To study effectiveness of radiofrequency ablation (RFA) of isthmus-dependent atrial flutter in the early post-operation period after open-heart surgery conducted in January 2012 through November 2013, 185 patients aged 58.4±8.4 years including 142 men (76.8%) were assessed. Group I included 14 patients with isthmus-dependent atrial flutter which occurred in the early post-operation period (during the same hospitalization) after open-heart surgery with the use of extracorporeal circulation. Two subjects of Group I underwent surgical treatment of coronary artery disease (CAD), five subjects were treated because of congenital or acquired valvular disease, congenital heart disorders, or the left atrium myxoma; simultaneous surgical correction of CAD and valvular procedures was performed in 7 patients. Atrial flutter developed 5.3±2.4 days (2 9 days) after the surgical intervention. RFA of cavo-tricuspid isthmus (CTI) was performed 10.4±3.3 days after the surgery (6 18 days). Group II included 20 patients with a history of surgical treatment of CAD (6 patients), surgical treatment of congenital or acquired valvular disease or congenital heart disorders (11 patients), and simultaneous surgical correction of CAD and valvular procedures (3 patients). RFA CTI was performed 4 606 months after the open-heart surgery (median: 21 months; Q25: 11.7; Q75: 68.7). Group III (control group) consisted of 151 patients with isthmus-dependent atrial flutter without history of open-heart surgery. RFA was indicated to all study subjects in accordance with the Russian Scientific Arrhythmia Society guidelines. During RFA, linear applications were attempted gradually moving the electrode from the tricuspid valve ring at intervals of 2-3 mm to the lower cave vein ostium. If they were ineffective, additional linear applications were made to connect ostia of the coronary sinus with the lower cave vein, as well as in the lateral isthmus. RFA applications were made also after the sinus rhythm recovery until bidirectional block in the right isthmus was detected. The CTI block was achieved in 174 patients of 185; the success rate was 94.1%. The CTI block was documented in 13 patients of 14 in Group I, in 18 patients of 20 in Group II, and in 143 patients of 151 in Group III (p=0.849); therefore effectiveness of the procedure did not significantly differ in different groups. The duration of the RFA CTI procedure was 73.3±33.6 min; the fluoroscopy time was 717.7±453.6 s. Thus, based on the data obtained, RFA can be considered effective in patients with isthmus-dependent atrial flutter documented shortly after open-heart surgery. The authors consider conducting RFA in isthmus-dependent atrial flutter as soon as possible after the open-heart surgery. The low number of case reports warrants further experience and clinical research.

To reveal predictors of response to cardiac resynchronization therapy (CRT) by comparing zones of maximal intraventricular dyssynchrony (IVD) and location of ventricular electrodes (VE), the retrospective study included 40 patients, including 26 men (65%) and 14 women (35%), with the sinus rhythm and implanted CRT system according to the commonly accepted indications. The patients aged 60.91±11.43 years; ischemic cardiomyopathy was documented in 48% of cases according to the data of coronary angiography and/or the documented evidence of myocardial infarction. Patients with significant valvular disease (more than moderate valvular regurgitation or any valvular stenosis) as well as more than mild pulmonary hypertension were excluded from the study. The study subjects were distributed into two groups. Group I (n=20) included subjects with a pronounced response to CRT. The CRT response criteria were as follows: decrease in the left ventricular (LV) end-systolic volume (ESV) by at least 15%, a relative increase in the LV ejection fraction (EF) by at least 10%, improvement of the chronic heart failure (CHF) by at least 1 functional class. Group II (n=20) included patients with an inadequate response to CRT (no positive changes in size, dimensions, and EF LV). While implanting the CRT system, the right atrial (RA) electrode was positioned at the right auricle; the right ventricular (RV) electrode was positioned at basal or medial parts of the inter-ventricular septum (IVS) or the RV apex. The LV electrode was implanted into any branch of the coronary sinus. The follow-up period lasted for 12.0±1.7 months. Coincidence of the zone of maximal IVD with the site of the LV electrode implantation was assessed with the aid of the vector ECG analysis in 12 standard leads during the isolated LV pacing using 12 conventional segments, as follows: 3 posterior segments, 3 posterolateral ones, 3 lateral ones, and 3 anterolateral ones on the basal, medial, and apical levels. The RV electrode location was assessed during the isolated RV pacing using 3 following conventional segments: basal part of IVS., medial part of IVS., and apex of RV. After 12 months of follow-up, considerable difference between the study groups in the end diameters, volume, and LV EF was shown (p<0.001). LV EF was 44.9±5.9% in Group I, 26.9±6.4% in Group II. A better functional class of CHF was found in Group I than in Group II (15 and 6 of patients with CHF II (NYHA), respectively, p=0.043). No IVD after 12 months of follow-up was observed in 19 patients of Group I and 16 patients of Group II, p=0.493. It should also be noted that in patients with IVD at baseline (13 subjects of Group I and 12 subjects of Group II), in 12 months IVD was detected in 1 patient of Group I and 4 patients of Group II. Thus, IVD recovered in 91.7% of cases in Group I and in 66.7% of cases in Group II, p=0.068. According to the ECG data, coincidence of the zone of maximal IVD with the site of the LV electrode implantation was more frequent in Group I (13 patients) than in Group II (6 patients), p=0.028. Thus, CRT is a complex process which includes the correct selection of patients, the device implantation itself, as well as subsequent long-term follow-up with the CRT parameter correction and medical therapy. IVD at baseline, coincidence of the zone of maximal IVD with the site of the LV electrode implantation and the distance between ventricular electrodes can be considered predictors of a better outcome in CRT to be taken into consideration during implantation. Coincidence of the zone of maximal IVD with the site of the LV electrode implantation in associated with a substantial long-term improvement in the hemodynamics of subjects with CRT.

