To study contractile function of the left atrium (LA) and pulmonary veins (PV) before and immediately after the PV antrum isolation, transthoracic and transesophageal echocardiography was performed in 17 patients (10 men and 7 women) aged 57.4±8.3 years. Five patients suffered from paroxysmal atrial fibrillation (AF) and 12 patients had persistent AF. The arrhythmic history was 25.2±8.1 months. The arrhythmia was considered idiopathic in 12 patients and a sign of post-infarction or post-myocarditic cardiosclerosis in 5 ones. All patients before the PV antrum isolation had the sinus rhythm; in none of them, signs of the LA stunning were revealed during transthoracic echocardiography. Multispiral computed tomography (MSCT) of the heart was performed using a 64 slice device, Somatom Sensation 6 (Siemens). 100 ml of contrast media containing iodine in a concentration of 350 mg/ml were administered as intravenous bolus injections into the cubital vein with the aid of automated syringe injector. The images recorded were analyzed using the Leonardo multi-modal workstation (Siemens). Transthoracic echocardiography was carried out using ultrasound scanner Aloka SSD 500 ProSound. Alterations of transmitral flow typical for the left ventricle (LV) diastolic dysfunction in most patients were revealed after the PV antrum isolation. The normal type of transmitral flow reported at baseline transformed into the pseudo-normal type in 17% of cases (2 cases of 12) and into the restrictive type in 10 cases (83%). The baseline diastolic dysfunction of hypertrophic type upon the procedure termination was followed by restrictive type of transmitral flow in all 5 cases. However, end diastolic LV pressure measured invasively after the PV antrum isolation did not change (8.2±2.2 mm Hg and 8.3±2.2 mm Hg, respectively). Thus, the transmitral flow dynamics were related to alterations of contractile function of the left atrium itself rather than the LV diastolic dysfunction. The assessment of circulation in PA showed that their isolation led to a decreased peak velocity of both anterograde and retrograde phases. Thus, after the PV antrum isolation, deterioration of the LA reservoir function occurs, without alterations in the left auricle contractile function. The contractile function of LA and PV muscular muffs was assessed with the aid of transesophageal echocardiography and continuous direct manometry in the cavities of LA, LV, as well as inside a balloon inflated at the level of PV muffs. The soft elastic balloon was inflated by a contrast medium until complete occlusion of the corresponding PV, without stretching its muscular muffs. All measurements were conducted both before and after the PV antrum isolation. Peaks of balloon pressure revealed did not absolutely coincide with E and A peaks relevant to the transmitral flow. During the LA passive relaxation, LV muscular muffs were also contracting. Elevated LA and balloon pressure was achieved also during active atrial systole, therefore, the PV muff was also contracting. After the PV antrum isolation, the balloon pressure curve dampened that probably gave evidence of the relief of active contractile function of PV mechanic muffs. During multi-spiral computed tomography, the PV diameter fluctuation also decreased significantly. Thus, after the LV antrum isolation, deterioration of the LA reservoir function takes place, without changes in the left auricle contractility. Hemodynamic alterations in PV due to an impaired contractility of their muffs are main mechanisms of this effect.

