophageal fistula or procedure related death occurred. Univariate analysis for overall complications showed that age ≥ 65 years (P = 0.0231), female gender (P = 0.0438), hypertension (P = 0.0488), CHA2DS2-VASc score ≥ 2 (P = 0.0156), and previous AF ablation procedure (P

ObjectivesThe association between obesity and atrial fibrillation (AF) is well-established. We aimed to evaluate the impact of index body mass index (BMI) on AF recurrence at 12 months following catheter ablation using propensity-weighted analysis. In addition, periprocedural complications and fluoroscopy details were examined to assess overall safety in relationship to increasing BMI ranges.MethodsBaseline, periprocedural and follow-up data were collected on consecutive patients scheduled for AF ablation. There were no specific exclusion criteria. Patients were categorised according to baseline BMI in order to assess the outcomes for each category.ResultsAmong 3333 patients, 728 (21.8%) were classified as normal (BMI 2), 1537 (46.1%) as overweight (BMI 25.5–29.0 kg/m2) and 1068 (32.0%) as obese (BMI ≥30.0 kg/m2). Procedural duration and radiation dose were higher for overweight and obese patients compared with those with a normal BMI (p=0.002 and p2led to a 1.2-fold increased likelihood of experiencing recurrent AF at 12-months follow-up as compared with overweight patients (HR 1.223; 95% CI 1.047 to 1.429; p=0.011), while no significant correlation was found between overweight and normal BMI groups (HR 0.954; 95% CI 0.798 to 1.140; p=0.605) and obese versus normal BMI (HR 1.16; 95% CI 0.965 to 1.412; p=0.112).ConclusionsPatients with a baseline BMI ≥30 kg/m2have a higher recurrence rate of AF following catheter ablation and therefore lifestyle modification to target obesity preprocedure should be considered in these patients.

Funding Acknowledgements Type of funding sources: None. Background Catheter ablation is the cornerstone for rhythm control in patients with drug-refractory atrial fibrillation (AF). Baseline predictors of AF recurrence after catheter ablation are well established, such as female gender and left atrial enlargement. The role of the spatial relationship between the left superior pulmonary vein (LSPV) and left atrial appendage (LAA) is unknown. Purpose We sought to evaluate whether juxtaposed LSPV and LAA plays a role in AF recurrence after catheter ablation for paroxysmal AF. Methods Consecutive patients, who underwent point-by-point radiofrequency catheter ablation for paroxysmal AF at our hospital between January of 2014 and December of 2017, were enrolled in the study. All patients underwent pre-procedural cardiac CT-angiography (CTA) for the assessment of left atrial (LA) and pulmonary vein (PV) anatomy. Abutting LAA-LSPV was defined as cases when LSPV touched the posterior aspect of LAA (distance less than 2 mm). Results We included 428 patients (60.7 ± 10.8 years, 35.5% female). AF recurrence rate was 33.4% with a median recurrence-free time of 21.2 (IQR = 8.8-43.0) months. In the univariate analysis, female sex (HR = 1.45; 95%CI = 1.04-2.01; p = 0.028), LA volume (HR = 1.01; 95%CI = 1.00-1.01; p = 0.042), and cases when LSPV touched the posterior wall of LAA (HR = 1.53; 95%CI = 1.09-2.14; p = 0.013) were associated with AF recurrence. In the multivariate analysis, female sex (adjusted HR = 1.55; 95%CI = 1.06-2.28; p = 0.024), LA volume (adjusted HR = 1.01; 95%CI = 1.00-1.02; p = 0.028), and abutting LAA-LSPV (adjusted HR = 1.60; 95%CI = 1.13-2.50; p = 0.008) remained significant predictors of AF recurrence. Conclusion Female gender, higher LA volume, and abutting LSPV and LAA predispose patients to have a higher chance for arrhythmia recurrence after catheter ablation for paroxysmal AF.

