Dan Dobreanu

### Abbreviations 1st AV : First-degree atrioventricular block AF : atrial fibrillation AT : atrial tachyarrhythmia ATP : Anti-tachycardia pacing AV : atrioventricular BBB : bundle branch block CHF : congestive heart failure CI : confidence interval CPG : Committee for Practice Guidelines CRT : cardiac resynchronization therapy CRT-D : cardiac resynchronization therapy and defibrillator CRT-P : cardiac resynchronization therapy and pacemaker ECG : electrocardiogram EDMD : Emery-Dreifuss muscular dystrophy EF : ejection fraction EPS : electrophysiological study ESC : European Society of Cardiology HCM : hypertrophic cardiomyopathy HF : heart failure HR : hazard ratio HV : His-ventricular ICD : implantable cardioverter defibrillator ILR : implantable loop recorder IVCD : intraventricular conduction delay LBBB : left bundle branch block LQTS : long QT syndrome LV : left ventricular LVEF : left ventricular ejection fraction LVSD : left ventricular systolic dysfunction MR : mitral regurgitation MRI : magnetic resonance imaging NYHA : New York Heart Association PM : pacemaker OR : odds ratio QALY : quality-adjusted life year RBBB : right bundle branch block RCT : randomized controlled trial RV : right ventricular SB : sinus bradycardia SNRT : sinus node recovery time SR : sinus rhythm SSS : sick sinus syndrome TAVI : transcatheter aortic valve implantation VF : ventricular fibrillation VT : ventricular tachycardia VV : interventricular (delay) ### Acronyms of the trials referenced in the recommendations or reported in the tables ADEPT : ADvanced Elements of Pacing Randomized Controlled Trial ADOPT : Atrial Dynamic Overdrive Pacing Trial AOPS : Atrial Overdrive Pacing Study APAF : Ablate and Pace in Atrial Fibrillation ASSERT : ASymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial ATTEST : ATrial Therapy Efficacy and Safety Trial AVAIL CLS/CRT : AV Node Ablation with CLS and CRT Pacing Therapies for Treatment of AF trial B4 : Bradycardia detection in Bundle Branch Block BELIEVE : Bi vs. Left Ventricular Pacing: an International Pilot Evaluation on Heart Failure Patients with Ventricular Arrhythmias BIOPACE : Biventricular pacing for atrioventricular block to prevent cardiac desynchronization BLOCK-HF : Biventricular versus right ventricular pacing in patients with AV block B-LEFT : Biventricular versus LEFT Univentricular Pacing with ICD Back-up in Heart Failure Patients CARE-HF : CArdiac REsynchronization in Heart Failure CLEAR : CLinical Evaluation on Advanced Resynchronization COMBAT : COnventional vs. Biventricular Pacing in Heart Failure and Bradyarrhythmia COMPANION : COmparison of Medical Therapy, Pacing and Defibrillation in Heart Failure DANPACE : DANish Multicenter Randomized Trial on Single Lead Atrial PACing vs. Dual Chamber Pacing in Sick Sinus Syndrome DECREASE-HF : The Device Evaluation of CONTAK RENEWAL 2 and EASYTRAK 2: Assessment of Safety and Effectiveness in Heart Failure FREEDOM : Optimization Study Using the QuickOpt Method GREATER-EARTH : Evaluation of Resynchronization Therapy for Heart Failure in Patients with a QRS Duration GREATER Than 120 ms LESSER-EARTH : Evaluation of Resynchronization Therapy for Heart Failure in Patients with a QRS Duration Lower Than 120 ms HOBIPACE : HOmburg BIventricular PACing Evaluation IN-CHF : Italian Network on Congestive Heart Failure ISSUE : International Study on Syncope of Unexplained Etiology MADIT : Multicenter Automatic Defibrillator Trial MIRACLE : Multicenter InSync RAndomized CLinical Evaluation MOST : MOde Selection Trial in Sinus-Node Dysfunction MUSTIC : MUltisite STimulation In Cardiomyopathies OPSITE : Optimal Pacing SITE PACE : Pacing to Avoid Cardiac Enlargement PAVE : Left Ventricular-Based Cardiac Stimulation Post AV Nodal Ablation Evaluation PATH-CHF : PAcing THerapies in Congestive Heart Failure II Study Group PIPAF : Pacing In Prevention of Atrial Fibrillation Study PIRAT : Prevention of Immediate Reinitiation of Atrial Tachyarrhythmias POT : Prevention Or Termination Study PREVENT-HF : PREventing VENTricular Dysfunction in Pacemaker Patients Without Advanced Heart Failure PROSPECT : PRedictors Of Response to Cardiac Resynchronization Therapy RAFT : Resynchronization–Defibrillation for Ambulatory Heart Failure Trial RethinQ : Cardiac REsynchronization THerapy IN Patients with Heart Failure and Narrow QRS REVERSE : REsynchronization reVErses Remodelling in Systolic left vEntricular dysfunction SAFARI : Study of Atrial Fibrillation Reduction SCD HeFT : Sudden Cardiac Death in Heart Failure Trial SMART-AV : The SMARTDelay Determined AV Optimization: a Comparison with Other AV Delay Methods Used in Cardiac Resynchronization Therapy SYDIT : The SYncope DIagnosis and Treatment SYNPACE : Vasovagal SYNcope and PACing TARGET : TARgeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy THEOPACE : Effects of Oral THEOphylline and of Permanent PACEmaker on the Symptoms and Complications of Sick Sinus Syndrome VASIS-PM : VAsovagal Syncope International Study on PaceMaker therapy V-HeFT : Vasodilator in HEart Failure Trial VPSII : Second Vasovagal Pacemaker Study (VPS II) Additional references are mentioned with ‘w’ in the main text and can be found on the online addenda along with 5 figures (1, 6, 7, 9, 11, 12) and 10 tables (3, 4, 5, 9, 11, 12, 19, 21, 22, 23). They are available on the ESC website only at http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/cardiac-pacing-and-cardiac-resynchronisation-therapy.aspx Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a …

Sodium–glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of hospitalization for heart failure and cardiovascular death among patients with chronic heart failure and a left ventricular ejection fraction of 40% or less. Whether SGLT2 inhibitors are effective in patients with a higher left ventricular ejection fraction remains less certain.

This report describes the baseline clinical profiles and management of DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trial participants and how these compare with those in other contemporary heart failure with preserved ejection fraction trials.The DELIVER trial was designed to evaluate the effects of the sodium-glucose cotransporter-2 inhibitor dapagliflozin on cardiovascular death, heart failure (HF) hospitalization, or urgent HF visits in patients with HF with mildly reduced and preserved left ventricular ejection fraction (LVEF).Adults with symptomatic HF and LVEF >40%, with or without type 2 diabetes mellitus, elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and evidence of structural heart disease were randomized to dapagliflozin 10 mg once daily or matching placebo.A total of 6,263 patients were randomized (mean age: 72 ± 10 years; 44% women; 45% type 2 diabetes mellitus; 45% with body mass index ≥30 kg/m2; and 57% with history of atrial fibrillation or flutter). Most participants had New York Heart Association functional class II symptoms (75%). Baseline mean LVEF was 54.2 ± 8.8% and median NT-proBNP of 1,399 pg/mL (IQR: 962 to 2,210 pg/mL) for patients in atrial fibrillation/flutter compared with 716 pg/mL (IQR: 469 to 1,281 pg/mL) in those who were not. Patients in both hospitalized and ambulatory settings were enrolled, including 10% enrolled in-hospital or within 30 days of a hospitalization for HF. Eighteen percent of participants had HF with improved LVEF.DELIVER is the largest and broadest clinical trial of this population to date and enrolled high-risk, well-treated patients with HF with mildly reduced and preserved LVEF. (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [NCT03619213]).

The aim of this European Heart Rhythm Association (EHRA) survey was to assess clinical practice in relation to the tools and techniques used for cardiac implantable electronic devices procedures in the European countries. Responses to the questionnaire were received from 62 members of the EHRA research network. The survey involved high-, medium-, and low-volume implanting centres, performing, respectively, more than 200, 100-199 and under 100 implants per year. The following topics were explored: the side approach for implantation, surgical techniques for pocket incision, first venous access for lead implantation, preference of lead fixation, preferred coil number for implantable cardioverter-defibrillator (ICD) leads, right ventricular pacing site, generator placement site, subcutaneous ICD implantation, specific tools and techniques for cardiac resynchronization therapy (CRT), lead implantation sequence in CRT, coronary sinus cannulation technique, target site for left ventricular lead placement, strategy in left ventricular lead implant failure, mean CRT implantation time, optimization of the atrioventricular (AV) and ventriculo-ventricular intervals, CRT implants in patients with permanent atrial fibrillation, AV node ablation in patients with permanent AF. This panoramic view allows us to find out the operator preferences regarding the techniques and tools for device implantation in Europe. The results showed different practices in all the fields we investigated, nevertheless the survey also outlines a good adherence to the common standards and recommendations.

Implantable cardioverter-defibrillator (ICD) is the standard of care for prevention of sudden cardiac death (SCD) in high-risk patients. For primary prevention of SCD, in patients with ischaemic heart disease, there is more robust data on the effect of ICD therapy compared with patients with non-ischaemic heart disease, but current real-life practice may differ substantially. The aim of this European Heart Rhythm Association survey was to evaluate the clinical practice regarding implantation of ICD for primary prevention among European countries in patients with non-ischaemic and ischaemic heart disease. Furthermore, we wanted to investigate the impact of the results of the recently published DANISH trial on clinical practice among European countries. In total, 48 centres from 17 different countries responded to the questionnaire. The majority did not implant ICD for primary prevention on a regular basis in patients with non-ischaemic heart disease despite current guidelines. Also, centres have changed their indications after the recent report on the efficacy of ICD in these patients. In patients with ischaemic heart disease, the guidelines for primary prevention ICD were followed on a regular basis, and no relevant change in indications were reported.

