Aim. To compare the immediate and long-term efficacy of cardioversion in patients with persistent atrial fibrillation (AF) in the setting of active myocarditis versus those without myocardial inflammation.

Methods. The study included 80 patients with persistent atrial AF (mean age 58.39±14.3 years; 56.2% male), of whom 40 had biopsy- or magnetic resonance imaging-confirmed myocarditis, elevated antimyocardial antibody titers, and ≥3 points on a non-invasive myocarditis diagnostic algorithm (main group). The control group (n=40) consisted of patients with non-inflammatory cardiovascular diseases (coronary artery disease, hypertension). All patients with myocarditis received standard anti-inflammatory therapy. Following pre-treatment with amiodarone for 10-12 days, electrical cardioversion (ECV) was performed. The efficacy of ECV, the need for radiofrequency ablation (RFA), the incidence of persistent AF, and adverse outcomes were evaluated. Differences were considered statistically significant at p < 0.05.

Results: Patients in the myocarditis group were characterized by a higher proportion of males (80.0% vs. 32.5%), younger age (49.1±12.0 vs. 67.7±9.5 years), lower left ventricular ejection fraction (LVEF) (37% [30;41] vs. 56% [52;59]), and larger left ventricular end-diastolic volume (152 ml [119;184] vs. 89 ml [76;106]), all with p < 0.001. The duration of AF history and left atrial size did not differ significantly between groups. Only in the myocarditis group did spontaneous sinus rhythm (SR) restoration occur during amiodarone loading, observed in 17.5% of cases. ECV was successful on the first attempt in all patients of the control group and in 57.5% of patients with myocarditis; an additional 15% achieved SR with a second ECV attempt (p < 0.001). Reversible recurrences of AF, terminated by intravenous amiodarone, were observed in 20% of myocarditis patients versus 5% in the control group (p=0.012). By the end of the one-week observation period, irreversible recurrences were recorded in two patients in each group. LVEF improved more significantly in the myocarditis group (to 42% [33;49], p < 0.001). At six months post-ECV, SR was maintained in 50% of patients with myocarditis and 66.5% in the control group (p=0.530). Rhythm control was discontinued in 15% of patients with myocarditis and in 5% of the control group (p=0.547), and radiofrequency ablation was performed in 10% and 5% of patients, respectively (p=0.509). All-cause mortality was documented in 12.5% (n=5) of myocarditis patients. No thromboembolic events or heart transplantations were reported in either group.

Conclusion: AF in the context of myocarditis more commonly affects individuals of working age and worsens LV systolic dysfunction. The immediate and long-term efficacy of ECV was non-significantly lower in patients with myocarditis; however, successful restoration and maintenance of SR were associated with a more pronounced improvement in LVEF, supporting the rationale for a rhythm control strategy. Further research is planned to identify predictors of sustained SR in this population.

Aim. To evaluate the relationship between mechanical dyssynchrony, defined as myocardial work components and manifestations of cardiac dysfunction in patients with permanent right ventricular pacing.

Material and methods. The study included 55 patients (25 men, mean age 63±12 years) with implanted permanent pacemakers and left bundle branch block type paced QRS complex morphology and 20 healthy volunteers (15 men, mean age 32.4±7.4 years). The patients included in the study were examined twice: initially before pacemaker implantation and again at the time of study inclusion. A standard echocardiographic study was performed with an additional assessment of the degree of global longitudinal strain (GLS) and myocardial performance parameters - global constructive myocardial work (GCW), global wasted myocardial work (GWW), global work index (GWI) and global work efficiency (GWE) before and after pacemaker implantation. In all patients, segments with maximum and minimum GWI were determined. The parameters of myocardial function were analyzed depending on the localization of the pacemaker stimulating head, and a comparison was made with the parameters of myocardial function in 20 healthy volunteers.

Results. In 18.2% of patients, against the background of right ventricular pacing, a decrease in left ventricular ejection fraction (LVEF) from normal values to 55 (53.5; 55.8) % was recorded, in 5 (50%) of them, signs of chronic heart failure functional class II-III were recorded. An increase in the degree of tricuspid regurgitation (TR) was found in 29.9% of patients. In patients against the background of long-term pacing, the GLS, GWI, GCW and GWE indicators were statistically significantly lower than in the group of healthy volunteers, and the GWW indicator was higher than the reference values of the control group. Patients with an apical-septal localization of the stimulating electrode head have statistically lower GWI and GCW values than patients with a more “basal” location of the electrode head in the middle third of the interventricular septum (1042.23±308.85 versus 1430±514 mmHg%, p = 0.049 and 1457 (1256; 1766) versus 2089 (1831; 2186) mmHg%, p = 0.04).

Conclusion. The localization of the stimulating electrode head does not affect the development of negative dynamics of LVEF and TR, but has a significant effect on the myocardial performance indicators. In patients with the apical-septal localization of the electrode, the worst values of the constructive work of the myocardium were noted, and in patients with the localization of the stimulating electrode head in the right ventricular outflow tract area, the best indicators of the constructive work of the myocardium were noted.