To optimize an algorithm of endocardial mapping of idiopathic ventricular arrhythmias (VA) in pediatric patients by evaluating the data of invasive electrophysiological study (EPS) and to develop a method of prognosis of the VA substrate radiofrequency ablation (RFA) outcome, 337 patients, including 193 male (57.3%) and 144 female subjects (42.7%) were assessed and treated in 2003 2013. The patients aged 5 18 years (median: 14 years; IQR: 12 16 years). The study inclusion criteria were as follows: focal slow ventricular tachycardia (VT), fascicular tachycardia or monomorphic frequent ventricular premature contractions (VPC) associated with symptoms and/or arrhythmogenic myocardial dysfunction; frequent early VPC, and VPC provoked by exertion. The exclusion criteria were as follows: structural heart disease, polymorphic PVC or VT, number of monomorphic VPC less than 15,000 per day (according to the data of 24 hour Holter ECG monitoring), and the subject’s age under 5 years. To identify predictors to be used to localize the VA substrate, the data of activation (AM) and stimulation mapping (SM) were analyzed. According to the AM data, the “presystolic activity” was evaluated defined as an interval between the ventricular activation on endocardial bipolar electrogram and the onset of QRS complex on surface ECG at the background of ectopic activity. The SM results are given as presence of “identity” or “similarity” of paced and spontaneous QRS complexes at the background of ectopic activity. The statistically significant association between the results of AM and SM was found (r=-0.2; p<0.05). The SM results were statistically significantly associated with the effectiveness of RFA of the idiopathic VA substrate. There is a 2.6 times more pronounced likelihood of successful RFA in case of “identical” than in “similar” spontaneous and paced QRS complexes at the background of ectopic activity. In addition, the mathematic model analysis showed that irrespective of “identity” or “similarity” of spontaneous and paced QRS complexes at the background of ectopic activity, the success rate of RFA can be considered intermediate (0.75