The age of patients presenting with complex arrhythmias is increasing. Frailty is a multifaceted syndrome characterized by an increased vulnerability to stressors and a decreased ability to maintain homeostasis. The prevalence of frailty is associated with age. The aims of this European Heart Rhythm Association (EHRA) EP Wire survey were to evaluate the proportion of patients with frailty and its influence on the clinical management of arrhythmias. A total of 41 centres-members of the EHRA Electrophysiology Research Network-in 14 European countries completed the web-based questionnaire in June 2017. Patients over 70 years represented 53% of the total treated population, with the proportion of frail elderly individuals reaching approximately 10%; 91.7% of the responding centres reported treating frail subjects in the previous year. The respondents usually recognized frailty based on the presence of problems of mobility, nutrition, and cognition and inappropriate loss of body weight and muscle mass. Renal failure, dementia, disability, atrial fibrillation, heart failure, falls, and cancer were reported to characterize the elderly frail individuals. Atrial fibrillation was considered the prevalent arrhythmia associated with frailty by 72% of the responding centres, and for stroke prevention, non-vitamin K antagonist oral anticoagulants were preferred. None of the respondents considered withholding the prevention of thrombo-embolic events in subjects with a history of falls. All participants have agreed that cardiac resynchronization therapy exerts positive effects including improvement in cardiac, physical, and cognitive performance and quality of life. The majority of respondents preferred an Arrhythmia Team to manage this special population of elderly patients, and many would like having a simple tool to quickly assess the presence of frailty to guide their decisions, particularly on the use of complex cardiac implantable electrical devices (CIEDs). In conclusion, the complex clinical condition in frail patients presenting with arrhythmias warrants an integrated multidisciplinary approach both for the management of rhythm disturbances and for the decision on using CIEDs.

The purpose of our survey is to analyse the clinical approach used to prevent and treat cardiovascular implantable electronic device (CIED) infections in Europe. The survey involves high-volume implanting centres. According to the survey the incidence of CIED infections shows a slight decrease in most centres and is substantially under 2% in the majority of centres interviewed. However, there are still differences in terms of prophylactic antibiotic therapy: 8.9% of the centres administer oxacillin as preoperative treatment, 4.4% of them do not give any antibiotic therapy, all centres use some kind of skin antisepsis, but only 42.2% use chlorhexidine. In case of local infection, 43.5% of centres perform lead extraction as first approach. In the case of systemic infection or evidence of lead or valvular endocarditis, 95% of centres treat these conditions by extracting the leads, which indicates that the adherence to the lead extraction guidelines is quite good.

This pre-specified analysis of the DELIVER trial examined whether clinical benefits of dapagliflozin in heart failure (HF) with left ventricular ejection fraction (LVEF) >40% varied by baseline New York Heart Association (NYHA) class and examined the treatment effects on NYHA class over time.Treatment effects of dapagliflozin by baseline NYHA class II (n = 4713) versus III/IV (n = 1549) were examined on the primary endpoint (cardiovascular death or worsening HF event) and key secondary endpoints. Effects of dapagliflozin on change in NYHA class at 4, 16, and 32 weeks were also evaluated. Higher baseline NYHA class was associated with older age, female sex, greater comorbidity burden, lower LVEF, and higher natriuretic peptide levels. Participants with baseline NYHA class III/IV, as compared with II, were independently more likely to experience the primary endpoint (adjusted hazard ratio [HR] 1.16 [95% confidence interval, 1.02-1.33]) and all-cause death (adjusted HR 1.22 [1.06-1.40]). Dapagliflozin consistently reduced the risk of the primary endpoint compared with placebo, irrespective of baseline NYHA class (HR 0.81 [0.70-0.94] for NYHA class II vs. HR 0.80 [0.65-0.98] for NYHA class III/IV; pinteraction = 0.921). Participants with NYHA class III/IV had greater improvement in Kansas City Cardiomyopathy Questionnaire total symptom scores between baseline and 32 weeks (+4.8 [2.5-7.1]) versus NYHA class II (+1.8 [0.7-2.9]; pinteraction = 0.011). Dapagliflozin was associated with higher odds of any improvement in NYHA class (odds ratio [OR] 1.32 [1.16-1.51]), as well as improvement to NYHA class I (OR 1.43 [1.17-1.75]), versus placebo at 32 weeks, with benefits seen as early as 4 weeks.Among symptomatic patients with HF and LVEF >40%, treatment with dapagliflozin provided clinical benefit irrespective of baseline NYHA class and was associated with early and sustained improvements in NYHA class over time.

Importance Dapagliflozin has been shown to improve overall health status based on aggregate summary scores of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in patients with heart failure (HF) with mildly reduced or preserved ejection fraction enrolled in the Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure (DELIVER) trial. A comprehensive understanding of the responsiveness of individual KCCQ items would allow clinicians to better inform patients on expected changes in daily living with treatment. Objective To examine the association of dapagliflozin treatment with changes in individual components of the KCCQ. Design, Setting, and Participants This is a post hoc exploratory analysis of DELIVER, a randomized double-blind placebo-controlled trial conducted at 353 centers in 20 countries from August 2018 to March 2022. KCCQ was administered at randomization and 1, 4, and 8 months. Scores of individual KCCQ components were scaled from 0 to 100. Eligibility criteria included symptomatic HF with left ventricular ejection fraction greater than 40%, elevated natriuretic peptide levels, and evidence of structural heart disease. Data were analyzed from November 2022 to February 2023. Main Outcomes and Measures Changes in the 23 individual KCCQ components at 8 months. Interventions Dapagliflozin, 10 mg, once daily or placebo. Results Baseline KCCQ data were available for 5795 of 6263 randomized patients (92.5%) (mean [SD] age, 71.5 [9.5] years; 3344 male [57.7%] and 2451 female [42.3%]). Dapagliflozin was associated with larger improvements in almost all KCCQ components at 8 months compared with placebo. The most significant improvements with dapagliflozin were observed in frequency of lower limb edema (difference, 3.2; 95% CI, 1.6-4.8; P < .001), sleep limitation by shortness of breath (difference, 3.0; 95% CI, 1.6-4.4; P < .001), and limitation in desired activities by shortness of breath (difference, 2.8; 95% CI, 1.3-4.3; P < .001). Similar treatment patterns were observed in longitudinal analyses integrating data from months 1, 4, and 8. Higher proportions of patients treated with dapagliflozin experienced improvements, and fewer had deteriorations across most individual components. Conclusions and Relevance In this study of patients with HF with mildly reduced or preserved ejection fraction, dapagliflozin was associated with improvement in a broad range of individual KCCQ components, with the greatest benefits in domains related to symptom frequency and physical limitations. Potential improvements in specific symptoms and activities of daily living might be more readily recognizable and easily communicated to patients. Trial Registration ClinicalTrials.gov Identifier: NCT03619213

This survey was conducted to provide an insight into the current clinical practice regarding the use of cardioversion for atrial fibrillation (AF) in Europe. Responses were received from 57 centres across Europe, 71.9% of which were university hospitals. For electrical cardioversion, general anaesthesia was managed by an anaesthesiologist in 73.9% of centres and by a cardiologist in 37%. In the majority of centres, electrical cardioversion was performed using a biphasic defibrillator (85.1%). Antiarrhythmic drugs were routinely prescribed prior to electrical cardioversion by 54.3% of hospitals. For pharmacological cardioversion in patients with no or minimal heart disease, the majority of centres (63.1%) chose intravenous flecainide or propafenone, whereas vernakalant was used by 35% of centres in patients with no or minimal-to-moderate structural heart disease. Most centres (71.7%) used a mandatory strategy of 3 weeks of oral anticoagulation prior to elective cardioversion in patients AF > 48 h, but 28.3% performed immediate cardioversion after a transoesophageal echocardiogram. Many centres are now performing electrical cardioversion on treatment with novel oral anticoagulants (up to 23.6% of cardioversions).

Although it is well known that silent atrial fibrillation (AF) is associated with morbidity and mortality rates similar to those of symptomatic AF, no specific strategy for screening and management of this form of AF has been advocated. The purpose of this survey was to identify current practices for the diagnosis and management of silent AF. This survey is based on an electronic questionnaire sent to the European Heart Rhythm Association Research Network partners. Responses were received from 33 centres in 16 countries. The preferred screening methods for silent AF in patients with rhythm control by pharmacological therapy was 12-lead electrocardiogram (ECG) at outpatient visits (31.3%) and periodical 24 h Holter ECG recordings (34.4%), while after pulmonary vein isolation the corresponding figures were 6.3 and 65.6%, respectively. No consensus has been reached concerning the therapeutic approach for such patients. Most responders preferred rate control over rhythm control in patients with silent AF, although some favoured pulmonary vein isolation in young patients. However, oral anticoagulant therapy in patients at high thromboembolic risk was considered mandatory by most, provided that at least one episode of silent AF was documented, without recommending further investigations. The results of this survey have confirmed that there is currently no consensus regarding the screening and management of patients with silent AF and that clinical practice is not always consistent with the few existing evidence-based recommendations.

The purpose of this patient survey was to analyse the knowledge, experiences, and attitudes regarding cardiac implantable electronic devices (CIED) in patients with pacemakers, implantable cardioverter-defibrillators (ICDs), or cardiac resynchronization devices. Of the 1644 patients with CIEDs from seven European countries, 88% were over 50 years of age. Most patients (90%) knew what device they were implanted with and felt sufficiently informed about the indications for therapy. As many as 42% of patients needed additional information on the battery replacement and limitations in physical activity. The self-reported incidence of complications was 9%, and among these, a quarter of the respondents felt insufficiently informed about the possibility of complications and their management. The majority of patients (83%) were followed by face-to-face visits, which was the most commonly preferred follow-up strategy by the patients. Nearly 75% of the patients reported improved quality of life after device implantation, but about 40% had worries about their device. Less than 20% had discussed with their physician or thought about device handling in the end-of-life circumstances or end-stage disease. Notably, almost 20% of the ICD patients did not wish to answer the question regarding what they wanted to be done with their ICD in case of end-stage disease, indicating the challenges in approaching these issues.

The aim of this EP Wire survey was to assess the indications and anticoagulation strategies post-left atrial appendage occluder (LAAO) implantation for stroke prevention in patients with non-valvular atrial fibrillation in Europe. A total of 33 centres in 13 European countries completed the survey. All centres were members of the European Heart Rhythm Association Electrophysiology Research Network. Left atrial appendage occluder procedures were performed by electrophysiologists in 52% of the centres and by interventional cardiologists in the remaining centres. The EP Wire survey has revealed that the most common indications for LAAO are stroke prevention in patients at high thrombo-embolic risk and absolute contraindications to oral anticoagulation (OAC) therapy or a history of bleeding. Early- and long-term post-implantation anticoagulation strategies in patients with and without device thrombosis were very heterogeneous between centres with most strategies not being supported by the randomized trials. In patients without contraindications to OAC, 41% of the centres would prescribe no therapy at all after 6 months following LAAO implantation. In patients with LAA thrombus during follow-up and patients with absolute contraindications to OAC, management was highly heterogeneous and included aspirin, clopidogrel, non-vitamin K antagonist oral anticoagulants, low molecular weight heparin, surgery, unfractionated heparin, or no therapy.