Aim. Permanent atrial fibrillation (AF) requires rate control. However, the optimal heart rate (HR) remains a matter of debate. Hemodynamic parameters such as mean arterial pressure (MAP) and the proportion of hemodynamically ineffective beats (HIB), derived from pulse pressure (PP), may provide insight into the hemodynamic characteristics of AF at different HRs and left ventricular ejection fractions (LVEF).

Methods. The study included 135 patients with permanent AF (aged 37-90 years, symptom class 1-2A according to the mEHRA scale). For each patient, beat-to-beat systolic BP, diastolic BP, and PP were measured using the “volume clamp” method over a 15-minute period with the “Cardiotechnika-SAKR” system (Incart, Saint Petersburg). On each cardiac cycle, MAP and its variability were calculated using two independent metrics: Average Real Variability (ARV) and Root Mean Square of Successive Differences (RMSSD).

Results. The percentage of HIBs, defined per patient as deviations from the mean PP, considered as 1 («mild» 110 bpm), except 90-110 bpm, HIBs were more frequent in patients with reduced LVEF (110 bpm, MAP was 80.4 ± 12.3 mmHg in the reduced LVEF group versus 94.1 ± 14.1 mmHg in the preserved LVEF group (p0.05).

Conclusion. Heart rate control in permanent AF should be individualized, hemodynamically guided, and account for LVEF. Beat-to-beat monitoring enables identification of the optimal HR that minimizes HIBs and MAP variability while maintaining MAP within accepted reference values, particularly in patients with impaired contractile function.

Aim. To stratify the risk of recurrent syncope and the risk of sudden cardiac death (SCD) / sudden cardiac arrest in young patients with cardiogenic syncope without structural heart disease using the Evaluation of Guidelines in Syncope Study (EGSYS score). To conduct the first retrospective analysis of the personalized risk of sudden cardiac death, as well as the sensitivity of the EGSYS scale for patients with different nosological entities.

Methods. The study included 63 patients with syncope aged 18 to 44 years, the average age of the patients was 25,98±6,69 years. The patients were divided into 5 groups: the first group (12 patients, average age: 21,84±4,37 years) consisted of patients with cardiac channelopathies, the second group (16 patients, average age 25,84±6,56 years) consisted of patients with sinus node dysfunction in the form of arrest of the Kiss-Fleck node, the third group consisted of patients with atrioventricular block (15 patients, the average age 26,71±7,13 years), the fourth group consisted of patients with paroxysmal monomorphic and polymorphic ventricular tachycardia (15 patients, the average age of the group was 25,74±7,79 years), the fifth group consisted of patients with syncope in the Wolff-Parkinson-White (WPW) syndrome (5 patients, average age - 25,64±3,05 years). The frequency of recurrence of syncope and SCD episodes was assessed over a 2-year period from the time of the first syncope. The EGSYS score was used to stratify the risk of recurrence of syncope and SCD.

Results: A total of 23 patients, or 36.5% of the study population, had an EGSYS score more than 5 points (very high), with a 2-year risk of SCD of 21% and a risk of recurrent syncope of 77%. In addition, the highest score on the EGSYS scale was associated with a higher frequency of cardiogenic syncope and SCD episodes. Patients with cardiac channelopathies had the highest EGSYS score (mean score 5.84), which was associated with the highest incidence of syncope and episodes of SCD with cardiopulmonary resuscitation over a 2-year period (r=0,58, p=0,01). The risk of developing SCD over a 2-year period in the group of patients with sinus node dysfunction (sinus node arrest) does not exceed the average population (less than 2%), which was associated with the absence of episodes of sudden cardiac death (sudden cardiac arrest) for a period of 2 years in the patients in this group. The highest validation of the EGSYS score and the frequency of syncope over a 2-year period were in patients with ventricular tachycardia ((r=0,73, р=0,002).

Conclusion: Thus, already at the debut syncopal state there is a possibility of determining the personalized risk of recurrent syncope and sudden cardiac death using the EGSYS scale. According to the study, the area of the highest sensitivity of the scale was patients with ventricular tachycardia (the main cause of SCD), which allows us to consider this scale as a basis for constructing a prognostic model for stratifying the risk of sudden cardiac death in young patients with cardiogenic syncope without structural heart disease.

Aim. To evaluate the effectiveness and safety of catheter treatment of typical atrial flutter (AFl) using exclusively intracardiac echocardiography (ICE) compared to the fluoroscopic method.

Material and methods. There were 176 patients with typical AFl (88 patients in each group). The study group consisted of patients who underwent radiofrequency ablation (RFA) with intracardiac ultrasound visualization only (ZF - Zero Fluoro). The comparison group included patients who underwent RFA of the AFl using minimal fluoroscopy time and ICE (MF - Minimal Fluoro). The follow-up period was 12 months.

Results. Intraoperative success rate was 100% in both groups. The absence of recurrence of AFl during the follow-up period was comparable (94.3% vs. 96.6%, p=0.4703). No acute or delayed complications were reported. Fluoroscopy was used in none patient who underwent the procedure under intracardiac ultrasound guidance (p < 0.001). Surgery time and overall RF-ablation time did not differ statistically (69.4 min vs. 63.9 min, p=0.1030; 9.1 min vs. 8.3 min, p=0.1606, respectively) in the MF- and ZF-group.

