To assess effectiveness of cardiac resynchronization therapy (CRT) in combination with intra-myocardial transplantation of autologous bone marrow mononuclear stem cells (IABMSCT) in patients with ischemic heart failure, left bundle branch block, and electromechanical dyssynchrony of the left ventricle (LV), 50 patients were examined and surgically treated. The patients were randomized into two groups, each of them consisted of 25 patients. Group 1 received IABMSCT and CRT in the passive mode and Group 2, received IABMSCT and CRT in the active mode. In 6 months, the CRT type was changed in a crossover mode. IABMSCT was performed after the LV mapping. In the area of interest which included damaged (hibernating) but viable myocardium, 10 IABMSCT procedures were carried out. The overall duration of the IABMSCT procedure was 69±22 min, with the X ray exposure of 15±9 min. The total duration of the CRT system implantation was 92±29 min. The 6 minute walk test distance increased during the passive CRT from 206.5±51.7 m to 266.4±79.2 m (p=0.006) and during the active CRT to 389.4±51.6 m (p<0.001 as compared with passive CRT). The functional class of heart failure as per the NYHA classification improved during the active CRT from 3.5±0.5 to 2.1±0.6 (p<0.001) but did not change significantly during the passive CRT. During the active CRT, the heart failure improvement by one functional class occurred in 54% of cases and by two functional classes, in 46%. During the passive CRT, the heart failure severity improved by one functional class in 32% of cases, with no heart failure dynamics in other subjects. The LV ejection fraction during the passive CRT increased from 27.4±2.8^ΰ/ο to 31.3±5.6^ΰ/ο (p<0.02) and during the active CRT, to 43.2±4.1% (p<0.001 as compared with passive CRT). Thus, CRT and IABMSCT independently contributed to elimination of the LV electromechanical dyssynchrony and improvement of myocardial perfusion, respectively. The combination of both techniques can lead to a considerable improvement of clinical and functional state of patients with severe ischemic heart failure and electromechanical dyssynchrony of the LV.

To assess correlation between the portion (percentage) of the scar tissue in the left ventricle (LV) and the risk of ventricular arrhythmias in patients with coronary artery disease and implanted cardioverter-defibrillator (ICD), 49 patients (46 men and 3 women) aged 63±12 years were examined. Only patients with ischemic cardiomyopathy were included into the study (LV ejection fraction less than 45%). Prior to the ICD implantation, 48 patients underwent aorto-coronary bypass grafting or percutaneous coronary intervention. In all patients, prior to the ICD implantation performed were echocardiography and ECG analysis using the computational tables (method by R.H. Selvester et al. for assessment of the scar tissue area). The patients were distributed into two following groups: Group I included patients without the ICD activity (n=25) and Group II, patients with the episodes of ICD activation (n=24). The percentage of scar tissue was 17.3±8.8^ΰ/ο in Group I and 25.5±13.4^ΰ/ο in Group II (p=0.014). The QRS complex width did not statistically significantly differ in both groups (127.6±35.6 ms in Group I and 121.9±34.6 ms in Group II; p=0.58). It could be related to fact that the QRS widening in the patients with ischemic cardiomyopathy can be considered a predictor of death due to heart failure deterioration. A statistically significantly lower LV ejection fraction in the patients without episodes of ICD activity (Group I) is possible related to a greater number of patients with ICDs implanted for the primary sudden death prevention. Principal limitations of the current study were a small sample and the retrospective nature of the study. Thus, ECG assessment using the technique by R.H. Selvester et al. can be used for the risk stratification of ICD activity due to ventricular arrhythmias.