Management of patients with cardiac arrhythmias is increasingly complex because of continuous technological advance and multifaceted clinical conditions associated with ageing of the population, the presence of co-morbidities and the need for polypharmacy. The aim of this European Heart Rhythm Association Scientific Initiatives Committee survey was to provide an insight into the role of the Arrhythmia Team, an integrated, multidisciplinary approach to management of patients with cardiac arrhythmias. Forty-eight centres from 18 European countries replied to the Web-based questionnaire. The presence of an Arrhythmia Team was reported by 44% of the respondents, whereas 17% were not familiar with this term. Apart from the electrophysiologist, health professionals who should belong to such teams, according to the majority of the respondents, include a clinical cardiologist, a nurse, a cardiac surgeon, a heart failure specialist, a geneticist, and a geriatrician. Its main activity should be dedicated to the management of patients with complex clinical conditions or refractory or inherited forms of arrhythmias. When present, the Arrhythmia Team was considered helpful by 95% of respondents; the majority of centres (79%) agreed that it should be implemented. The Arrhythmia Team seems to be connected to important expectations in the management of cardiac arrhythmias. The efficacy of such an integrated and multidisciplinary approach should be encouraged and tested in clinical practice.

Abstract Aims There is currently no reliable tool to quantify the risks of ventricular fibrillation or sudden cardiac arrest (VF/SCA) in patients with spontaneous Brugada type 1 pattern (BrT1). Previous studies showed that electrocardiographic (ECG) markers of depolarization or repolarization disorders might indicate elevated risk. We aimed to design a VF/SCA risk prediction model based on ECG analyses for adult patients with spontaneous BrT1. Methods and results This retrospective multicentre international study analysed ECG data from 115 patients (mean age 45.1 ± 12.8 years, 105 males) with spontaneous BrT1. Of these, 45 patients had experienced VF/SCA and 70 patients did not experience VF/SCA. Among 10 ECG markers, a univariate analysis showed significant associations between VF/SCA and maximum corrected Tpeak–Tend intervals ≥100 ms in precordial leads (LMaxTpec) (P < 0.001), BrT1 in a peripheral lead (pT1) (P = 0.004), early repolarization in inferolateral leads (ER) (P < 0.001), and QRS duration ≥120 ms in lead V2 (P = 0.002). The Cox multivariate analysis revealed four predictors of VF/SCA: the LMaxTpec [hazard ratio (HR) 8.3, 95% confidence interval (CI) 2.4–28.5; P < 0.001], LMaxTpec + ER (HR 14.9, 95% CI 4.2–53.1; P < 0.001), LMaxTpec + pT1 (HR 17.2, 95% CI 4.1–72; P < 0.001), and LMaxTpec + pT1 + ER (HR 23.5, 95% CI 6–93; P < 0.001). Our multidimensional penalized spline model predicted the 1-year risk of VF/SCA, based on age and these markers. Conclusion LMaxTpec and its association with pT1 and/or ER indicated elevated VF/SCA risk in adult patients with spontaneous BrT1. We successfully developed a simple risk prediction model based on age and these ECG markers.

How patient characteristics and outcomes vary according to the duration of heart failure (HF) is unknown in individuals with mildly reduced or preserved ejection fraction. We compared these, and the efficacy and safety of dapagliflozin, according to the time from diagnosis of HF in a prespecified analysis of the DELIVER trial (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure).HF duration was categorized as ≤6 months, >6 to 12 months, >1 to 2 years, >2 to 5 years, or >5 years. The primary outcome was the composite of worsening HF or cardiovascular death. The effect of treatment was examined by HF duration category.The number of patients in each category was as follows: 1160 (≤6 months), 842 (>6 to 12 months), 995 (>1 to 2 years), 1569 (>2 to 5 years), and 1692 (>5 years). Patients with longer-duration HF were older and had more comorbidities with worse symptoms. The rate of the primary outcome (per 100 person-years) increased with HF duration: ≤6 months, 7.3 (95% CI, 6.3 to 8.4); >6 to 12 months, 7.1 (6.0 to 8.5); >1 to 2 years, 8.4 (7.2 to 9.7); >2 to 5 years, 8.9 (7.9 to 9.9); and >5 years, 10.6 (9.5 to 11.7). Similar trends were seen for other outcomes. The benefit of dapagliflozin was consistent across HF duration category: the hazard ratio for the primary outcome in the ≤6-month group was 0.67 (95% CI, 0.50 to 0.91); >6 to 12 months, 0.78 (0.55 to 1.12); >1 to 2 years, 0.81 (0.60 to 1.09); >2 to 5 years, 0.97 (0.77 to 1.22); and >5 years, 0.78 (0.64 to 0.96; Pinteraction=0.41). The absolute benefit was greatest in longest-duration HF; the number needed to treat for HF >5 years was 24 versus 32 for ≤6 months.Patients with longer-duration HF were older, had more comorbidities and symptoms, and had higher rates of worsening HF and death. The benefits of dapagliflozin were consistent across HF duration. Even patients with long-standing HF and generally mild symptoms are not stable, and it is not too late for such patients to benefit from a sodium-glucose cotransporter 2 inhibitor.URL: https://www.gov; Unique identifier: NCT03619213.

The aims of this survey was to provide insight into treatment activity, the strategy of treatment, and risk stratification of patients with asymptomatic and symptomatic ventricular pre-excitation across Europe. Fifty-eight centres, members of the European Heart Rhythm Association EP research network, covering 20 countries answered the survey questions. All centres were high-volume ablation centres. A younger person with asymptomatic Wolff–Parkinson–White (WPW) pattern has a higher likelihood of being risk-stratified or receiving ablation therapy compared with an older subject. Two-thirds of centres report that they have observed a decline in the number of patients ablated for an accessory pathway during the last 10 years. Pre-excited atrial fibrillation is rarely seen. Discontinuation of a scheduled WPW ablation due to close vicinity of the accessory pathway to the AV node happens very rarely. Patients with a first episode of pre-excited atrial fibrillation would immediately be referred for catheter ablation to be performed within weeks by 80.4% of the centres. A significant proportion of responders (50.9%) would use electrical cardioversion to restore sinus rhythm in a patient with pre-excited atrial fibrillation. With respect to the choice of antiarrhythmic medication for a patient with pre-excited AF, the majority (80.0%) would choose class 1C antiarrhytmic drugs while waiting for a catheter ablation. A patient seen in the emergency room with a second episode of orthodromic atrioventricular reentry tachycardia would be referred for immediate ablation by 79.2–90.6% of centres depending on the presence of pre-excitation. The volume of paediatric ablations performed on children younger than 12 years was low (46.4%: 0 patients per year; 46.4%: 1–9 patients per year). The majority of responding centres (61–69%) report that their country lack national guidelines dealing with clinical strategies related to WPW. There is a need for national guidelines dealing with clinical strategy in patients with WPW syndrome. Older individuals with asymptomatic WPW pattern have a higher risk of not receiving risk stratification or curative therapy with ablation compared with younger patients, despite the higher risk of developing atrial fibrillation.

The purpose of this European Heart Rhythm Association (EHRA) survey was to assess clinical practice in relation to stroke prevention in atrial fibrillation (AF), particularly into the use of novel oral anticoagulants (NOACs) for stroke prevention, among members of the EHRA electrophysiology (EP) research network. In this EP Wire survey, we have provided some insights into current practice in Europe for the use of NOACs for stroke prevention in AF. There were clear practice differences evident, and also the need for greater adherence to the guidelines, especially since guideline adherent management results in better outcomes in AF.

The purpose of our survey was to evaluate the experience, current practice and attitudes of performing magnetic resonance imaging (MRI) studies in patients with cardiac implantable electronic devices. Fifty-one centre-members of European Heart Rhythm Association Research network have responded to the survey. According to the obtained data, 55.2% of responding centres do not perform MRI scans in patients with non-MRI-certified pacemakers and 65.8% in patients with such implantable cardioverter defibrillators (ICDs). Reported complication rate in patients with non-MRI-certified devices is low and conforms to the literature data. Experience with newer MRI-compatible pacemakers and ICDs is limited to single cases in most centres. This survey shows limited experience with performing MRI studies in patients with implanted pacemakers and ICDs. In concordance with available guidelines, most centres limit MRI scans in patients with non-MRI-certified devices. The implant numbers for MRI-certified devices and experience with performing MRI scans in these patients are still low.

The aim of this European Heart Rhythm Association (EHRA) survey was to provide an insight into the current practice of work-up and management of patients with syncope among members of the EHRA electrophysiology research network. Responses were received from 43 centres. The majority of respondents (74%) had no specific syncope unit and only 42% used a standardized assessment protocol or algorithm. Hospitalization rates varied from 10% to 25% (56% of the centres) to >50% (21% of the centres). The leading reasons for hospitalization were features suggesting arrhythmogenic syncope (85% of respondents), injury (80%), structural heart disease (73%), significant comorbidities (54%), and older age (41%). Most widely applied tests were electrocardiogram (ECG), echocardiography, and Holter monitoring followed by carotid sinus massage and neurological evaluation. An exercise test, tilt table test, electrophysiological study, and implantation of a loop recorder were performed only if there was a specific indication. The use of a tilt table test varied widely: 44% of respondents almost always performed it when neurally mediated syncope was suspected, whereas 37% did not perform it when there was a strong evidence for neurally mediated syncope. Physical manoeuvres were the most widely (93%) applied standard treatment for this syncope form. The results of this survey suggest that there are significant differences in the management of patients with syncope across Europe, specifically with respect to hospitalization rates and indications for tilt table testing in neurally mediated syncope. The majority of centres reported using ECG, echocardiography, and Holter monitoring as their main diagnostic tools in patients with syncope, whereas a smaller proportion of centres applied specific assessment algorithms. Physical manoeuvres were almost uniformely reported as the standard treatment for neurally mediated syncope.