Objective Pulmonary vein isolation (PVI) is the cornerstone of the interventional treatment of atrial fibrillation (AF). Traditionally, during these procedures the catheters are guided by fluoroscopy, which poses a risk to the patient and staff by ionizing radiation. Our aim was to describe our experience in the implementation of an intracardiac echocardiography (ICE) guided zero fluoroscopic (ZF) ablation approach to our routine clinical practice. Methods We developed a simplified ICE guided technique to perform ablation procedures for AF, with the aid of a 3D electroanatomical mapping system. The workflow was implemented in two phases: (1) the Introductory phase, where the first 16 ZF PVIs were compared with 16 cases performed with fluoroscopy and (2) the Extension phase, where 71 consecutive patients (including repeat procedures) with ZF approach were included. Standard PVI (and redoPVI) procedures were performed, data on feasibility of the ZF approach, complications, acute and 1-year success rates were collected. Results In the Introductory phase, 94% of the procedures could be performed with complete ZF with a median procedure time of 77.5 (73.5–83) minutes. In one case fluoroscopy was used to guide the ICE catheter to the atrium. There was no difference in the complication, acute and 1-year success rates, compared with fluoroscopy guided procedures. In the Extension phase, 97% of the procedures could be completed with complete ZF. In one case fluoroscopy was used to guide the transseptal puncture and in another to position the ICE catheter. Acute success of PVI was achieved in all cases, 64.4% patients were arrhythmia free at 1-year. Acute major complications were observed in 4 cases, all of these occurred in the redo PVI group and consisted of 2 tamponades, 1 transient ischemic attack and 1 pseudoaneurysm at the puncture site. The procedures were carried out by all members of the electrophysiology unit in the Extension phase, including less experienced operators and electrophysiology fellows (3 physicians) under the supervision of the senior electrophysiologist. Consequently, procedure times became longer [90 (75–105) vs 77.5 (73.5–85) min, p = 0.014]. Conclusions According to our results, a ZF workflow of AF ablations can be successfully implemented into the routine practice of an electrophysiology laboratory, without compromising safety and effectivity.

Összefoglaló. A ritmuszavarok előfordulása gyakoribb a terhes nők esetén, mint a nem várandósok körében. A legtöbb esetben terápiás beavatkozás nélkül is kihordható a magzat. Hemodinamikai instabilitás és magzatkárosodáshoz vezető fetalis hypoperfusio jöhet létre, amennyiben tartós, magas kamrai frekvenciával járó epizódok jelentkeznek. Ezekben az esetekben a ritmuszavar megszüntetése indokolttá válhat. Az antiarrhythmiás gyógyszerek korlátozottan és nagy körültekintéssel alkalmazhatók a gyermeket várók körében, így a katéterablatio jelenthet biztonságos és használható alternatívát. Ezen beavatkozásokat hagyományosan röntgensugár segítségével végzik, ez azonban az ionizáló sugárzásnak a magzati fejlődésre gyakorolt hatása miatt magas rizikót jelentene. Több éve elérhető a szív-elektrofiziológiában az ún. zéró fluoroszkópiás ablatio, mely a pitvarfibrilláció kezelésében és más ritmuszavarok esetében egyaránt alkalmazható. A terheseknél alkalmazott eljárást két eseten keresztül mutatjuk be. A röntgensugár használatát, a jelen cikkben bemutatott beavatkozások esetén is, sikerült teljesen kiküszöbölnünk. Az első, 23 hetes gravid páciensnél recidív paroxysmalis supraventricularis tachycardia miatt végeztünk elektrofiziológiai vizsgálatot. E vizsgálat során atrioventricularis nodalis reentry tachycardiát igazoltunk és abláltunk sikerrel. Második esetbemutatásunkban egy anteroseptalis járulékos köteg katéterablatiós megoldását mutatjuk be. A terhesség során jelentkező, az anyára és/vagy magzatára veszélyt jelentő ritmuszavar esetén a háromdimenziós térképező rendszer (szükség esetén intracardialis ultrahangvizsgálattal kiegészítve) biztonságos és hatásos alternatívát jelent, olyan esetekben, ha röntgensugár nem használható. Orv Hetil. 2021; 162(41): 1643-1651. Summary. Arrhythmias are more common in pregnant women than in others. In most cases, the fetus can be delivered without therapeutic intervention. Hemodynamic instability and fetal hypoperfusion leading to fetal harm may occur if persistent episodes of high ventricular rate occur. In these cases, resolution of the arrhythmia may be advised. Antiarrhythmic drugs can be used with limitations and great caution in those expecting a child, so catheter ablation may be a safe and usable alternative. These interventions are traditionally performed using X-ray, however, due to the effect of ionizing radiation on fetal development, this would pose a high risk. Zero-fluoroscopic ablation has been available for several years in cardiac electrophysiology, which can be used both in the treatment of atrial fibrillation and in other arrhythmias. The procedure which we used in pregnant women is presented in two cases. We also managed to completely eliminate the use of X-ray during the interventions presented in this article. In the first case, a 23-week-old gravid patient underwent electrophysiological examination for recurrent paroxysmal supraventricular tachycardia. In the electrophysiological study, atrioventricular nodal reentry tachycardia was confirmed and successfully ablated. In our second case study, we present a catheter ablation for anteroseptal accessory pathway. Three-dimensional mapping system (supplemented with intracardiac ultrasound, if necessary), in the case of significant arrhythmia, is a safe and effective alternative where X-rays, which poses a risk to the mother and/or the fetus, cannot be used during pregnancy. Orv Hetil. 2021; 162(41): 1643-1651.