To assess safety and effectiveness of ablation of ganglion plexuses and areas of complex fractionated atrial electrograms revealed during overdrive pacing in patients with paroxysmal atrial fibrillation (AF), 84 patients aged 59±7 years were included into the study. The ablation sites were defined as areas where vagus reflexes developed in response to overdrive pacing conducted with the frequency of 20 Hz, amplitude of 15 V, and impulse duration of 10 ms. Areas of complex fractionated atrial electrograms were defined as fractionated atrial electrograms which consisted of two or more deviations from baseline, with the persistent deviation from the prolonged activation complex. Radiofrequency ablation was performed in all areas with the positive vagus response during overdrive pacing and additionally continued in the area of complex fractionated atrial electrograms. In all study subjects, by the end of ablative procedure, the recorders Reveal XT (Medtronic Inc.) have been implanted according to the commonly accepted technique for persistent cardiac rhythm analysis. During the follow-up period, the patients were free of therapy with antiarrhythmics and β-blockers. Sustained AF was inducible by overdrive pacing in all study subjects. The number of overdrive suppressions made was 41±7 per patient. The number of radiofrequency applications sufficient to eliminate completely the vagus response was 5.4±2.5 ones per area revealed. In addition, 8.7±5.2 radiofrequency applications were performed in each area of complex fractionated atrial electrograms. In total, 68.2±9.4 radiofrequency applications were made. During the follow-up period, AF recurrence (i.e., AF burden >0.5%) was observed in 24 patients of 84 (28.6%). Thus, the expanded ablation of ganglion plexuses can be performed safely and provides the sinus node maintenance in a majority of patients with paroxysmal AF during a 12 month of follow-up. Effectiveness of the procedure can be caused by more pronounced autonomic denervation.

To assess the effect of simultaneous renal artery denervation (RAD) and circulatory pulmonary vein isolation (CPVI) on the clinical course of atrial fibrillation (AF) and arterial hypertension (AH), 35 patients were examined (18 patients with CPVI and 17 patients with CPVI+RAD). In all patients, the complete electric CPVI without additional linear applications was performed. In all patients randomized to the CPVI+RAD group, bilateral RAD was performed immediately after the CPVI procedure. 3D reconstruction of aorta and renal arteries was performed using the navigational system and catheter for pulmonary vein isolation. The access was performed through the femoral artery. Mapping and RAD were carried out at the background of sedation with Propofol. Radiofrequency spiral application (8 10 W) was made from the distal part of the renal artery (from its bifurcation) towards its ostium. The duration of each application was 2 minutes. The number of applications did not exceed 6, and they were made more than 5 mm from the previous in longitudinal-rotary direction. The applications were made in both renal arteries. The complete CPVI was successfully achieved in 35 patients (100%). RAD was successfully performed in all 17 subjects of Group II which led to termination of the blood pressure increase in response to the overdrive suppression after ablation. The number of application per renal artery was 4.4±0.8 (4 6 applications, median: 4). The duration of procedure made up 152±29 min for the CPVI Group and 194±39 min for the CPVI+RAD Group (including 32±18 minutes for RAD; p=0.17). The X ray exposure was 22±17 min for the CPVI group and 29±12 min for the CPVI+RAD Group (including 9±2 min for RAD; p=0.22). No case of renal artery stenosis in patients with RAD was revealed during magnetic resonance tomography 6 months after the surgery. In the patients with RAD, the glomerular filtration rate did not significantly change as compared with the pre-operation data and made up 77.0±6.2 ml/min/1.72 m2 and 82±4.7 ml/min/1.72 m2, respectively, (p=0.42). Twelve months after the surgery, 12 patients of 17 in Group II (70.6%) were free of arrhythmia. In the pulmonary vein isolation group, only 6 patients of 18 (33.4%) were free of AF paroxysms (p=0.01). All 17 patients of Group II showed a decrease in the systolic blood pressure of more than 10 mm Hg after the RAD procedure. Thus, the additional RAD had a positive effect on the sinus rhythm maintenance in patients with AF and resistant AH, in whom CPVI was performed. RAD led to a considerable and stable decrease in the systolic and diastolic blood pressure within 12 months following the surgery.