To develop management strategy for patients with recurrence of atrial fibrillation (AF) in the early post-operation period based on the loop recorder data, 314 patients were included into the study. Group 1 included patients with no recurrence of arrhythmia in the early post-operation period; Group 2 consisted of 182 patients (58%) with recurrence of the arrhythmia. The subjects of Group 2 were randomized into Group 3 (n=88) or Group 4 (n=89); 5 patients were excluded from the study. The Group 3 subjects received only medical antiarrhythmic therapy. In Group 4, management of early post-operation period depended on the AF mechanism recorded by the loop recorder. In the case of the first occurrence of AF, only antiarrhythmic therapy was prescribed; if AF was induced by any trigger activity, the early re-ablation was carried out. The pulmonary vein ostia antral isolation by the common collectors was performed in all study subjects with creation of ablation lines on the roof of the left atrium and mitral isthmus. The loop recorder implantation was carried out as a final stage of the operation. After 12 months of follow-up, 120 of 129 patients of Group 1 (95%) were responders. Only 29 of 88 patients of Group 3 (33%) were responders (p<0.001, as compared with Group 1). In Group 4, 71 patients of 89 (80%) were responders (p=0.001, as compared with Group 1; p<0.0001, as compared with Group 3). In Group 3, 24 patients of 35 (69%) with the sudden AF onset were responders, as compared with only 6 patients of 52 (8 %) with the trigger AF onset (p<0.0001 as compared with the subjects with sudden AF onset). In Group 4, 22 patients of 32 (63%) with the sudden AF onset were responders (p=0.38, as compared with the patients with sudden AF onset in Group 3). Among 57 patients with the trigger AF induction, 49 ones (89 %) were responders (p=0.003 as compared with the sudden AF onset and p<0.001 as compared with the trigger onset in the patients of Group 3).

To report the first experience of application of the CartoSound technique in Russia for three-dimensional mapping in the real time mode during radiofrequency ablation (RFA) of atrial fibrillation (AF), six patients with paroxysmal (n=2) and persistent (n=4) AF were examined and operated on. All study subjects were younger than 70 years (aged 58±3.8 years) and were free of structural heart pathology. Mean class of arrhythmic symptoms by EHRA was 3.6±0.2. In one patient, antral isolation of pulmonary vein ostia was performed twice. The anterio-posterior left atrium (LA) size was 4.8±0.5 cm, the left ventricle ejection fraction by Simpson, 49±4%. During the procedure, the following catheters have been introduced: 10 polar diagnostic electrode into the coronary sinus, ultrasound catheter into the right atrium, and ablation catheter into the left atrium. All ultrasound images were synchronized with the R-wave of surface ECG; three-dimensional maps of the LA, pulmonary veins, and esophagus were generated. Ultrasound mapping was accompanied by fast electroanatomic mapping (FAM) of LA and pulmonary veins. After three-dimensional mapping of the LA, pulmonary veins, and esophagus, antral pulmonary vein isolation was performed with the power of 30 40 W, temperature of 40 45°C, and irrigation velocity of 17 ml/min. The time necessary for development of maps of the LA, pulmonary veins, and esophagus, decreased from the first patient to the sixth one from 23.5 min to 16 min and the overall duration of the procedure, from 167 min to 138 min. According to the 24 hour Holter ECG monitoring data performed on the 3-4 days after the procedure, the sinus rhythm was documented in 5 patients of 6. Thus, three-dimensional ultrasound mapping of LA, pulmonary veins, and esophagus is a reliable method of visualization control during antral pulmonary vein isolation. Intracardiac echocardiography is not associated with any radiological (X--ray) exposure, does not require administration of the contrast medium, and is, per se, the only method of “monitoring of anatomy” in the real time mode. It seems to be a safe and effective alternative to tomographic techniques; however, no relevant data of randomized studies are currently available. In the nearest future, the technique seems to be applied increasingly, taking a continuous rise in the number of radiofrequency ablations due to AF into the account. Thus, three-dimensional ultrasound mapping is a reliable visualizing method for antral pulmonary vein isolation.