To study the prognostic value of atrial fibrillation (AF) and risk factors associated with adverse outcome in patients with hypertrophic cardiomyopathy (HCM), 293 patients (188 men and 105 women) aged 17 68 years (median: 47 years; quartiles: 34 and 52 years) were assessed in October 2001 through October 2013. The follow-up period lasted for 4.2±2.8 years. The patients were excluded from the study if they (1) were under 16 years of age; (2) had the terminal “dilated” stage of the disease; (3) had a history of stroke. The study subjects were distributed into two following groups: patients with AF (paroxysmal and permanent AF) (n=49) and patients without AF (n=244). Symptomatic patients with HCM received β blockers (88%), calcium channel blockers (2%), antagonists of receptors to angiotensin II (53.5%), angiotensin converting enzyme inhibitors (23.5%), spironolactone (48.5%), and warfarin (20%). Asymptomatic subjects (8.9%) did not receive medical treatment. During the follow-up period, adverse outcomes and events were documented in 25 patients (8.5%), including sudden cardiac death (SCD) in 6 patients, 4 patients resuscitated after SCD with subsequent implantation of implantable cardioverter-defibrillator (ICD), death due to chronic heart failure (CHF) progression to the terminal stage in 7 patients, and stroke in 8 patients (including 2 lethal outcomes). The annual cardiovascular mortality in the cohort was 0.85%. Multifactor regression analysis showed that AF is an independent risk factor of cardiovascular events and outcomes (OR: 3.78; 95% CI: 1.39 10.25; p=0.009), death due to CHF progression (OR: 7.17; 95% CI: 1.69 30.31; p=0.007), and disability and death because of stroke (OR: 170.64; 95% CI: 10.46 2,784.88; p<0.001). No association of AF with SCD was revealed in the study cohort of patients with HCM. Thus, in the study cohort of patients with HCM, AF occurred in 16.7% of subjects and was associated with a higher risk of cardiovascular events and outcomes, death due to CHF progression, and adverse outcome of stroke (disability and death) irrespective of the AF type (paroxysmal or permanent AF) in 17 of 49 subjects (34.7%). Nevertheless, at the background of appropriate oral anticoagulant therapy, the favorable clinical outcome of other 32 patients (65.3%) was achieved.

To develop methods of early diagnostics and to reveal risk factors of ventricular arrhythmias (VA) and electrical storm (ES) in patients with chronic heart failure (CHF), 459 patients (men: 87%) aged 64.07±12.11 years were included into the study. The study subjects were assessed and treated in 1999 through 2014 in four general hospitals in St. Petersburg, Russia. For prevention of sudden cardiac death (SCD) and therapy of CHF, 125 single-chamber cardioverters-defibrillators (ICD) (27.2%), 167 dual-chamber ICD (36.4%), and 167 cardiac resynchronization therapy defibrillators (CRT D) (36.4%) were implanted. Implantation of ICD or CRT D was made for primary prevention of SCD in 68.7% of cases. The study subject follow-up period lasted for 6.2±2.8 years. The study subjects were distributed into two following groups: Group I (n=38) included patients with electric storm and Group II (n=421), patients without electric storm. The annual incidence of ICD shocks was 319 ones, without significant difference in patients with and without ES. In 13.2% of patients, ES occurred within the first year after implantation of ICD or CRT D. The following most significant risk factors of ES were revealed: QRS complex width, mean heart rate (HR), left ventricular (LV) ejection fraction (EF), end-diastolic diameter (EDD) of LV, end-systolic diameter (ESD) of LV, LV hypertrophy, extent of mitral insufficiency, LV diastolic dysfunction, number of episodes of antitachycarditic pacing, number of ICD shocks per year, and changes in CHF functional class. In 1999 through 2014, 22.9% of patients with ICD or CRT D deceased (15% of patients due to CHF deterioration, 5.2% of patients due to ES., and 2.7% of patients due to extracardiac causes). Mortality of patients with CHF progression was significantly higher than in subjects with stable or improving CHF (p<0.005). The survival analysis showed no significant difference between the study groups during first two years of follow-up. After the third year of follow-up, a significantly increased mortality of patients with ES was observed; after the fifth year, survival of patients with ES decreased to 30%, as opposed to 99% reported in the patient group without ES.