O study the -455G>A gene polymorphism of the fibrinogen β-chain (FGB) in families of patients with atrial fibrillation (AF) and stroke, 43 probands with chronic AF and a history of stroke (25 women and 18 men) and their 56 relatives of degrees of kinship of grades I III (39 women and 17 men), as well as 153 subjects of the control group free of cardiovascular pathology (82 women and 71 men) were examined. The patients with stroke aged 63.7±18.86 years (45 85 years), their relatives aged 53.6±16.8 years (12 73 years), and the control group subjects, 52.4±16.4 years (45 69 years). In the study subjects, performed were assessment of complaints and the medical history, physical examination, electrocardiography, and echocardiography. The gene polymorphism was tested with the aid of polymerase chain reaction in the real time mode. A significant prevalence of the homozygous genotype AA was revealed in the patients with AF and stroke as compared with the control group (11.6% and 2.6%; p=0.037). A tendency to prevalence of the above genotype was noted in the relatives of patients with AF and stroke (8.9% and 2.5%; p=0.108). The prevalence of the AA genotype in the probands with AF and stroke and their relatives did not differ (11.6% and 8.9%; p=0.916). In the patients with AF and stroke, a considerable prevalence of the A allele as compared with the control group was revealed (32.6% and 19.6%; p=0.017). In the relatives of the patients with AF and stroke, Allele A was also revealed more frequently than in control group (30.4% and 19.6%; p=0.028). Thus, taking the results obtained into the account, an correlation of the genotype AA and allele A with stroke in the families of patients with AF and stroke was revealed.

To study morphological and morphometric peculiar features of the right atrium (RA) and the Bachmann bundle structure with regard to the implantation technique of electrodes for atrial pacing, 84 hearts from 49 male and 35 female corpses aged 34 75 years were studied. Morphometry of the heart chambers and separate heart structures, macro-and micro-preparations, diaphanoscopy of preparations, injection of bi-color polymeric compound with subsequent soft tissue corrosion were performed; and methods of polymerase embalming was used. The heart and heart chambers’ size, dimensions of the right atrium (RA) structures, as well as the RA morphometric indices affecting the endocardial electrode positioning during pacemaker implantation were assessed. The antero-posterior (longitudinal) heart size, superio-inferior heart size at the level of tricuspid valve, superio-inferior RA size, transversal RA size, superio-inferior and transversal left atrium (LA) size, basis of the right auricle, diameters of the superior and inferior cave veins (SCV and ICV), oval fossa (both cranio-caudal and antero-posterior axes), coronary sinus diameter, distance from the lateral edge of SCV to the right auricle apex, distance from the lateral edge of SCV to the Bachmann bundle area, distances from the Bachmann bundle area to the Koch triangle apex, from the right auricle apex to the Koch triangle apex, from the anterior edge of the oval fossa to the Bachmann bundle area, and mean myocardial thickness in the areas of RA am Bachmann bundle were measured. The antero-posterior (longitudinal) heart size was 159.9±6.5 mm (140 173 mm), the superio-inferior heart diameter at the level of tricuspid valve was 93.9±3.3 mm (86 102 mm), the superio-inferior RA size was 49.3±2.6 mm (43 57 mm), the transversal RA size was 40.6±2.5 mm (35 50 mm), the superio-inferior LA size was 39.3±2.7 mm (34 46 mm), the transversal LA size was 42.1±3.1 mm (35 51 mm). The SCV diameter was 18.2±1.5 mm (14.6 21.7 mm). The ICV diameter was longer by 3.1 mm on the average and made up 21.3±1.3 mm (17.8 24.8 mm). The superio-inferior oval fossa diameter was 23.7±2.6 mm (18 31 mm) and the antero-posterior diameter, 22.6±3.0 mm (16 30 mm). The distance from the superio-anterior edge of the oval fossa to the Bachmann bundle area was 16.6±2.3 mm. The distance of excitation wave from the Bachmann bundle area to the compact part of AV node was on the average shorter by 17.9 mm than that from the right auricle (40.6±4.6 mm and 58.5±2.8 mm, respectively, p<0.001). The Bachmann bundle thickness and width were 5.1±0.7 mm and 15.3±3.1 mm, respectively. The atrial wall thickness in the Bachmann bundle area (from 2.2±0.5 mm through 3.7±0.7 mm) was bigger than in the right auricle (from 1.6±0.3 mm through 3.5±0.7 mm). Thus, the electrode positioning in the Bachmann bundle area, unlike its implantation into the right auricle, is more grounded from the morphological viewpoint.