The issue of postoperative arrhythmias requiring pacemaker therapy is widely studied in the field of cardiac surgery and it is a complex perioperative problem. The aim of this paper is to summarize the relevant international guidelines and recommendations and to present our hospital's experience. We present the current, decisive recommendations and important studies, and present patients who underwent pacemaker implantation within one month after cardiac surgery between 01. 01. 2014 and 31. 12. 2018 in our hospital and compare them with the international findings. According to the international literature, the rate of permanent pacemaker implantation after cardiac surgery ranges from about 1.5% to 5%, and this rate seems to increase later. We have detailed information and many identified predictors about the development of conduction disturbances, but the current guidelines provide only weak recommendations. In the early perioperative period (1 month), pacemaker implantation was required in 15 cases (0.55%); in the course of long-term follow-up, 6 patients were still pacemaker-dependent. Perioperative arrhythmias are frequent and serious complications after cardiac surgery, prolong patient recovery time and put financial burden on the hospitals. The rate of need for a permanent pacemaker is low in our hospital, and in the late follow-up we can find only a small part of patients with pacemaker dependency. It would be necessary to start a prospective study and to develop a standardized protocol based on the information currently available. This would be a useful and authoritative help for the postoperative care in cardiac surgery. Orv Hetil. 2020; 161(31): 1271-1280.

Aims There are previous studies on quality of life (QoL) in cardiac resynchronization therapy (CRT) patients; however, there are no data with the short EuroQol-five dimensions (EQ-5D) questionnaire predicting outcomes. We aimed to assess the predictive role of baseline QoL and QoL change at 6 months after CRT with EQ-5D on 5-year mortality and response. Methods and results In our prospective follow-up study, 130 heart failure (HF) patients undergoing CRT were enrolled. Clinical evaluation, echocardiography, and EQ-5D were performed at baseline and at 6 months of follow–up, continued to 5 years. Primary endpoint was all-cause mortality at 5 years. Secondary endpoints were (i) clinical response with at least one class improvement in New York Heart Association without HF hospitalization and (ii) reverse remodelling with 15% reduction in left ventricular end-systolic volume at 6 months. Fifty-four (41.5%) patients died during 5 years, 85 (65.3%) clinical responders were identified, and 63 patients (48.5%) had reverse remodelling. Baseline issues with mobility were associated with lower response [odds ratio (OR) 0.36, 95% confidence interval (CI) 0.16–0.84; P = 0.018]. Lack of reverse remodelling correlated with self-care issues at baseline (OR 0.10, 95% CI 0.01–0.94; P = 0.04). Furthermore, self-care difficulties [hazard ratio (HR) 2.39, 95% CI 1.17–4.86; P = 0.01) or more anxiety (HR 1.51, 95% CI 1.00–2.26; P = 0.04) predicted worse long-term survival. At 6 months, mobility (HR 3.95, 95% CI 1.89–8.20; P