To study plasma levels of selectins (E., L, P), intercellular (ICAM 1), platelet-endothelial (PECAM 1), and vascular (VCAM 1) cell adhesion molecules and their interrelations with ventricular arrhythmias (VA), 82 patients aged 21.7±4.2 years (65 men and 17 women) with the connective tissue dysplasia (CTD) were examined. Most widespread symptoms of dysplasia included asthenic constitutional type (54.9%), scoliosis (41.5%), longitudinal flat foot (36.6%), teeth growth disorder and overcrowding teeth (29.3%). Less widespread symptoms included arachnodactylia (18.3%), and hypermobility of joints (17.1%), Grade I pectus excavatum (15.9%), Gothic palate (14.6%), atrophic striae (3.7%), and others. Also revealed were mitral valve prolapse (MVP) syndrome (84.1% of patients), unclassified phenotype (3.8%), myxomatous MVP (1.2% of patients), syndrome of hypermobility ofjoints (1.2%), and benign hypermobility ofjoints (1.2%). According to the ECG Holter monitoring data, all CTD patients were distributed into two groups. Group I consisted of 20 patients (16 men and 4 women) aged 22.5±4.2 years with VA. Group II consisted of 62 subjects (49 men and 13 women) aged 21.4±3.9 years without VA. Control Group consisted of 10 healthy persons (6 men and 4 women) of comparable age without signs of CTD. The immunoenzyme essay assessed plasma concentrations of L-, E-, and P-selectins, ICAM 1, PECAM 1, and VCAM 1 (Bender MedSystems CmbH, Austria). The statistical analysis showed that, in the whole group of the CTD patients, the plasma concentrations of E selectin, ICAM 1, and VCAM 1 were significantly higher and PECAM 1, on the contrary, lower than in healthy subjects. The Land P-selectin levels had no significant difference with the control. In patients with VA, the levels of E selectin, ICAM 1, and VCAM 1 were higher than those in healthy subjects. The patients with CTD without VA were characterized only by an increased ICAM 1. The comparison of diagnostic values of different levels of increased E selectin, ICAM 1, and VCAM 1 for prediction of the VA risk in CTD (Table 4) subjects showed that more than a 2 fold increase in the molecule concentration had high specificity, negative prognostic value, and accuracy. In case of simultaneously increased plasma concentrations of 2-3 molecules (e.g., E selectin, ICAM 1, VCAM 1), the risk of high-grade VPB increased 2.6 times (RR: 2.6, 95% CI: 1.1 6.1). The sensitivity of the result is 63.6%, specificity: 88.9%, diagnostic value of the positive result: 87.5%, diagnostic value of the positive result: 87.5%, accuracy: 75%. Thus, established were peculiar features of plasma selectin levels and adhesion molecules in CTD, including that associated with VA.

To develop the ultrasound-guided technique of endocardial electrode implantation and to compare it with traditional fluoroscopy-guided technique, 60 patients aged 61.4±21.4 years with clinically significant bradycardia were assessed and treated. The patients were distributed into two following groups: the ultrasound-guided procedure was performed in 30 patients of Group I; the commonly accepted fluoroscopy-guided procedure of endocardial electrode implantation was carried out in 30 patients of Group II. Electrodes with passive and active fixation were implanted through a standard surgical access; the electrode location in veins was controlled by ultrasound, if needed. When introducing ventricular electrodes, apical (four chamber view) or subcostal ultrasound access were the most commonly used ones. The ventricular electrode was placed in the apex or basal parts of interventricular septum (IVS); tests were made to confirm stability of the electrode location. For visualization of the ventricular electrode location in the right ventricular apex, modified apical views were most commonly used. The final electrode position was controlled by several echocardiographic views. Transesophageal echocardiography was used in complicated cases of unacceptable visualization. The atrial electrode was located in the right atrium appendage. When introducing the atrial electrode, the apical views (both two-chamber and four-chamber ones) during transthoracic echocardiography were the most commonly used. The fluoroscopy time in the study group was 76.26±4.14 s and in the control group, 204.35±6.06 s. For the last 5 procedures, its duration in both the study and control group became equal; the fluoroscopy time in the study group shrank to 5 s (control fluoroscopy). In 6 cases, tricuspid regurgitation (up to 9 cm2) along the ventricular electrode was revealed during the procedure, which caused the electrode relocation. Thus, the ultrasound-guided implantation of endocardial electrodes can significantly reduce the fluoroscopy time, optimize the intracardiac electrode location, and to find the most optimal location for implantation of a ventricular electrode into IVS.