The purpose of this European Heart Rhythm Association (EHRA) Survey was to assess the perceptions of 'valvular' atrial fibrillation (AF) and management of AF patients with various heart valve abnormalities in daily clinical practice in European electrophysiology (EP) centres. Questionnaire survey was sent via the Internet to the EHRA-EP Research Network Centres. Of the 52 responding centres, 42 (80.8%) were university hospitals. Choosing the most comprehensive definition of valvular AF, a total of 49 centres (94.2%) encountered a mechanical prosthetic heart valve and significant rheumatic mitral stenosis, 35 centres (67.3%) also considered bioprosthetic valves, and 25 centres (48.1%) included any significant valvular heart disease, requiring surgical repair in the definition of valvular AF. Only three centres (5.8%) would define valvular AF as the presence of any (even mild) valvular abnormality. None of the centres would use non-vitamin K antagonist oral anticoagulants (NOACs) in AF patients with mechanical prosthetic valves, only 5 centres (9.8%) would use NOACs in patients with significant mitral stenosis, 17 centres (32.7%) would consider the use of NOACs in patients with bioprosthetic valves, and 21 centres (41.2%) would use NOACs in patients with a non-recent transcatheter valve replacement/implantation, while 13 centres (25.5%) would never consider the use of NOACs in AF patients with even mild native heart valve abnormality. Our survey showed marked heterogeneity in the definition of valvular AF and thromboprophylactic treatments, with the use of variable NOACs in patients with valvular heart disease other than prosthetic heart valves or significant mitral stenosis, indicating that this term may be misleading and should not be used.

This study sought to compare sex difference for procedural aspects and complications in the European Society of Cardiology CRT Survey II, exploring whether adverse events were related to the type of CRT device implanted.Sex-related differences in procedural aspects and complications in patients undergoing cardiac resynchronization therapy (CRT) implantation has not been explored in a real-life population.A post-hoc analysis of procedural data and complications in different sexes and factors associated with events was performed from data collected in the European Society of Cardiology CRT Survey II.Of all patients (n = 11,088) included, 24.3% were women. The mean age (70 years of age) of male and female recipients was similar. Female patients more frequently had an idiopathic cardiomyopathy (67.4% vs. 44.1%) and fewer comorbidities, including atrial fibrillation (34.8% vs. 42.8%), diabetes (29.1% vs. 32.1%), chronic obstructive lung disease (10.3% vs. 12.6%), and renal failure (28.7% vs. 31.9%), compared with men. More women compared with men had a pacemaker (56.6% vs. 46.3%) and much less often an implantable cardioverter-defibrillator (CRT-D) (19.0% vs. 34.7%) implant. Periprocedural event rate was the highest in women with CRT with defibrillator (7.1% vs. 4.8% in men), followed by women with a CRT with pacing (5.5% vs. 4.4% in men). The higher periprocedural event rate in CRT-D women was attributable primarily to the occurrence of pneumothorax (1.4%), coronary sinus dissection (2.1%), and pericardial tamponade (0.3%). The rate of in-hospital major adverse events (6.0%) and complications necessitating reoperation (4.0%) was not different among sex and device type.Women are more likely to experience adverse procedure-related events during CRT implantation. Thus, preventive strategies should be employed to minimize complication rate.

In this survey, European physicians who deal with arrhythmia patients gave their opinions about diagnostic work up when they see patients with ventricular premature beats (VPBs) or non-sustained ventricular tachycardia (NSVT). In general, similar work-up regimens were used for these two arrhythmias except for coronary angiography, which was considered by one in four physicians when dealing with NSVT but by almost none for VPBs. The majority of physicians believe that it is acceptable to abstain from pharmacological therapy in an asymptomatic patient with VPBs. When considering second-line therapy almost half of the respondents would consider amiodarone in patients with NSVT whereas almost none would when dealing with VPBs. When the effect of therapy was evaluated, its influence on symptoms and arrhythmia burden were ranked highest.

The aim of this EP Wire was to assess the management, indications, and techniques for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) device replacement in Europe. A total of 24 centres in 14 European countries completed the questionnaire. All centres were members of the European Heart Rhythm Association Electrophysiology Research Network. Replacement procedures were performed by electrophysiologists in 52% of the centres, by cardiologists in 33%, and both in the remaining centres. In the majority of centres, the procedures were performed during a short hospitalization (<2 days; 61.2%), or on an outpatient basis (28%). The overwhelming majority of centres reported that they replaced ICDs at the end of battery life. Only in a small subset (<10%) of patients with ICD for primary prevention and without ventricular tachycardia (VT) since implantation, ICD was not replaced. In inherited primary arrhythmia syndromes, 80% of the centres always replaced the ICD at the end of battery life. After VT ablation, only few centres (9%) explanted or downgraded the device that was previously implanted for secondary prevention, but only in those patients without new VT episodes. Patient's life expectancy <1 year was the most commonly reported reason (61%) to downgrade from a CRT-D to a CRT-P device. While warfarin therapy was continued in 47% of the centres, non-vitamin K oral anticoagulants were discontinued without bridging 24 h prior to replacement procedures in 60%. Finally, in 65% of the centres, VT induction and shock testing during ICD and CRT-D replacement were performed only in the case of leads with a warning or with borderline measurements. This survey provides a snapshot of the perioperative management, indications, and techniques of ICD and CRT device replacement in Europe. It demonstrates some variations between participating centres, probably related to local policies and to the heterogeneity of the ICD population.

Essentials The impact of long-term thrombin inhibition outside the coagulation cascade is far from clear. We aimed to assess the impact of dabigatran etexilate (DE) in diabetic and control rats. In diabetic rats, DE increased platelet aggregation and lead to coronary lipid deposits. Long-term thrombin inhibition may increase atherosclerotic and atherothrombotic risk. SUMMARY: Background Besides its role in the coagulation cascade, thrombin contributes to platelet aggregation and to a plethora of non-hemostatic functions. Objectives To assess the impact of long-term thrombin inhibition with dabigatran etexilate (DE) on platelet aggregation and on extrahemostatic thrombin-related functions in diabetic and control rats. Methods Markers of inflammation, endothelial dysfunction, oxidative stress, angiogenesis and cell adhesion molecules were quantified in control rats (Control; n = 6), DE-treated control rats (Control-Dabi; n = 8), diabetic rats (Diabetes; n = 5), and DE-treated diabetic rats (Diabetes-Dabi; n = 8). Agonist-induced platelet aggregation, aortic and coronary lipid deposits and aortic protease-activated receptor 4 (PAR4) expression were also assessed. Results Control-Dabi rats showed significantly higher high-sensitivity C-reactive protein, von Willebrand factor (VWF), vascular endothelial growth factor (VEGF) and fibronectin levels, and significantly lower PAR4 agonist-induced aggregation, than Control rats. Control-Dabi rats also showed mild aortic lipid deposits, whereas no such changes were observed in Control rats. Diabetes-Dabi rats showed significantly higher VWF, VEGF and fibronectin levels than Diabetes rats, and similar PAR4 agonist-induced aggregation as Diabetes rats, and significantly higher ADP-induced aggregation than Diabetes rats. Coronary lipid deposits were observed in 75% of Diabetes-Dabi rats and in none of the Diabetes rats. PAR4 expression was 20.4% higher in Control-Dabi rats and 27.4% higher in Diabetes-Dabi rats than in their non-treated peers. Conclusions This study indicates that long-term thrombin inhibition increases vascular PAR4 expression, promotes atherosclerosis-related mechanisms, and, in diabetic rats, increases platelet aggregation and favors the occurrence of coronary lipid deposits. These experimental data suggest that long-term thrombin inhibition may increase atherosclerotic and atherothrombotic risk, particularly in the presence of diabetes.

The purpose of this EP wire is to examine clinical practice in the field of out-of-hospital cardiac arrest (OHCA) management, with special focus on in-hospital diagnostic and therapeutic strategies.Fifty-three European centres, all members of the EHRA-EP Research network, completed the questions of the survey. A dedicated strategy for OHCA management is active in 85% of the centres. Shockable tachyarrhythmias such as initial OHCA rhythm are reported in >70% of the patients in 64% of the centres. In-hospital therapeutic hypothermia was applied in >50% of the patients in 53% of the centres and in <50% in 47% of the centres. In the year 2011 90% of the centres performed >10 primary percutaneous coronary angioplasties (PCI) in OHCA patients. The survival rate, when the initial documented rhythm was shockable, was >30% in 42% of the centres, and conversely, was significantly lower when asystole or pulseless electrical activity was the initial rhythm. A favourable neurological recovery was reported in >50% of the patients in 13 (26%) centres and in 21-50% of the patients in 21 (44%).This EP wire survey demonstrates a favourable implementation in OHCA of an invasive management strategy, including coronary angiography/PCI and implantable cardioverter defibrillator therapy, while therapeutic hypothermia appears to be underused.

We performed a survey on current atrial fibrillation (AF) ablation techniques used for catheter ablation of AF among the European Heart Rhythm Association Research Network. The focus of this questionnaire is on the ablation strategy, such as the use of different lesion sets or sites of ablation in the various forms of AF, and on the technical aspects of catheter ablation with respect to energy sources and imaging modalities.

The conference of the ‘Implantable Cardioverter Defibrillator for Life’ Initiative—Fighting against Sudden Cardiac Death in Emerging Economies was jointly organized by the European Heart Rhythm Association and the Hungarian Society of Cardiology. The aim of the summit was to demonstrate the benefit and efficacy of the prevention of sudden cardiac death (SCD). Sudden cardiac death is responsible for a significant number of deaths at an annual level and it is the leading cause of death in industrial countries. Many arrhythmias could be treated by means of device therapy and this would also reduce the death rates. The target of the summit was to build bridges between medical, political, and industrial sectors to procure greater political and economic care and support for the primary and secondary prevention of sudden cardiac death, heart failure, and arrhythmias. The number of implantable cardioverter-defibrillator (ICD) implantations has increased enormously in the recent years based on the proven efficacy of implantable devices in the treatment of heart failure and heart rhythm disturbances. However, many patients with high risk of SCD still do not undergo ICD implantation. The reason is partly economic, and partly due to the lack of public awareness and the lack of qualified specialists. The conference emphasized that both the theoretical background of device therapy—professional recommendations, choice of implantable devices, programming, and problem solving—and the practical education of implantation methods are important to increase the implantation rates. The paradoxity of the effort to reduce SCD in economies in transition is that there is a high prevalence of high-risk patients on one side and actual implant rates both for primary and secondary prevention are disproportially low. The summit attempted to reflect regional disparities, their political, economic, financial, and, last but not least, educational background through a series of lectures held by the representatives of countries …

The aim of this study is to observe the differences between mechanical and electrical dyssynchrony in patients with impaired systolic ventricular function and symptomatic heart failure and to highlight the importance of mechanical dyssynchrony besides electrical dyssynchrony in clinical guidelines and clinical practice. Fifty-eight patients with heart failure, who are with the New York Heart Association (NYHA) functional class II-IV and left ventricular ejection fraction (LVEF) under 35%, were enrolled. Patients were divided into two groups, according to the duration of QRS complex (> 120 ms and ≤ 120 ms respectively). Echocardiographic parameters of interventricular (interventricular mechanical delay - IMD) and intraventricular (septal-to-posterior wall motion delay - SPWMD) dyssynchrony were measured in both groups. Results indicate that the duration of the QRS complex (i.e. electrical dyssynchrony) is not a fully reliable indicator of ventricular dyssynchrony; therefore ecocardiographic evaluation of mechanical dyssynchrony should also be recommended for better selection of candidates for cardiac resynchronization therapy (CRT).