To compare safety and effectiveness of pulmonary vein isolation (PVI) in combination with linear ablation (LA) or ganglionic plexus ablation (GPA), 264 patients with persistent and long-lasting persistent atrial fibrillation (AF) were examined and surgically treated. The patients were randomized into two following groups: PVI+LA (n=132) and PVI+GPA (n=132). The primary endpoint was freedom from any atrial tachyarrhythmia including AF, atrial flutter, and atrial tachycardia after the first ablative procedure recorded by loop recorders. The “blind period” data obtained within first 3 months following ablation was excluded from analysis. The circular PVI was performed to the patients of both groups. The anatomic area of GPA was determined by vagus response to overdrive pacing with the amplitude of 15 W, duration of 10 ms, frequency of 20 50 Hz, and duration of pacing up to 5 s. Target areas also included adjacent areas with complex fractionated atrial electrograms detected. In the PVI+LA group, ablative lines were made which connected the left inferior pulmonary vein with the mitral valve annulus (the left isthmus), as well as the line of the left atrium roof between two superior pulmonary veins. In 132 patients of the PVI+GPA group, 5.6±0.4 applications for each target area were made, additional 8.9±2.7 radiofrequency applications were performed in the areas with complex fractionated atrial electrograms. For each patient, the total number of 64.7±3.8 radiofrequency applications in the ganglionic plexus areas was carried out. The complete electric PVI and the cavo-tricuspid conduction block were achieved in all 264 subjects of both study groups. The duration of radiofrequency application was 58±11 min in the PVI+LA group and 69±4 min in the PVI+GPA group (p<0.001), the duration of procedure and X-ray exposure in the PVI+GPA group was longer than in the PVI+LA group (192±21 min and 153±37 min, respectively, p<0.001; 34±11 min and 29±15 min, respectively, p=0.002). After the single ablative procedure, during a 12 month follow-up period, 71 patients (54%) from the PVI+GPA group were free of atrial fibrillation/flutter/tachycardia as compared with 62 patients (47%) from the PVI+LA group (p=0.29). After 36 months of follow-up, 65 patients (49%) from the PVI+GPA group and 45 patients (34%) from the PVI+LA group were free of atrial fibrillation/flutter/tachycardia (p=0.035). The patients of both groups did not take antiarrhythmics. The percentage of patients with the left atrial flutter was significantly higher in the PVI+LA group than in the PVI+GPA group and made up 18% (24 patients) and 6% (8 patients), respectively (p=0.002). The number of AF recurrence (excluding atrial flutter) did not significantly differ in the study groups: 56 patients (42%) in the PVI+GPA group and 50 patients (38%) in the PVI+LA group after 12 months of follow-up (p=0.71) and 59 patients (45%) in the PVI+GPA group and 63 patients (48%) in the PVI+LA group after 36 months of follow-up (p=0.44). Within the follow-up period of 28.4±14.4 months, recurrence of atrial fibrillation/flutter/tachycardia occurred in 154 patients (58%). Re-ablation was carried out in 78 patients (59%) from the PVI+LA group and 55 patients (42%) from the PVI+GPA group (p=0.002). Other 21 patients (16%) with recurrence of atrial fibrillation/flutter/tachycardia refused of the repetitive procedure. After re-ablation, the procedure effectiveness in patients free of antiarrhythmic therapy was 68% in the PVI+GPA group and 52% in the PVI+LA group (p=0.006). Thus, in patients with persistent AF, PVI+GPA is a more promising technique than PVI+LA.

To study influence of cardiac pacing of Bachmann bundle and the right auricle on atrio-ventricular conduction and cumulative percentage of ventricular pacing, 74 patients with the sick sinus syndrome were examined. Group I consisted of patients with atrial electrodes implanted into Bachmann bundle; in the patients of Group II, electrodes were implanted into the right auricle. The atrial electrode location was confirmed in three radilogical projections. The following standard indices were measured: pacing threshold, resistance and amplitude of endogram. Pacemakers of all subjects were programmed in the DDDR mode, with the minimal pacing rate of 60 bpm. The stimulated atrio-ventricular delay was programmed as constant and equal to 250 ms, and the sensed one was shorter by 20 ms. The cumulative percentage of atrial and ventricular pacing was assessed 6 months and 12 months after the procedure. In 6 months, in the patients of Group I (pacing of Bachmann bundle), the median of cumulative percentage of ventricular pacing was 6.8 times lower (6% [1.5 17.5%] and 41% [29 49.5%], respectively, p<0.001). The same tendency took place 12 months after the procedure (4% [2 18%] and 43% [32 52%], respectively, p<0.001), as well. In the patients with atrial electrodes located in the Bachmann bundle area, the cumulative percentage of ungrounded ventricular pacing is statistically significantly lower (in absolute values) in 6 months by 28%, on the average, and in 12 months by 29%. Thus, atrial pacing of Bachmann bundle as opposed the right auricle leads to a decrease in the cumulative percentage of ventricular pacing due to a higher likelihood of natural conduction through His bundle.