To study effectiveness of radiofrequency ablation (RFA) of atrial fibrillation (AF) in patients with coronary artery disease (CAD) during the aortocoronary bypass grafting surgery (ACBG), to assess freedom from arrhythmia in the late post-operation period, pro-arrhythmic effects, and quality of life of patients after the surgery, 95 patients (74 men; 78%), aged 62.8±8.8 years were examined and surgically treated. Group I included 31 patients, in whom radiofrequency ostial pulmonary vein isolation (ROPVI) was performed. The radiofrequency procedure Cox-Maze was performed in 30 patients of Group II. In 34 patients of Group III, only the ABCG surgery was performed. According to the echocardiography data, ejection fraction lower than 35% was found in 8 patients, moderate mitral insufficiency, in 22 patients, and the left ventricular aneurysm, in 9 subjects. ROPVI included application of ablation lines on common collectors of pulmonary vein ostia. The radiofrequency procedure Cox-Maze included the ostial pulmonary vein isolation, resection of the left auricle, as well as application of ablation lines from the resected left auricle towards the left upper and lower pulmonary veins, as well as the fibrous ring of the mitral valve, and on the left atrial roof. For persistent long-term ECG monitoring in the late post-operation period, implantable devices Reveal XT were used. The ACBG surgery in combination with different types of AF ablation took place in the study subjects without technical issues. During the application of ablative lines, no issues related to the branch positioning were noted. All patients after AF ablation received antiarrhythmic and anticoagulant therapy in early post-operation period to prevent iatrogenic arrhythmias. No significant difference was observed in the duration of stay in ICU in all three groups; no differences between both study and control group in the clinical course of the post-operation period and incidence of complications developed in the early post-operation period were revealed, as well. At the discharge from hospital, the sinus rhythm was documented in all patients from Group I and control group excluding one patient from both above groups apiece who had the pacemaker rhythm after the planned pacemaker implantations occurred during the surgery. In the late post-operation period, the sinus rhythm was detected in 26 patients of 30 (86.7%). In Group II, 28 patients of 29 (96.5%) had the sinus rhythm one year after the operation. In the control group after one year of follow-up, only 18 patients of 34 had the sinus rhythm, i.e. the freedom from arrhythmia was 53%. Thus, RFA of persistent AF during the ACBG procedure is a highly effective and safe method of treatment of AF. Radiofrequency isolation of pulmonary vein ostia during the ACBG surgery permits one to restore the sinus rhythm in 100% of patients and radiofrequency procedure Cox-Maze, in 96.7% of patients. The radiofrequency procedure Cox-Maze is associated with a less pro-arrhythmic effect than the radiofrequency isolation of pulmonary vein ostia. The effective AF elimination during the ACBG surgery improves the quality of life of the patients according to all scales of the SF 36 questionnaire. Insertable cardiac monitors are highly effective in detection of AF paroxysms and permit one to correct or discontinue antiarrhythmic and/or anticoagulant therapy in proper time. Radiofrequency isolation of pulmonary vein ostia during the ACBG surgery maintains the sinus rhythm in the late post-operation period in 80% of patients with persistent AF, the radiofrequency procedure Cox- Maze, in 86.2% of patients, and the ACBG surgery alone, in 44.1% of subjects.