To describe electrocardiographic (ECG) features of isolated right ventricular (RV) and left ventricular (LV) pacing in case of different electrode location in standard radiographic projections, 40 patients receiving cardiac resynchronization therapy were assessed. ECG in the area of LV electrode was assessed during the isolated LV pacing using 12 conventional segments of myocardium, as follows: 3 posterior, 3 postero-lateral, 3 lateral, and 3 antero-lateral segments on the basal, medial, and apical levels. The RV electrode location was assessed during the isolated RV pacing using 3 following conventional segments: basal part of interventricular septum (IVS), medial part of IVS., and RV apex. The following positions of ventricular electrode were revealed in the study group: LV lateral wall (in most patients; 47.5%), including its basal part (30%); the electrode was positioned in the postero-lateral wall (35%) as well as in the posterior wall of LV (17.5%). The RV electrode was placed in in the RV apex (62.5%) or in the IVS basal part (30%). The difference in the ECG pattern of pacing of apical area of postero-lateral and posterior walls of LV consisted in the axis in leads I and aVL; more positive it was more posterior location of the pacing area took place; right chest ECG leads remained positive. In the study group, the LV electrode apical location was found in 17 cases (42.5%) and was confirmed by standard radiological projections, including lateral wall in 3 cases, postero-lateral wall in 8 cases, and posterior LV wall in 6 cases. Thus, ECG appears to be a useful tool for follow-up of patients with CRT without additional time expenditure. The ECG pattern of isolated RV and LV pacing correctly reflects the radiological position of the corresponding electrodes. The vector ECG analysis can be used as a safe indirect method of evaluation of the LV electrode location during follow-up of patients with CRT.

To study potentialities of remote monitoring systems in patients with implanted antiarrhythmic devices, 49 patients (including 40 men) managed in Federal Center of Cardiovascular Surgery and connected to the Carelink system were studied. Cardioverters-defibrillators (ICD) were implanted to 12 patients; cardiac resynchronization therapy defibrillators (CRT-D), to 37 patients. The study subjects aged 50 60 years (mean: 53 years); the left ventricular ejection fraction was 27 36% (mean: 32%). Dilated cardiomyopathy was documented in 30 subjects (61%), ischemic cardiomyopathy was found in 19 patients (39%). A history of cardiovascular surgical interventions were documented in 12 patients (25%). Within the analyzed period of time (on 20 August 2013 through 30 September 2014), 497 transmissions were carried out (10 transmissions per patient, on the average), 10% of them were related to transmissions with events, which were high priority unexpected ones. Approximately in one fourth of study subjects, anxiety about potential fluid retention was revealed which coincided with their hospitalization due to clinical deterioration of chronic heart failure (CHF). The authors suggest that frequent sustained paroxysms of atrial fibrillation (AF), a decreased burden of biventricular pacing, and discontinuation of medical treatment are major causes of an increased OptiVol index. 403 episodes of ventricular arrhythmia were detected, as follows: 25 events in the area of ventricular fibrillation - ventricular fibrillation was detected in 7 patients; 330 events in the area of ventricular tachycardia (VT) - ventricular tachycardia was detected in 7 patients; and 48 events in the area of fast VT - fast VT was detected in 2 subjects). In 78% of cases (315 events), the implanted device attempted to terminate tachycardia by antitachycarditic pacing (ATP) with the success rate of 85%. The tachycardia termination using ATP occurred mostly in patients with VT and fast VT. In 11% of documented ventricular arrhythmias (46 events), ICD applied shocks which restored the sinus rhythm in 76% of cases. In the overwhelming majority of cases, ICD shocks were related to detection of events in the ventricular fibrillation area (75%). Approximately 60% of ICD shocks were submaximal ones (lower than 35 J). Other paroxysms terminated spontaneously. Grace to the results of remote monitoring, the procedure of radiofrequency ablation for arrhythmia registered for the first time by the implanted device was performed in 6 patients. Thus, the active implementation of systems of remote monitoring of patients with implanted antiarrhythmic devices is of a high priority especially in big centers/departments for surgical treatment of arrhythmia and is an important tool for optimization of their activities and improvement of their quality.

A clinical case is given of assessment and treatment of a 62 year old female patient with paroxysmal atrialfibrillation, in whom, after the pulmonary vein isolation, activation mapping of localized re-entry triggering the atrial fibrillation activity was made; radiofrequency applications in this area terminated the arrhythmia.

A clinical case report is given of the left atrium appendage air embolism which developed in the course of implantation of the Amplatzer Cardiac Plug occlusive device.

A clinical case report is given of ultrasound mapping and radiofrequency catheter ablation of the ventricular tachycardia substrate in a patient with dilated cardiomyopathy and electrical storm.