Recent technological advances have provided fully absorbable scaffolds available for coronary angioplasty. These new materials ensure both mechanical support for the coronary artery and drug-elution, while presenting the advantage of full absorption into the vessel wall after a predetermined interval of time. This later feature appears to ensure full restoration of the vasomotor function and of physiological responses of the stented and peri-stented segments to vasoactive stimuli, while avoiding long-term stent-related complications [ [1] Serruys P.W. Onuma Y. Dudek D. et al. Evaluation of the second generation of a bioresorbable everolimus-eluting vascular scaffold for the treatment of de novo coronary artery stenosis: 12-month clinical and imaging outcomes. J Am Coll Cardiol. 2011; 58: 1578-1588 Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar ]. However, additional experience is needed in order to establish the entire spectrum of complications related to the use of these emerging materials. Herein we report the first case of coronary artery aneurysm formation within a new-generation, everolimus-eluting bioresorbable stent, with possible intra-scaffold thrombosis.

Abstract Cardiogenic shock (CS) is a critical condition which often complicates the evolution of an acute myocardial infarction (AMI). At the same time, co-existence of chronic multi-vessel disease can lead to the development of cardiogenic shock in cases with pronounced haemodynamic instability. Different clinical studies have tried to identify the most appropriate treatment for critical cases of CS complicating AMI. This review aims to present the current status of recommended therapeutic strategies for severe cases of CS presenting as a complication of AMI, and try to shed light on the most appropriate therapeutic strategy as outlined in the current literature. The paper will discuss the different current strategies available for use in the treatment of this condition, includig interventional revascularisation, (complete or culprit), the role of new devices for providing mechanical circulatory support, and the potential role of new drug therapies and of hypothermia.

The purpose of this EP Wire is to compare indications, techniques, implant strategy, and follow-up regarding cardiac resynchronization therapy (CRT) in several countries across Europe.Forty-one centres, members of the EHRA-EP Research Network, responded to this survey and completed the questions. Thirty-two per cent of the responding centres always use CRT in heart failure (HF) patients with New York Heart Association functional class II and QRS width >120 ms, and 55% of the responding centres demand additional criteria when indicating CRT, most often QRS width >150 ms (49%) and echocardiographic criteria of asynchrony (34%). Only 10% of centres indicate CRT in all HF patients with QRS >120 ms and right bundle branch block, and 51% demand additional criteria, most frequently echocardiographic asynchrony parameters. The vast majority of centres also indicate CRT in patients with atrial fibrillation and standard criteria for CRT. In 24% of the centres, biventricular pacemaker (CRT-P) is implanted in all situations, unless there is an indication for secondary prevention of sudden cardiac death, while 10% always choose to implant a biventricular defibrillator (CRT-D). There are no clear evidence-based recommendations concerning the implant procedure and follow-up in patients treated with CRT; therefore, the chosen strategies vary widely from one centre to another.This EP Wire survey shows a wide variation not only as far as CRT indications are concerned, but especially in techniques, implant strategy, and follow-up across the European countries.

Abstract Background Dabigatran etexilate ( DE ) has similar stroke prevention efficacy in patients with and without diabetes mellitus ( DM ). However, the benefit of reducing major bleeding was not seen in diabetics. Thus, this study investigated anticoagulant responses to DE and the biological predictors of this response in a DM model. Methods Experiments were performed in six control (C), eight DE ‐treated control ( CD ), five diabetic (D), and eight DE ‐treated diabetic ( DD ) rats. Dabigatran etexilate (50 mg/kg/day) was administered in chow for 12 weeks. At the end of the study, plasma glucose, triglycerides, total cholesterol ( TC ), high‐density lipoprotein cholesterol, low‐density lipoprotein cholesterol ( LDL‐C ), and plasma creatinine were measured. Correlations were ascertained with the diluted thrombin time (d TT ). Results When corrected for similar DE intake, d TT was significantly higher in DD than CD rats ( P &lt; 0.001). There was a significant negative correlation between creatinine clearance ( CC r) and d TT ( r = −0.91, P &lt; 0.01) in DD rats. In addition, d TT was positively correlated with TC ( r = 0.96, P &lt; 0.01), LDL‐C ( r = 0.75, P = 0.04), and glucose ( r = 0.83, P = 0.02). In multiple regression analysis, CC r ( r = −0.81, P = 0.01), TC ( r = 0.93, P &lt; 0.001), and LDL‐C ( r = 0.74, P &lt; 0.01) remained the only independent predictors of d TT . Conclusions The results show a significantly more intense DE ‐induced anticoagulation in diabetic rats that does not seem to be solely related to altered kidney function, and demonstrate that plasma cholesterol can significantly affect DE anticoagulation in this setting.

Abstract Coronary chronic total occlusion (CTO) is caused by organized thrombi or atherosclerotic plaque progression. The presence of a CTO is an independent predictor of mortality in patients presenting with ST-segment elevation myocardial infarction (STEMI). Platelets have a crucial role in the pathophysiology of atherosclerosis. The aim of this retrospective study was to investigate platelet indices as predictors of CTO in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). A total number of 334 patients admitted for STEMI between January 2011 and December 2013 were included and divided in two groups based on the presence of CTO (48 patients in CTO+ group, 286 patients in CTO-group). Platelet count, mean platelet volume (MPV), platelet distribution width (PDW), platelet-large cell ratio (P-LCR), lymphocyte and neutrophil count determined on admission were analyzed. MPV was larger in patients with CTO compared with patients without CTO (p=0.02), as were PDW (p=0.03) and P-LCR (p=0.01). Platelet-to-lymphocyte ratio (PLT/LYM) was lower in patients with CTO: 105.2 (75.86-159.1) compared to 137 (97-188.1), p&lt;0.01. Receiver-operator characteristic curve analysis identified an area under the curve of 0.61 (95%CI=0.57-0.67, p&lt; 0.01) for PLT/LYM in predicting the presence of a CTO, with a cut-off value at 97.73. Lower values than this were independent predictors of a CTO in multivariate logistic regression analysis, with an Odds Ratio of 2.2 (95%CI=1.15-4.20, p=0.02). Our results support the use of platelet indices and PLT/LYM as predictors of CTO in patients presenting with STEMI.

Inflammatory reactions in coronary plaques play an important role in the pathogenesis of acute atherothrombotic events. The most powerful class of lipid-lowering drugs available-statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors)--have additional actions, unrelated to cholesterol reduction, including anti-inflammatory and immunomodulatory properties. This study sought to determine if atorvastatin affects monocyte and lymphocyte activation in patients with unstable angina and mild primary hypercholesterolemia. Following a 4-weeks hypolipemiant-free baseline period, 22 patients-12 with unstable angina (UA) and 10 patients with stable coronary heart disease (SCHD) - were treated with Atorvastatin 20 mg/day. Lipopolysaccharide (LPS)-receptor (CD14) and HLA-DR expression on monocytes and beta-integrins (CD11b, 11c, 49d) on monocytes and lymphocytes were measured by flow cytometry before and after treatment with atorvastatin for 8 weeks. Monocyte CD11b, 11c and CD14 expression and T lymphocytes CD11b expression were significantly (p < 0.001) higher in UA patients before treatment when compared with that in SCHD patients. In patients with UA, they decreased markedly with atorvastatin treatment. The reduction in expression of adhesion molecule on monocytes and lymphocytes and the concentrations of CRP and sICAM-1 may crucially contribute to the clinical benefit of atorvastatin in coronary artery disease, independent of cholesterol lowering effects.

Cardiac resynchronization therapy (CRT) was shown to improve left atrial (LA) size and function within months after the procedure. We aimed to assess the impact of CRT on left atrial (LA) size and function within days after the procedure. Materials and methods: Twenty-eight consecutive patients with CRT were evaluated before the procedure and within 3 days afterwards, and 25 of them were also examined at three months. Echocardiography was performed to assess LA size and function: LA volumes indexed to body surface (LAVIs) were measured at different moments during the cardiac cycle: ventricular end-systole - maximum LAVI (LAVImax), before atrial systole (LAVIpreA), and at ventricular end-diastole - minimum LAVI (LAVImin). These measurements were further used to calculate LA function parameters: LA total emptying fraction, activeemptying fraction and passive emptying fraction.LAVImax decreased within days after the procedure - 45.5 mL/ m2 (38.2-56.7) vs. 42.9 mL/m2 (32.1- 56.2), p <0.05, as did LAVImin - 27.1 mL/m2 (22.9-41.9) vs. 25.9 mL/m2 (17.8-38.1), p <0.05, and LAVIpreA - 40.0 mL/m2 (31.3-53.0) vs. 35.5 mL/m2 (25.8-49.1), without significant changes in functional parameters. All LAVIs were correlated to the diastolic filling time/RR interval ratio after CRT, but not before.LAVIs may be reduced within days after the implant procedure in responders to CRT, while atrial functional parameters remain unchanged. Correlations beween LAVIs and the diastolic filling time/RR interval ratio after CRT suggest that early optimization of atrio-ventricular and ventriculo-ventricular delays may have a positive and immediate impact on LA size.