Background Treatment of left ventricular electrode dislocation and phrenic nerve stimulation remains an issue in the era of new electrode designs. Methods Safety and efficacy of minimal invasive lead repositioning and pocket opening reposition procedures were evaluated between December 2005 and December 2012 at our center. Minimal invasive method was developed and widely utilized at our center to treat phrenic nerve stimulation. The distally positioned left ventricular lead is looped around by a deflectable catheter in the right atrium introduced from the femoral vein access and then pulled back. Coronary stent implantation was used afterwards for lead stabilization in some patients. Results 42 minimal invasive and 48 electrode repositions with pacemaker pocket opening were performed at 77 patients for left ventricular lead problems. Minimal invasive reposition could be carried out successfully in 69% of (29 patients) cases. Note that in 14.3% of the cases (six patients) minimal invasive procedures were acutely unsuccessful and crossover was necessary. In 16.6% of the cases (seven patients) lead issues were noted later during follow-up. Opening of the pocket could be carried out successfully in 81.2% (39 patients) and was unsuccessful acutely in 6.25% (three patients). Repeated dislocation was noticed, 12.5%, in this group (six patients). Complication during minimal invasive procedures was electrode injury in one case. Pocket openings were associated with several complications: atrial fibrillation, pericardial effusion, fever, hematoma, and right ventricular electrode dislodgement. Conclusion Minimal invasive procedure-as the first line approach-is safe and feasible for left ventricular electrode repositioning in selected cases.

Background Cardiac resynchronization therapy (CRT) in chronic heart failure has been shown to improve mortality and morbidity. However, comprehensive data are not available as concerns how circulating biomarkers reflecting different organ functions, such as serum uric acid, blood urea nitrogen (BUN), albumin, cholesterol, or various liver enzymes, change over time as a consequence of CRT. The aim of this prospective study was to overview these possible changes. Methods A total of 20 routine laboratory parameters were measured in 122 control subjects and in 129 patients with chronic heart failure before CRT, 6 months, and 2 years later. Results The levels of serum uric acid [before: 432 (331–516) mmol/L, 6-month: 372 (304–452) mmol/L, 2-year: 340 (290–433) mmol/L; p