To assess late effectiveness of the following techniques of radiofrequency ablation (RFA) of atrial fibrillation (AF): pulmonary vein isolation (PVI), left atrium (LA) ganglionic plexus ablation (GPA), and their combination, according to the data of implantable loop recorders in patients with paroxysmal AF during a 2 year follow-up period, 327 patients were examined. The patients were randomized into three following groups: Group I (n=112) with PVI, Group II (n=108) with anatomic GPA, and Group III (n=107) with PVI in combination with GPA. The circular PVI was performed using the navigation system CARTO (Biosense Webster Inc.) by the commonly accepted technique, without linear ablations made in LA. During GPA, main accumulations of autonomic ganglionic plexuses concentrated in four LA areas were affected. At the end of procedure, loop recorders were implanted to all subjects. The follow-up period after the procedure was 24 months. Freedom from AF paroxysms (AF <0.5%) or any other arial arrhythmias according to the loop recorder data after a single ablation procedure was the primary endpoint. In Group I, 78.4±14.5 radiofrequency applications were performed. The sinus rhythm was restored in 16 patients (14.3%) during RFA; in 18 patients (16.1%), electric cardioversion was required. RFA of cavo-tricuspid isthmus was performed in 26 patients (23.2%). In Group II, 69.5±11.7 radiofrequency applications were performed. The sinus rhythm was restored in 14 patients (13%) during RFA; in 22 patients (20.4%), electric cardioversion was carried out. RFA of cavo-tricuspid isthmus was performed in 12 patients (18.5%). In Group III, the number of radiofrequency applications made up 102.7±12.4 (p=0.04 as compared with Group I and Group II). The sinus rhythm was restored during the procedure in 19 patients (17.8%); in 18 patients (16.8%), after the procedure, electric cardioversion was required. RFA of cavo-tricuspid isthmus was performed in 27 patients (25.2%) (p=0.2). By the end of follow-up period, 73 patients of Group I (65.2%), 69 patients of Group II (63.9%), and 84 patients of Group III (78.5%) were responders, i.e. had the AF percentage <0.5% according to the implantable loop recorder data. Thus, the combination of anatomic GPA and circular PVI is associated with an increased effectiveness of the procedure as compared with that of the isolated procedures of GPA and PVI, which ensures the sinus rhythm retention in 78.5% of patients with paroxysmal AF within the 24 month follow-up period according to the loop recorder data.

To assess correlation between intrathoracic impedance and ventricular arrhythmias, 32 patients aged 53±9 years with chronic heart failure of functional class IIIV (HYNA) were examined.

An example is given of use of the non-invasive activation mapping system during radiofrequency ablation in a male patient with incessant post-infarction ventricular tachycardia.

A clinical case report is given of treatment of atrial tachycardia using radiofrequency catheter ablation in a 14 year old female patient after surgical correction of transposition of the great vessels (atrial switch by A. Senning).

A case report of stress-induced takotsubo cardiomyopathy is given which occurred in a 61 year old female patient, who reported acute chest pain and severe dyspnea at rest 40 minutes after the pacemaker replacement.

Two clinical case reports are given of application of cryoablation for treatment of frequent symptomatic ventricular premature beats originating from the right ventriclular inflow tract after unsuccessful repetitive radiofrequency ablations.

A clinical case report is given of the successful surgical treatment of the right atrial thrombosis in a 43 year old male patient with chronic atrial fibrillation, in whom permanent pacemaker was implanted due to symptomatic pauses.

On an example of a 66 year old male patient with a history of two large transmural myocardial infarctions with development of the left ventricular aneurism, potentialities of analysis of surface electrocardiogram and endograms in the diagnostics of concealed problems of cardiac pacing are shown.

The case report is given of a 48 year old female patient with a long history of diabetes mellitus who reported presyncope and syncope developing in orthostasis.