Atrioventricular nodal reentrant tachycardia (AVNRT) is one of the most common causes of paroxysmal supraventricular tachycardia. For many years, the pharmacological approach was the only therapeutic modality available for managing this arrhythmia. More recently transcatheter radiofrequency (RF) ablation has become a safe and effective alternative to medical therapy. During the last 2 years, 20 patients with AVNRT were evaluated in our department. The diagnosis was made using the classical electrophysiological protocols with three multipolar catheters placed in AV node-His region, coronary sinus and a mapping/ablation catheter. In all cases, a discontinuous AV conduction curve during programmed atrial stimulation with progressively increasing prematurity was demonstrated associated with AV nodal echo beats and induction of the arrhythmia. Typical AVNRT was present in 19 patients. One patient with typical AVNRT also had inducible unusual (slow-slow) AVNRT. An additional patient had unusual slow-slow variant of AVNRT. The arrhythmia was treated in all cases by RFA of the slow AV node pathway, guided by anatomic and electrophysiologic criteria. RF ablation was successful in all patients. Two patients had clinical recurrence of arrhythmia; all have undergone successful reablation. No patient had significant complications of the procedure. As intraprocedural predictors for successful RF ablation were considered the slow pathway potentials with evidence of the junctional accelerated rhythm during RF current delivery and modification of AV node physiology with noninducibility of arrhythmia after RF ablation. The persistence of slow pathway with or without single AV node echo beat during a limited numbers of atrial extrastimuli was accepted as a successful procedure. In all cases, the AV node physiology was tested also after autonomic modulation of AV node. In both cases with clinical recurrence, the intraprocedural RF ablation results were misevaluated probably because of the autonomic modulation of fast pathway electrophysiology masking the persistence of slows pathway conduction. In conclusion invasive electrophysiological evaluation and RF ablation not only eliminate AVNRT, but also provide a unique opportunity to gain insights into the complexity of AV node physiology. This complexity makes more difficult the evaluation of the success of slow pathway ablation for AVNRT and a careful examination of multiple criteria is necessary for a good procedural result.

Infective endocarditis (IE) is a serious, life-threatening disease with highly variable clinical signs, making its diagnostic a real challenge. A diagnosis is readily made if blood cultures are positive, but in 2.5 to 31% of all infective endocarditis cases, routine blood cultures are negative. In such situations, alternative diagnostic approaches are necessary. Coxiella burnetii and Bartonella spp. are the etiological agents of blood culture-negative endocarditis (BCNE) most frequently identified by serology. The purpose of this study is to investigate the usefulness of molecular assays, as complementary methods to the conventional serologic methods for the rapid confirmatory diagnostic of Q fever endocarditis in patients with BCNE. Currently, detection of C. burnetii by culture or an antiphase I IgG antibody titers >800 represents a major Duke criterion for defining IE, while a titers of >800 for IgG antibodies to either B. henselae or B. quintana is used for the diagnosis of endocarditis due to Bartonella spp. We used indirect immunofluorescence assays for the detection of IgG titers for C. burnetii, B. henselae and B. quintana in 57 serum samples from patients with clinical suspicion of IE. Thirty three samples originated from BCNE patients, whereas 24 were tested before obtaining the blood cultures results, which finally were positive. The results of serologic testing showed that nine out of 33 BCNE cases exhibited antiphase I C. burnetii IgG antibody titer >800, whereas none has IgG for B. henselae or B. quintana. Subsequently, we used nested-PCR assay for the amplification of C. burnetii DNA in the nine positive serum samples, and we obtained positive PCR results for all analyzed cases. Afterwards we used the DNA sequencing of amplicons for the repetitive element associated to htpAB gene to confirm the results of nested-PCR. The results of sequencing allowed us to confirm that C. burnetii is the causative microorganism responsible for BCNE. In conclusion, the nested PCR amplification followed by direct sequencing is a reliable and accurate method when applied to serum samples, and it may be used as an additional test to the serological methods for the confirmatory diagnosis of BCNE cases determined by C. burnetii.

UNLABELLED Syncope is defined as a transient, self-limited loss of consciousness. It is an important cause of morbidity in general population and the vasovagal syncope (VVS) is a common clinical problem which often leads to hospital admission, multiple office visits, and performing of many diagnostic tests. Head-up tilt table testing (HUTT) is a widely used diagnostic tool, with proved efficiency in diagnosing the many types of VVS. The aim of our study was to assess the efficacy of the HUTT with sublingual nitroglycerin (NTG) challenge for the diagnosis of vasovagal syncope. PATIENTS AND METHODS The study groups consisted of 72 patients (37 women, 35 men), mean age (+/-SD) 38.5 +/- 15.7 years, referred to our clinic for syncope of unknown origin and 16 healthy volunteers as control subjects (9 women and 7 men) with a mean age 26 +/- 6.5 years and no history of syncope. The HUTT protocol was performed in the morning after an overnight fast, with a 15 minutes supine equilibration phase followed by a 30 minutes drug free tilt phase at an angle of 70 degrees. If no positive response was recorded, 400 micrograms of NTG spray were given sublingually and the HUTT continued for 20 minutes. RESULTS The HUTT was positive in 58 patients (80.5%) and negative in 14 (19.5%) while in the control subjects 4 (25%) had positive HUTT response. The sensitivity of the HUTT protocol with nitroglycerin challenge used in our study was 81% and the specificity was 75% (p<0.0001). CONCLUSION The described HUTT protocol appears to be a simple and efficient tool for the diagnosis of syncope associated with normal ECG and no signs of organic heart disease. The sublingual nitroglycerin challenge was safe to use and showed no side effects while keeping the sensitivity and specificity of the test to an accepted level.

To determine the prognostic value of a low T/R ratio, defined as the amplitude ratio between the T waves and the R waves, in patients (pts) with a spontaneous type-1 Brugada pattern (SBT1). Abnormalities of myocardial repolarization may play a key role in the initiation of ventricular fibrillation (VF) in Brugada syndrome (BrS). Recent studies have shown that the height of the T waves and the T/R ratio are inversely proportional to sudden cardiac arrest (SCA) risk in early repolarization syndrome and hypertrophic cardiomyopathy. In an international retrospective study, we reviewed 115 pts. (105 males, 91.3%). 45 had VF and/or SCA (38.7 ± 11.5 years old, all males), while 70 (49.3 ± 12.0 years, 10 women) remained free of ventricular arrhythmia. 6 ECG markers plus the T/R ratio in leads V5 & II were studied. The T/R ratio among leads II & V5 was significantly lower in the VF/SCA group (0.24 [0.14; 0.38]vs. 0.34 [0.24; 0.45]; p = 0.006). 44.4% of pts. in the VF/SCA group had a lowest T/R ratio among leads II & V5 ≤ 0.17 compared to 11.4% in the non-VF/SCA group (p < 0.001). In multivariate analysis, a lowest T/R ratio among leads II & V5 ≤ 0.17 was independently associated with VF/SCA (OR 6.10, 95% CI 1.92–19.40; p = 0.002). Type 1 Brugada pattern in the peripheral leads (OR 10.78) and early repolarization (OR 3.60) were other independent markers of VF/SCA. A low T/R ratio among leads II & V5 is an independent marker for VF/SCA risk in patients with type-1 Brugada pattern.

Objectives: Aims: In patients with stable angina (SA) and non ST acute coronary syndrome (unstable angina-UA, acute myocardial infarction with ST elevation - STEMI and without ST elevation – NSTEMI) incidence of sudden cardiac death, other major acute cardiovascular events (MACE), blood pressure control and renal function were evaluated in relation with administration of drugs with reducing effects on oxidative stress, platelets hyperactivity and endothelial dysfunction.

Sciendo provides publishing services and solutions to academic and professional organizations and individual authors. We publish journals, books, conference proceedings and a variety of other publications.

The European Cardiac Resynchronization Therapy Survey II is the second CRT survey of the Heart Failure Association and European Heart Rhythm Association designed to observe implantation and follow-up practices across European countries. These data allow, for the fi rst time, a valuable insight on CRT implantation strategies for Romanian patients.

Platelet indices change in relation to cardiovascular risk factors, including type 2 diabetes mellitus (T2DM). An increase of platelet indices over time in patients undergoing percutaneous coronary intervention (PCI) could be a predictor of mortality.The objective of this study was to assess differences in platelet indices in patients with and without T2DM undergoing PCI, prior and more than one month after the procedure.In this retrospective observational study, patients undergoing PCI were included. Data were extracted from PCI Registry of the Emergency Institute for Cardiovascular Diseases and Transplantation of Tirgu Mures, Romania.Of the 718 patients included in the study, 222 (30.9%) had T2DM; 61% of patient underwent PCI for SCAD, the rest for NSTE-ACS or STEMI. Prior to PCI, MPV, PDW and P-LCR were not higher in T2DM patients irrespective of the indication for PCI. At a follow-up time of 69 (46-98) days, platelet indices were not different between TD2M+ and T2DM-, except from MPV (11.0 vs. 10.6, p=0.02) which were higher in TD2M patients with SCAD. Intraindividual variability of platelet indices was not different in diabetics, but MPV, PDW and platelet count decreased over time (3.5% and 8.4% respectively) in diabetics with STEMI (p=0.02).Platelet indices were not higher in patients with T2DM undergoing PCI, but we observed an important variation in platelet indices in diabetics after STEMI related PCI.

Abstract Objective: Cardioplegia is an important step to facilitate cardiac surgery while limiting intraoperative myocardial injury. Although recent advances in cardioplegic arrest methods have significantly contributed to better postoperative outcomes, there is still controversy regarding the optimal composition and temperature of the cardioplegic solution. Accordingly, we aimed to assess whether cold or lukewarm Sabax cardioplegia offer improved myocardial protection compared with the classical Krebs-Henseleit solution. Methods: The hearts of 40 male Wistar rats were isolated and submitted to constant-flow retrograde perfusion using a Langendorff perfusion apparatus. The hearts were randomly assigned to cold Krebs-Henseleit (K-H), cold Sabax, or lukewarm Sabax cardioplegia. The ECG, heart rates, and left ventricular systolic pressures (LVSP) were recorded pre- and post-cardioplegia. The time needed for cardioplegia induction and post-cardioplegia recovery were also noted. Results: Both cold and lukewarm Sabax cardioplegia insured faster induction and faster recovery following isothermic reperfusion compared to the standard K-H solution (both p&lt; 0.01). With K-H cardioplegia, the hearts presented a 21.7% force loss after reperfusion (p&lt; 0.001), whilst Sabax cardioplegia was associated with a slight increase in ventricular mechanical activity (3% LVSP increase with lukewarm Sabax cardioplegia, p&lt; 0.001 and 2% LVSP increase with cold Sabax cardioplegia, p = 0.02). With Sabax cardioplegia the hearts displayed considerably less major arrhythmic events and presented less significant bradycardia. Conclusions: The present data suggest that Sabax cardioplegia may be superior to the classical cold crystalloid K-H solution in preserving mechanical activity of the heart and may provide superior protection against major arrhythmias.