Levels of cardiac necroenzymes, high-sensitive troponin (hsTnT) and creatine kinase muscle-brain (CKMB) increase as a result of a myocardial damage following catheter ablation.To analyze the mid-term alteration of hsTnT and CKMB levels following radiofrequency ablation (RFCA) for atrial fibrillation (AF), atrial flutter (AFlu), AV-nodal reentry tachycardia (AVNRT) and electrophysiological studies (EPS) without ablation.Patients undergoing RFCA for various indications and EPS were consecutively enrolled in our prospective study. Concentrations of hsTnT and CKMB were measured from serial blood samples directly before and after the procedure, 4 and 20 hours later and at 3 months follow-up.Forty-seven patients (10 EPS, 12 AVNRT, 13 AFlu, 12 AF) with mean age of 55 ± 13 were included. hsTnT levels increased significantly in all groups after the procedures, while CKMB changed only in the AF group. hsTnT exceeded the reference value in all patients with ablation and in 80% of patients with EPS 4 hours post-ablation. Peak average hsTnT levels for EPS, AVNRT, AFlu were 24 ± 11, 260 ± 218 and 541 ± 233 ng/L, respectively. The highest hsTnT level was measured in the AF group (799 ± 433 ng/L). We found a positive correlation between hsTnT levels and ablation time after RFCA.The hsTnT levels significantly change after EPS and RFCA, in all patients who underwent ablation, and in 80% of those with EPS had hsTnT positivity in the early post-procedural phase. hsTnT levels depended significantly on the type of the subgroups and correlated with the ablation time. Awareness of those observations is essential to correctly interpret elevated hsTnT levels following RFCA. Orv Hetil. 2019; 160(14): 540-548.Absztrakt: Bevezetés: Ismert, hogy katéteres ablatio által okozott szívizom-károsodás következtében megnő a szívizom-specifikus nekroenzimek koncentrációja. Célkitűzés: A magas érzékenységű troponin T (hsTnT) és a szívizom-specifikus kreatin-kináz (CKMB) szintje középtávú változásának elemzése pitvarfibrilláció (PF), pitvari flutter (PFlu), AV-csomó reentry tachycardia (AVNRT) rádiófrekvenciás katéteres ablatióját követően, illetve elektrofiziológiai vizsgálat után. Módszer: Rádiófrekvenciás ablatión, illetve elektrofiziológiai vizsgálaton átesett betegeket vontunk be konszekutívan prospektív vizsgálatunkba. Sorozatvérmintákból meghatároztuk a hsTnT- és a CKMB-szinteket a procedúra előtt és után közvetlenül, majd 4 és 20 órával és 3 hónappal később. Eredmények: Negyvenhét, 55 ± 13 év átlagéletkorú beteget (10 elektrofiziológiai vizsgálat, 12 AVNRT, 13 PFlu és 12 PF) vontunk be vizsgálatunkba. A hsTnT-szintek minden csoportban szignifikánsan megemelkedtek a beavatkozást követően, a CKMB csak a PF-csoportban változott. A hsTnT-szint négy órával a beavatkozást követően az összes ablatión átesett betegnél és az elektrofiziológiai vizsgálaton átesett betegek 80%-ánál meghaladta a referenciatartományt. A legmagasabb átlagos hsTnT-koncentrációk EFV, AVNRT, PFlu esetén 24 ± 11, 260 ± 218 és 541 ± 233 ng/l-nek bizonyultak. A legmagasabb hsTnT-szint a PF-ablatiós csoportban volt kimutatható 20 órával az ablatio után (799 ± 433 ng/l). Pozitív korrelációt találtunk a rádiófrekvenciás ablatiót követő hsTnT-szint és az ablatio ideje között. Következtetések: A hsTnT alkalmas a rádiófrekvenciás ablatio és az elektrofiziológiai vizsgálat utáni myocardialis necrosis vizsgálatára, az ablatión átesett betegek mindegyikénél; elektrofiziológiai vizsgálat után 80%-ban pozitív a hsTnT. A necrosis mértéke jelentősen függ a beavatkozás típusától, és korrelál az ablatio kiterjedtségével. A fentiekben leírt megfigyelések iránymutatásként szolgálnak a rádiófrekvenciás ablatio utáni hsTnT-szint megfelelő értelmezéséhez. Orv Hetil. 2019; 160(14): 540–548.

Electroanatomical mapping is a useful tool during the ablation of atrial fibrillation. Respiratory movement might influence the mapping accuracy and merging. This study aims to investigate the effect of respiratory gating on the accuracy of magnetic-field-based electroanatomical mapping under spontaneous respiration. Fifty-one consecutive patients (35 male, aged 30–78 years) who underwent left atrial radiofrequency catheter ablation due to atrial fibrillation were included. Electroanatomical mapping was performed with CARTO 3 System under conscious sedation. Respiratory gating was achieved with the AccuResp algorithm (Biosense Webster). Average surface match and maximum distance of the pre-acquired and electroanatomical maps, as well as left atrial volume, were recorded with and without respiratory gating after merging. The average surface match of the electroanatomical map with the left atrial reconstruction was significantly better with respiratory gating than without using the algorithm (3.81 ± 1.09 vs 4.11 ± 1.61 mm, p = 0.0119). It was not dependent of the rhythm during mapping or the image modality used for left atrial reconstruction. The maximal distance between the two maps did not depend on the use of the algorithm (19.81 ± 6.24 mm for gated and 20.87 ± 7.99 mm for non-gated, p = 0.3161). Left atrial volume of the map was significantly lower when using the respiratory compensation module (106.3 ± 31.6 vs 127.0 ± 36.4 ml, p

The authors present the history of a 62-year-old man on continuous rivaroxaban therapy who was scheduled for pulmonary vein isolation due to persistent atrial fibrillation. Preoperative transesophageal echocardiography detected the presence of left atrial appendage thrombus. Thrombophilia tests showed that the patient was heterozygous carrier of the methylene-tetrahydrofolate reductase gene mutation. The authors hypothesized that a direct thrombin inhibitor might exert a more appropriate effect against thrombosis in this case and, therefore, a switch to dabigatran was performed. After two months of anticoagulation with the direct thrombin inhibitor and folic acid supplementation the thrombus resolved. The authors underline that thrombus formation may develop in atrial fibrillation even if the patient is adequately treated with rivaroxaban. This case suggests, that methylene-tetrahydrofolate reductase gene mutation may modulate the efficacy of direct Xa factor inhibitors. According to this case history, dabigatran may be an effective therapeutic option in resolving established thrombus. Orv. Hetil., 2016, 157(4), 154–156.