Conclusion. Catheter RFA of a typical AFl with ICE-visualization is feasible without the use of fluoroscopy, with comparable efficiency and safety results.

Aim. To study the frequency of a significant decrease in the esophageal temperature during the standard and “extended” cryoballoon ablation (CBA) procedure in patients with paroxysmal and persistent atrial fibrillation (AF).

Methods. The study included 160 patients (median age 66 [57;70] years, 90 [56.3%] male) with symptomatic paroxysmal and persistent AF. 139 (80.0%) patients with paroxysmal AF underwent pulmonary vein (PV) CBA, and 21 (20.0%) patients with persistent AF underwent “extended” PV CBA in combination with cryoablation of the left atrial posterior wall. At all stages of CBA exposure, esophageal temperature was assessed using the Astrocard Esosafety multichannel esophageal temperature monitoring system (MTP) (Astrocard, JSC Meditek). The criterion for stopping the CBA was considered to be a decrease in temperature below 20 °C.

Results. Electrical isolation of PV was achieved in all 160 patients with CBA. In the group of standard CBA PV (n=139), the temperature < 20 °C was observed significantly more often than in patients with a “central” esophagus (81% vs. 5.7%, p < 20 °C in MTP was determined in 22 (16%) patients, with an average value of 17.23±1.74 °C. In 13 of 22 (59%) patients the temperature < 20 °C in MTP was recorded with CBA of the left lower PV. In the group of “extended” CBA (n=21), the temperature < 20 °C in MTP was determined in 18 (86%) patients, with an average value of 17.1±0.6 °C. When evaluating the fluoroscopic options for the location of the MTP sensor in the esophagus relative to PV, the esophagus of “central localization” was determined in 105 (76%) patients, “left localization” in 21 (15%) patients, and “right localization” in 13 (9%) patients. In patients with a “left-sided” esophagus a decrease in temperature < 20 °C was observed significantly more often than in patients with a “central” esophagus (81% vs. 5.7%, p < 0.05 according to the Fisher exact test). No serious complications were observed during the follow-up period after CBA.

Conclusion. Temperature monitoring using the “Astrocard Esosafety” system allows us to assess the dynamics of temperature changes in the esophagus during standard and “extended” CBA of the LA, providing important information for selecting ablation strategies 

Aim. To evaluate the impact of upgrading from right ventricular apical pacing (RVAP) to left bundle branch area pacing (LBBAP) on the clinical and functional status of patients with complete atrioventricular block (AVB) in the acute period.

Methods. The study included 30 patients with complete AVB and previously implanted pacemakers. All patients underwent elective pacemaker replacement with repositioning of the ventricular lead from the apical site to the LBBAP area. Clinical and instrumental assessments were performed before surgery and on postoperative day 5, including electrocardiography, echocardiography, a 6-minute walk test and quality of life evaluation using the EQ-5D questionnaire.

Results. After conversion to LBBAP, QRS duration decreased (from 158.5±25.5 ms to 111.2±13.8 ms, p < 0.05), interventricular and intraventricular dyssynchrony indices (interventricular mechanical delay and time to peak systolic velocity) were reduced, and the degree of mitral regurgitation decreased. The 6-minute walk test distance increased from 368.7±87.06 m to 466.15±127.2 m, and patients reported improved quality of life according to the EQ-5D questionnaire.

Conclusion. Conversion from RVAP to LBBAP leads to improved electrical and mechanical synchrony of cardiac function, which is associated with increased exercise tolerance and enhanced quality of life. LBBAP demonstrates potential as a more physiological and effective alternative to conventional apical pacing.

Three cases of registration of a rare electrocardiographic (ECG) phenomenon - alternation of the QRS complex (AQRS) are presented. AQRS was detected in two girls aged 6 and 16 with third variant of long QT syndrome (LQT3) and in an asymptomatic patient aged 13 with a family history of sudden death at a young age. AQRS was recorded in combination with macroscopic alternans of the T wave during Holter monitoring and bicycle ergometry. A definition of AQRS is given and possible mechanisms and clinical significance of the detected ECG phenomenon are discussed.

The article presents a clinical case of a patient with recurrent refractory ventricular tachycardia (VT) on the background of postinfarction cardiosclerosis. Despite optimal drug therapy and several catheter ablation procedures using modern navigation technologies, episodes of VT persisted. The key factor of ineffectiveness of the endocardial approach turned out to be the intramural location of arrhythmogenic zones. Therefore, a decision was made to perform surgical intervention with cryoablation of scar tissues. After the surgery, a stable remission was achieved, which was confirmed by the data of regular checks of the implantable cardioverter-defibrillator. The presented case emphasizes the importance of individualized and multidisciplinary approach in the choice of treatment tactics for patients with refractory VT.

A fragment of Holter ECG recording is presented, demonstrating a pseudo-second-degree atrioventricular block type II pattern, diagnosed by the presence of a non-conducted sinus P wave following a ventricular ectopic complex.