Abstract Background: Right ventricular apical pacing has been used since the early years of pace-makers, despite the fact that it determined nonphysiological ventricular depolarization. As medical technologies developed, septal lead implantation became feasible, in order to outrun the above mentioned inconveniences. The question whether the apical or septal lead position is better still gives rise to a lot of controversies. Different echocardiographic parameters are currently used to assess the impact of specific sites of stimulation on ventricular function. The aim of the study was to determine which of the followed synchronicity parameters varied significantly during apical stimulation, compared to septal stimulation in patients requiring single chamber pacing. Material and method: Fifty-nine patients admitted between January 1st - December 31st 2012 either for battery replacement or for first implant of a single chamber pace-maker were included in this prospective study. Thirty-eight of them had the lead placed in the apex of the right ventricle and 21 on the interventricular septum. All were subjected to echocardiografic examination after device implantation. Measurements included complete chamber and valvular assessment, apart from the synchronicity evaluation, that comprised interventricular mechanical delay (IVMD), septal to posterior wall delay (SPWMD) and electro systolic delays (ESD), in order to assess the presence and compare the relevance of interventricular and intraventricular dissyncrony. All the investigations were in accordance with the Declaration of Helsinki. Results: Although preejection times were significantly different, there were no statistically significant differences (p = 0.06) between the values of IVMD in the two groups, as well as regarding the longitudinal intraventricular dyssynchrony expressed by ESD. Significant differences appeared though, between the values of SPWMD, reflecting the fact that radial intraventricular dissyncrony is present in apical stimulation. Conclusions: During apical right ventricular pacing, radial intraventricular dissyncrony appears, while in the case of septal pacing this parameter is close to normal. Surprisingly, although right ventricular pacing determines interventricular and longitudinal intraventricular dissincrony, we found no significant differences in this respect, between apical and septal pacing.

Abstract Background: Sepsis is a systemic host response to an infection which may evolve into severe sepsis and septic shock. It raises many health care related concerns around the world, carrying almost 30% mortality rates and a high financial burden. The disease is characterized by the triggering of some inflammatory pathways that are ultimately proven deleterious to the host organism. Although antibiotics, fluid administration, vasopressor therapy and infectious source control remain the recommended management strategies, emerging scientific data proposes statins as a new line of treatment. These drugs were first introduced in clinical practice for their cholesterol-lowering effect but the inhibition of HMG-CoA reductase and cholesterol biosynthetic pathway exhibits some less studied effects generally referred to as pleiotropic: anti-inflammatory, antithrombotic, immunomodulatory and antioxidant properties. Objective: To asses and compare the anti-inflammatory effect of two statins - Simvastatin and Rosuvastatin - measuring blood levels of IL-1β, IL-6 and TNFα using a previously described murinic model of sepsis. Methods: We compiled four groups (C, n=7; SEP, SV, RV, n=8). Statins were administered in two doses 18 and 3 hours before surgical intervention. Sepsis was induced using the caecal ligation and puncture technique. Blood samples were obtained by venepuncture from each subject in day 1, 4, 7 and 14 (the last samples were obtained by cardiac puncture). Complete blood count, Procalcitonin, IL-1β, IL-6 and TNF-α levels were assessed. Results: White blood cell counts differed across the groups showing a higher count for the septic but untreated group. Procalcitonin reacted in all septic groups but both statin treated groups had lower levels when compared to untreated group. IL-1β levels were higher in the Rosuvastatin treated group. IL-6 levels were more heterogeneously dispersed but higher levels were noticed in the untreated septic group. The Simvastatin treated group had higher levels compared to the Rosuvastatin treated one. TNFα levels were higher in the septic untreated group and in the Rosuvastatin treated one. For the Simvastatin treated subjects, the level of TNFα was similar with the control group. Conclusion: We concluded that both drugs showed anti-inflammatory effects on the murinic CLP-induced sepsis model. Between the two, Simvastatin had greater impact by lowering blood levels of established pro-inflammatory markers.

Cardiac resynchronization therapy has become a widely used procedure for the treatment of patients with heart failure and severely impaired systolic function who associate left bundle branch block and remain symptomatic, in New York Heart Association II to IV functional class, despite maximum tolerated medical therapy. Imaging evaluation of these patients is complex, aiming to provide an accurate and extensive assessment before and after implantation, although a standardized protocol is yet to be implemented. Extensive research has been conducted to assess the ability of different imaging techniques and parameters to identify and quantify mechanical dyssynchrony, assess myocardial remodeling, provide prognostic information, or help guide lead placement and pacing parameters optimization in this category of patients. For these purposes, ultrasound-based imaging techniques, as well as cardiac magnetic resonance imaging, multislice cardiac computed tomography and nuclear ventriculography have been and are currently used, for research, as well as for clinical purposes. The aim of the current paper was to provide some insights into the imaging assessment of candidates and patients who have undergone cardiac resynchronization therapy.

Abstract Introduction: combined myocardial infarction (MI) is defined as the simultaneous ischemic injury of two different myocardial territories, raising the possibility of multiple culprit lesions. The anomalous origin of a coronary artery could represent an important challenge during percutaneous coronary intervention (PCI). Case presentation: A 46 year old, smoker Caucasian male presented to a territorial hospital four hours after the onset of severe angina. Consecutive electrocardiograms showed complete atrioventricular block and inferior ST segment elevation (STE), later PQ prolongation with right bundle branch block plus STE in leads V4-V6. After administration of thrombolytic treatment, the patient was transferred to the regional PCI center. Emergent coronary angiography revealed acute occlusion of the left anterior descending artery (LAD) and a thrombus containing, severe stenosis of the anomalously originated right coronary artery (RCA). Rescue PCI with stent implantation in the LAD and RCA was performed nine hours after pain onset. At the 1 year follow-up visit the patient had no angina or heart failure symptoms. Conclusion: this is the first report of a combined MI caused by acute, sequentially occurring thrombotic occlusion of two coronary arteries, one of them with anomalous origin, in a patient treated by rescue PCI following partially successful thrombolysis.

Abstract Introduction : Coronary vasospasm is a possible cause of ventricular tachyarrhythmias and is frequently associated with atherosclerotic lesions. The revascularization of mild to moderate coronary artery stenosis which causes symptoms only due to associated vasospasm is still a matter of debate, as the standard treatment of Prinzmetal angina is represented by the long term administration of calcium-channel blockers. Case presentation : We present the case of a 46 year old woman with an intermediate severity coronary artery stenosis complicated by vasospastic angina and subsequent polymorphic ventricular tachycardia. Although the functional significance of the fixed coronary artery lesion was equivocal at invasive fractional flow reserve measurement, a combined pharmacologic and interventional treatment strategy was chosen with stent implantation and long acting calcium channel blocker administration with a symptom-free, good clinical outcome. Conclusion : Patients with vasospastic angina and intermediate severity atherosclerotic coronary artery stenoses are at risk of malignant ventricular arrhythmias, therefore myocardial revascularization should be considered in addition to the standard medical treatment.

Corrigendum to: Approach to cardiac resyncronization therapy [Europace 2012 14: 1359–1362] The authors would like to acknowledge the following: The …

Chronic apical right ventricular pacing may impair left ventricular function and cause heart failure in patients with indication for antibradycardia pacing and normal left ventricular ejection fraction at baseline, through multiple electro-mechanical changes.We describe the case of a patient who needed an upgrade to cardiac resynchronization therapy and developed angina early after single chamber right ventricular pacing and discuss pacing induced cardiomyopathy.

The current COVID-19 pandemic affects healthcare worldwide.Patients living with cardiac implantable electronic devices (CIEDs) are at high-risk to experience emotional distress and severe COVID-19 symptoms.Assessing their mental and physical health condition during the pandemic is crucial.An online questionnaire consisting of 45 multiple-choice questions regarding the patients' emotional and physical status was completed by 210 CIEDs participants.On the eligible 184 responses, a principal axis factoring (PAF) multivariate analysis was performed, which is part of the Exploratory Factor Analysis (EFA) class, frequently used in healthcare research.The considered variables in the PAF were CIEDs patients' concerns related to: device functioning, having received a shock (if ICD), the possibility to receive a shock (if ICD), access to medical care, reaching physicians, access to medication, getting infected by SARS-CoV-2, the health of caretakers, the health of their loved ones.However, one of the most difficult tasks in PAF is the selection of an appropriate number of factors.We proposed three rules to be considered, the verification of: the Kaiser criterion, the Cattell's Scree test, and the cumulative variance (to explain at least 60-65 %).After the number of factors had been established, we proposed a final verification, the Monte Carlo Parallel Analysis.Two factors were identified, subsequently defined as "Healthcare-related concerns" and "Fear of COVID-19 disease", which explained 75.56% of the cumulative variance.The factors highlight the need for accurate medical information provision, patient education, and support to improve healthcare during the pandemic.

Coronary artery disease of non-atherosclerotic aetiology, while rare in incidence, can have a wide aetiology, such as fibromuscular dysplasia, which is a non-inflammatory arteriopathy of numerous histopathological types of fibromuscular tissue accumulation. This brief report describes the case of a 22-year-old male with a recently developed dilated cardiomyopathy and a history of aborted cardiac arrest at the age of 14 years. Coronary angiogram revealed severe three vessels disease, while optical coherence tomography established fibromuscular dysplasia as aetiology. Balloon and stent angioplasty was performed guided by fractional flow reserve with acceptable angiographic result.

Abnormalities of myocardial repolarization may play a key role in the initiation of ventricular fibrillation (VF) in Brugada syndrome (BrS). Recent studies have shown that the height of the T-waves and the T/R ratio are inversely proportional to the sudden cardiac arrest (SCA) risk in early repolarization syndrome and hypertrophic cardiomyopathy. To study the prognostic value of a low T/R ratio in patients (pts) with a spontaneous Brugada type 1 pattern (SBT1). In an international retrospective study, we reviewed 115 pts (mean age 45.1 ± 12.8 years, 91.3% males) with SBT1. Forty-five presented a documented VF and/or SCA at a mean age of 38.7 ± 11.5 years, 20 came from a review of published cases reports. Six ECG markers and the T/R ratio in leads V5 and II were studied. A low T/R ratio was defined by < 0.2. The T/R ratio was significantly lower in pts with VF/SCA (lead V5: 0.28 ± 0.15 vs. 0.36 ± 0.17, P = 0.008; lead II: 0.47 ± 0.33 vs. 0.61 ± 0.51, P = 0.04). A low T/R ratio in lead V5 or II was significantly associated with VF/SCA (respectively 44.4% vs. 14.3%, P < 0.001 and 22.2% vs. 7.1%, P = 0.02). In multivariate analysis by logistic regression, a low T/R ratio in lead V5 was an independent marker of a higher risk of VF/SCA with an OR of 4.11 (P = 0.02). Brugada type 1 pattern in peripheral leads, wide QRS in lead V2 and early repolarization were other independent risk markers (see Fig. 1). A low T/R ratio in lead V5 is an independent marker for VF/SCA risk in patients with a SBT1.