Lead dislocations of pacemaker systems are reported in all and even in high-volume centers. Repeated procedures necessitated by lead dislocations are associated with an increased risk of complications. We investigated a minimal invasive method for right atrial and ventricular lead repositioning. The minimal invasive method was applied only when passive fixation leads were implanted. During the minimal invasive procedure, a steerable catheter was advanced through the femoral vein to move the distal end of the lead to the appropriate position. Retrospective data collection was conducted in all patients with minimal invasive and with conventional method, at a single center between September 2006 and December 2012. Forty-five minimal invasive lead repositionings were performed, of which eight were acutely unsuccessful and nine electrodes re-dislocated after the procedure. One hundred two leads were repositioned with opening of the pocket during the same time, including the ones with unsuccessful minimal invasive repositionings. One procedure was acutely unsuccessful in this group and four re-dislocations happened. A significant difference of success rates was noted (66.6% vs. 95.1%, p = 0.001). One complication was observed during the minimal invasive lead repositionings (left ventricular lead microdislodgement). Open-pocket procedures showed different types of complications (pneumothorax, subclavian artery puncture, pericardial effusion, hematoma, fever, device-associated infection which necessitated explantation, atrial lead dislodgement while repositioning the ventricular one, deterioration of renal function). The minimal invasive method as a first alternative is safe and feasible. In those cases when it cannot be carried out successfully, the conventional method is applicable.

Early recognition of ventricular tachycardias (VTs) with epicardial circuits is crucial. Surface electrocardiogram (ECG) suggesting an epicardial origin could guide ablation procedures and increase success rates. A 35-year-old female patient with VT treated by combined epicardial and endocardial ablation approach is presented in this report, and the role of surface electrocardiogram and timing of epicardial access is discussed.

Treatment of left ventricular electrode dislocation and phrenic nerve stimulation remains an issue in the era of new electrode designs.Safety and efficacy of minimal invasive lead repositioning and pocket opening reposition procedures were evaluated between December 2005 and December 2012 at our center. Minimal invasive method was developed and widely utilized at our center to treat phrenic nerve stimulation. The distally positioned left ventricular lead is looped around by a deflectable catheter in the right atrium introduced from the femoral vein access and then pulled back. Coronary stent implantation was used afterwards for lead stabilization in some patients.42 minimal invasive and 48 electrode repositions with pacemaker pocket opening were performed at 77 patients for left ventricular lead problems. Minimal invasive reposition could be carried out successfully in 69% of (29 patients) cases. Note that in 14.3% of the cases (six patients) minimal invasive procedures were acutely unsuccessful and crossover was necessary. In 16.6% of the cases (seven patients) lead issues were noted later during follow-up. Opening of the pocket could be carried out successfully in 81.2% (39 patients) and was unsuccessful acutely in 6.25% (three patients). Repeated dislocation was noticed, 12.5%, in this group (six patients). Complication during minimal invasive procedures was electrode injury in one case. Pocket openings were associated with several complications: atrial fibrillation, pericardial effusion, fever, hematoma, and right ventricular electrode dislodgement.Minimal invasive procedure-as the first line approach-is safe and feasible for left ventricular electrode repositioning in selected cases.