To compare late survival of patients with moderate-to-severe chronic heart failure (CHF) who received cardiac resynchronization therapy (CRT) depending on the QRS complex duration, 122 patients were examined. Group I consisted of 43 patients (41 men) aged 53±1.4 years with QRS duration <120 ms; Group II consisted of 79 patients (68 men) aged 56±1.2 years with QRS duration >120 ms. The follow-up period duration was 24±1.7 months (up to 80 months). The information on the patients’ survival was obtained for 36 patients of Group I (84%) and 60 patients of Group II (76%). Within the follow-up of 43 months, survival of the patients with the “narrow” QRS complex was significantly better than in those with the “wide” QRS complex (76% and 51%, respectively; p=0.03). Then, the survival curves intersected and, by the end of the follow-up period, no statistically significant difference between the study groups was revealed (42% and 66%, p=0.13). During the follow-up period, 7 patients with the “narrow” QRS complex (16%) deceased, including 5 patients (12%) who died within the first 43 months. In the group of patients with the “wide” QRS complexes, 19 patients (24%) deceased, all lethal outcomes occurred within first 43 months of the follow-up. The multivariant analysis showed that atrial fibrillation (AF) significantly worsened outcome of the patients with CHF and radiofrequency ablation, on the contrary, improved survival. The risk of death of patients with AF was three times higher and of those without radiofrequency ablation was twelve times higher. The QRS complex width and presence of angina did not show any effect on survival. Thus, in the real clinical practice, CRT was associated with a better survival of the patients with the “narrow” QRS complex within approximately first three years of follow-up. Later on, the difference diminished and, during a longer follow-up, no statistically significant difference in the survival of the patients with the “narrow” and “wide” QRS complex was revealed. The multivariant analysis data give evidence about the lack of correlation between the QRS complex duration and the patient survival during the long-term follow-up while on CRT.

To assess the atrial fibrillation (AF) burden using insertable cardiac monitors within first months of post-operation period and reveal its correlation with the late recurrence of arrhythmia, 642 patients (478 men) aged 56±7.6 years with symptomatic AF resistant to antiarrhythmic therapy were included into the retrospective study. Radiofrequency isolation of the right and left pulmonary veins (IPV) was performed by separate collectors using irrigated electrodes. The entrance and exit block was confirmed during pacing or with the aid of Lasso catheter. The Reveal XT device (Medtronic) was implanted between ribs III and IV parallel to the sternum, 1 cm from its edge. Patients with the AF burden of <0.5% according to the implantable recorder data were considered responders; and patients with AF burden of >0.5% were considered non-responders. After the first ablation procedure, by the end of 12 month follow-up, 417 patients of 642 (65%) were responders. In accordance with the ROC curve data, the patients with absence and presence of AF recurrence were separated based on the AF burden recorded by implantable recorders (devices) within 2 months following ablation. The curse showed 85% of specificity and 90% of sensitivity. The corresponding AF burden threshold according to the implantable recorder data obtained within 2 months following ablation which permitted one to identify patients with a risk of late recurrence of AF was 4.5%. It corresponded to the overall duration of AF of 65.9 hours (2.75 days). The positive and negative diagnostic value was 78.7% and 93.9%, respectively. The majority of patients with the AF burden >4.5% had also prolonged episodes of arrhythmia exceeding 20 hours/day within two consecutive days during two first months of post-operation period. In the group of patients with persistent AF, the AF burden equal to 4.5% showed 91% of specificity corresponding to the 100% sensitivity. All patients with persistent AF and the AF burden <4.5% were responders (p<0.001). Thus, the AF burden obtained according to the implantable recorder data within the “blind” period, can predict the late effectiveness of surgical treatment. The AF burden of >4.5% within the first two months after the operation can be used for selecting appropriate candidates for repetitive operation and medical treatment.

The data of endocardial electrophysiological study of a male patient with palpitations, which showed double potentials of His bundle, were given.

A clinical case is given of a female patient with combination of reciprocal atrio-ventricular tachycardias which required repetitive transesophageal and endocardial electrophysiological studies and radiofrequency catheter ablations, and the syndrome of postural orthostatic tachycardia.

A clinical case is considered of a female patient with the pseudopacemaker syndrome caused by pronounced first-degree atrio-ventricular block and severe heart failure resistant to medical treatment.

A case report is given of a 63-year-old female patient, in whom the permanent pacemaker implantation was complicated by external lymphorrhea.

Case reports of patients with atrialfibrillation complicated by Amiodarone-induced thyrotoxicosis are given; up-to-date approaches to the patient management are reported.