The aim of the study is to provide new data regarding the main factors that influence resting energy expenditure (REE) value, by analysing daily training activity and cardiopulmonary adaptation during 4 months of general cross country roller skiing training. Three different training stages, defined as P1, P2, and P3 were analysed. In order to program the training, one maximum oxygen consumption (VO2max) test was conducted at the beginning of the second stage (P2), while three RMR analyses were performed at an interval of 40–42 days period, between each of the analysed stages (P1–P3). An increased Z5 effort time (17.55%), during P2, was associated with an elevated VT (0.66 l/min) (0.59–0.80) during the RMR test (P = 0.0095). Increased VT determined a reduction in RQ (r = 0.75, 95%CI = −0.09 to −0.02, P = 0.01), with an increased REE value (r = 0.64, 95%CI = 0.07 to 0.89, P = 0.03). Changes in REE were identified during P1 and P3 stages unlike P2 (P = 0.0212). During the analysed periods, changes in EE were significantly correlated with high intensity effort time (90–100% of FCmax) conducted over the predetermined training stages (r = 0.81, 95%CI = 0.39 to 0.95; P < 0.01). Increased training intensity was correlated with an increased resting VO2 (r = 0.97, 95%CI = 0.69 to 0.97, P = 0.01), related to REE changes. Changes were recorded in the RMR results over 48 hours from the last training session, during both low and high intensity effort. RMR evolution was related to the effort intensity and the cardiopulmonary adaptation, as a result of training. An increased effort intensity over 42 analysed days, was associated with an important elevation in VE, PetO2, following a VT drop and an increased resting VO2, influencing REE values thorough important changes in RQ. Le but de cette étude est de fournir des nouvelles DATA en ce qui concerne les facteurs principaux qui influencent la valeur de la dépense énergétique du repos (REE) par l’analyse des entraînements quotidien et de l’ajustement cardiopulmonaire pendant 4 mois de formation générale en ski de fond. Il y a 3 stages différents d’entraînement qui ont été définis comme P1, P2 et P3, et qui ont été analysés. Afin de programmer la formation, la consommation maximale d’oxygène (VO2max) a été déterminée au début de l’étude. Puis, le rythme métabolique au repos (RMR) a été analysé trois fois, avec un intervalle de 40–42 jours entre les étapes d’analyse (P1–P3). Le prolongement de l’effort anaérobique pendant P2 a été associé avec des taux élevés du volume courent (VC) (0,66 L/min) (0,59–0,80) pendant le test de RMR (p = 0,01). L’augmentation du VC a déterminé la réduction du ratio de l’échange respiratoire (RER) (r = 0,64, IC 95 % = 0,07 à 0,89, p = 0,03) Les changements de la dépense énergétique du repos ont été identifiés pendant l’entraînement de phase P1 et P3, mais pas pendant le P2 (p = 0,0212). Pendant la période analysée, les changements de la dépense énergétique ont été significativement corrélés avec le temps d’effort de haute intensité (90–100 % of FCmax) pendant chaque des trois étapes d’entraînement prédéterminés (r = 0,97, IC 95 % = 0,69 à 0,95, p < 0,01). L’intensité d’entraînement a été corrélée avec une augmentation du VO2 de repos relatif à la dépense énergétique du repos. Les changements ont été enregistrés dans les résultats du RMR plus de 48 heures après l’entraînement, pendant des efforts de haute ou de basse intensité. L’évolution du RMR a été corrélée à l’intensité de l’effort et à l’adaptation cardiopulmonaire induite par la formation. L’augmentation de l’intensité d’effort pendant les 42 jours analysés a été associée avec une élévation importante de la ventilation et de la pression partielle de l’O2, suivant la baisse du VC et l’augmentation du repos de VO2, qui a influencé la valeur REE par des changements importants du RER.

Abstract Platelet indices have been linked to the severity and prognosis of coronary artery disease, but a very small number of studies assessed them under dual antiplatelet therapy after percutaneous coronary intervention (PCI). The aim of this study was to evaluate changes in mean platelet volume (MPV), platelet distribution width (PDW) and platelet-large cell ratio (P-LCR) in these patients. A number of 437 patients with stable coronary artery disease, 131 patients with non ST segment elevation acute coronary syndrome and 151 patients with ST segment elevation myocardial infarction were included in the study. There was no difference between the three groups regarding platelet indices prior to PCI. Follow-up data was available for 181 patients, at a mean follow-up time of 69 (46-98) days. MPV, PDW and PLC-R were similar to those prior to PCI in all three groups. Regarding the P2Y12 inhibitor, clopidogrel or ticagrelor, there was no difference at follow-up between platelet indices irrespective of the indication for PCI.

Prediction of the individual risk of sudden cardiac arrest (SCA) remains the main challenge in Brugada syndrome. Several studies have shown that the surface electrocardiogram (ECG) can provide useful information that allows to estimate the risk of SCA. The T-wave amplitude is inversely correlated with the risk of ventricular fibrillation (VF) & SCA in several heart diseases. The purpose of this study was to evaluate the prognostic value of a low T/R ratio in patients with a spontaneous type-1 Brugada pattern (SBT1). In a multicenter study, we retrospectively reviewed 115 pts (105 males, 91.3%) with a SBT1. 45 had VF and/or SCA (38.7 ± 11.5 years old, all males), while 70 (49.3 ± 12.0 years, 10 women) remained free of ventricular arrhythmia. 6 ECG markers plus the lowest T/R ratio among leads V5 & II were studied. The lowest T/R ratio among leads II & V5 was significantly smaller in the VF/SCA group (0.26 ± 0.15 vs. 0.35 ± 0.16; P = 0.006). The optimized cut-off value was ≤ 0.17 by the receiver operating characteristic curve method. 44.4% of pts in the VF/SCA group had a lowest T/R ratio among leads II & V5 ≤ 0.17 compared to 11.4% in the non-VF/SCA group (P < 0.001). In multivariate analysis, a lowest T/R ratio among leads II & V5 ≤ 0.17 was independently associated with VF/SCA (OR 6.10, 95% CI 1.92-19.40; P = 0.002). Type-1 Brugada pattern in a peripheral lead (OR 10.78) and early repolarization (OR 3.60) were the other independent ECG markers of VF/SCA (Fig. 1). A low T/R ratio among leads II & V5 is independently and strongly related to the risk of VF/SCA in patients with a spontaneous type-1 Brugada pattern.

A hypothesis of transition from atrial fibrillation to sinus rhythm in close relation with monophasic action potential duration is proposed. The first way: the prolongation of the right atrial refractoriness reduces the wave fronts below a critical number and their collision terminates the arrhythmia. The second way: progressive shortening of refractoriness at a critical level with block and collision of wave fronts.

We present the case of a 5-month-old infant with tetralogy of Fallot and congenital atrio-ventricular block that developed severe left ventricular dysfunction during apical left ventricular pacing, in which cardiac resynchronisation therapy was used as an emergency procedure due to persistent low cardiac output syndrome.

Monophasic action potential (MAP) represents an extracellular recording of electrical potentials variations produced simultaneously by several cells. Even if it does not represent the real cellular action potential, monophasic action potential generally reproduces with accuracy that aspect, being useful especially in the assessment of myocardial repolarisation phases. Monophasic action potential recording was performed with a quadripolar catheter designed by Franz; the quality of recordings was good and the procedure is safe. In clinical electrophysiology, monophasic action potential may be helpful in the study of certain aspects that cannot be evaluated adequately by standard electrophysiological techniques. The study was performed on six patients, in drug-free state. The duration of monophasic action potential at 90% of repolarisation and the atrial effective refractory period, at three basic cycle lengths (600, 500 and 400 msec) were determined. Both monophasic action potential duration at 90% of repolarisation and the atrial effective refractory period shortening at short cycle length and a linear correlation between these two parameters were seen. We conclude that the correlation between monophasic action potential duration and the effective atrial refractory period may be a simple and useful model to characterise in vivo the electrophysiologic profile of antiarrhythmic drugs.

Fourteen patients with atrial flutter (AFL) and rapid atrial tachycardia (AT) (8 AFL type I, 2 AFL type II and 4 AT) were treated with endocavitary atrial pacing (EAP). In 10 patients no antiarrhythmic agent was during this study and in 4 patients digoxin and/or verapamil was administered before. Conversion to sinus rhythm was successfully achieved in 7 patients, 50% (4 AFL type I and 3 AT). Primary success rate (return to sinus rhythm either immediately or after < 10 min of atrial fibrillation) was 71% (5/7) (2 AFL type I and 3 AT); delayed success (conversion to sinus rhythm in > 10 min, but < 24 h) was observed in 2 cases (29%) with AFL type I. At five patients AFL was converted in stable atrial fibrillation (4 AFL type I and 1 AFL type II). EAP failed to terminate the arrhythmia in 1 patient with uncommon AFL (type II) and 1 case with AT. EAP included single extrastimuli, coaction, single decremental atrial extrastimuli and incremental atrial pacing (burst) during AFL or AT. In conclusion, EAP is a method with few complications and has efficacy for converting AFL and rapid AT sinus rhythm or to atrial fibrillation.

Electrophysiologic investigation was done for ten patients with clinical and ECG criteria for sick sinus syndrome (SSS). Sinus node function was assessed through corrected sinus node recovery time (CSNRT) and sinoatrial conduction time (SACT), before and after autonomic blockade (AB) with propranolol 0.2 mg/kg and atropine 0.04 mg/kg, given intravenously. Four patients having electrophysiologic parameter in normal range before AB were not considered as SSS. In three patients extrinsic sinus node dysfunction (SND) was found, the pathologic values of CSNRT and SACT being normal after AB, and in one patient with sinus bradycardia, the sinus node function was difficult to be appreciated. In two patients only intrinsic SND was found and, in consequence, pacemaker device was implanted.

Postextrasystolic changes in ventricular depolarization were found in patients with coronary artery disease in two situations: a) after a compensatory postextrasystolic pause and, b) after an interpolated ventricular beat. The explanation and the underlying conditions of this phenomenon are discussed. In our opinion the postextrasystolic change may be a silent myocardial ischemia.