The chronic inflammation plays an important role in heart failure and complement components might be useful markers of the prognosis. We set out to evaluate their predictive value in the clinical outcomes of patients with cardiac resynchronization therapy (CRT).We determined the complement levels C3, C3a, sC5b-9 and also the N-terminus of the prohormone brain natriuretic peptide (NT-proBNP) of 126 heart failure patients in a prospective, single-center observational study before and 6 months after CRT implantation.CRT reduced the C3a [212.5 (148.2-283.6) vs. 153 (119.8-218.3) ng/mL, p 0.0001] and the sC5b-9 levels [296.9 (234.2-358.8) vs. 255.1 (210.1-319.0) ng/mL, p = 0.0006], but not the total C3 levels [1.43 (1.26-1.61) vs. 1.38 (1.23-1.57) g/L, p = 0.57]. C3a predicted the 5-year mortality of the patients [C3a 165 ng/mL hazard ratio = 4.21 (1.65-10.72), p = 0.003] independent of the NT-proBNP and other factors. After reclassification, we observed a significant net reclassification improvement [NRI = 0.71 (0.43-0.98), p 0.0001] and integrated discrimination improvement [IDI = 0.08 (0.03-0.12), p = 0.0002].In patients with CRT, elevated C3a levels increase the risk of mortality independent of the NT-proBNP levels or other factors. CRT exerts anti-inflammatory effect by reducing the complement activation.

The authors present the history of a 62-year-old man on continuous rivaroxaban therapy who was scheduled for pulmonary vein isolation due to persistent atrial fibrillation. Preoperative transesophageal echocardiography detected the presence of left atrial appendage thrombus. Thrombophilia tests showed that the patient was heterozygous carrier of the methylene-tetrahydrofolate reductase gene mutation. The authors hypothesized that a direct thrombin inhibitor might exert a more appropriate effect against thrombosis in this case and, therefore, a switch to dabigatran was performed. After two months of anticoagulation with the direct thrombin inhibitor and folic acid supplementation the thrombus resolved. The authors underline that thrombus formation may develop in atrial fibrillation even if the patient is adequately treated with rivaroxaban. This case suggests, that methylene-tetrahydrofolate reductase gene mutation may modulate the efficacy of direct Xa factor inhibitors. According to this case history, dabigatran may be an effective therapeutic option in resolving established thrombus.

There is remarkable interest on identifying factors predicting outcome after VT ablation. Our aim was to determine predictors of long-term all-cause mortality in patients undergoing VT ablation. Between 1st of January 2009 and 31st of December 2015 VT ablation was performed in 151 patients with

Idiopathic fascicular ventricular tachycardia is an important and not very rare cardiac arrhythmia with specific electrocardiographic features and therapeutic options. Ventricular tachycardia is characterized by relatively narrow QRS complex and right bundle branch block pattern. The QRS axis depends on which fascicle is involved in the re-entry. Left axis deviation is noted with left posterior fascicular tachycardia and right axis deviation with left anterior fascicular tachycardia. A left septal fascicular tachycardia with normal QRS axis is also possible. Idiopathic fascicular tachycardia is usually seen in individuals without structural heart disease. Response to verapamil is an important feature of fascicular tachycardia. In some cases intravenous adenosine may also terminate the arrhythmia. During electrophysiology study, presystolic or diastolic potentials precede the QRS, presumed to originate from the Purkinje fibers. The potentials can be recorded during sinus rhythm and ventricular tachycardia in many patients with fascicular tachycardia. This potential (so-called Purkinje potential) has been used as a guide to catheter ablation. Correct diagnosis of fascicular tachycardia is very important because catheter ablation is very effective in the treatment of this type of ventricular tachycardia. In this review, we describe three patients with idiopathic ventricular tachycardia and their successful catheter ablation, and summarize the actual knowledge of the diagnosis and management of this special ventricular tachycardia.

Clinical significance of resistance to aspirin and thienopyridine therapy is poorly defined. The authors aimed to evaluate whether more effective antiplatelet therapy is associated with better outcome in patients on dual-antiplatelet treatment. Using optical aggregometer, maximal platelet aggregation values were measured with induction of adenosine diphosphate, collagen, and adrenaline 30 ± 5 days after coronary stent implantation in 134 patients. Markers of platelet activation were also analyzed with fluorescent immunoassay in 57 patients. After 10 months of follow-up, 33 patients reached the composite endpoint of cardiovascular death, myocardial infarction, and revascularisation. Adenosine diphosphate-induced maximal aggregation values were in significant relationship with the development of major adverse cardiac events ( P < .01). Level of soluble P-selectin proved to be an independent risk factor of adverse outcome ( P < .05). As efficacy of thienopyridine therapy showed significant relation with clinical outcome, the authors conclude that interindividual variability in response to adenosine diphosphate-receptor antagonists may be of substantial clinical importance.