[How to improve response to cardiac resynchronization therapy?]. / Jak zlepsit odpoved'na srdecní resynchronizacní lécbu?

Cardiac resynchronization therapy decreases mortality and rehospitalization for heart failure. However, around 30% of patients do not respond to this therapy. The paper analyses factors, with a possible impact on the response to this therapy. It is a left ventricular lead proximity to the left ventricle segment with the latest activity, presence and size of postinfarction scar and a percentage of fully captured paced beats. Methods of optimalization of these factors are described as well as circumstances, under which some patients should be indicated for cardiosurgical lead implantation or if a cardiac resynchronization therapy should be ommited.

[Newly diagnosed Churga-Strauss syndrome in a female patient with suspect acute coronary syndrome]. / Nove diagnostikovaný syndrom Churga-Straussové u pacientky s podezrením na akutní koronární syndrom.

We present a case of 60 years old patient with the history of repeated sinusitis and bronchial asthma, who developed Churg-Strauss syndrome (CSS) with mono-neuritis multiplex, skin laesions on the head and acute perimyocarditis, which led to suspicion on myocardial infarction. Diagnosis of CSS was based on clinical manifestations, blood hypereosinophilia and histological examination of nasal mucous membrane biopsy. Subsequent immunosuppressive therapy led to regression of symptoms and improvement of temporarily decreased left ventricular function.

[The importance of determining the viability of the myocardium prior to revascularisation in patients with ischaemic cardiomyopathy and left ventricular systolic dysfunction]. / Význam stanovení viability myokardu pred revaskularizací u pacientu s ischemickou kardiomyopatií a systolickou dysfunkcí levé komory srdecní.

Chronic heart failure is a worldwide clinical syndrome with substantial socio-economical impact. The aim of this overview is the summary of contemporary knowledge in epidemiology, elementary pathophysiological implications and some possibilities of treatment of ischemic cardiomyopathy, which represents the most frequent cause of heart failure in developed countries. Emphasis is on the right indication for myocardial revascularization as a causal option of therapy of ischemic cardiomyopathy, timing and risk of revascularization and especially on importance of assessment of viability of myocardium using presently available imaging methods.

[Chronic benign exsudative pericarditis--a case of familiar incidence]. / Chronická exsudativní benigní perikarditida--popis familiárního výskytu.

Pericarditis is a common disease caused by a number of factors. Chronic pericarditis is defined as the presence of pericardial effusion for more than 3 or 6 months. The case study reports a case of familiar incidence of chronic exsudative pericarditis in a young woman, her sister and her mother, with an analysis of diagnostic and therapeutic options. According to available literature, this is the second case described of such form of familiar incidence.

[Malignant arrhythmia in a patient with variant (Prinzmetal's) angina pectoris]. / Maligní arytmie u pacienta s variantní (Prinzmetalovou) anginou pectoris.

Malignant arrhythmia is a frequent complication of myocardial ischemia due to the occurrence of coronary artery spasm. The paper describes a patient with variant angina pectoris with an ICD implant who was repeatedly resuscitated for circulatory arrest in malignant arrhythmia. During myocardial ischemia the ECG showed elevations in the ST segments in the region of the ventral cardiac wall, with the formation of permanent polymorphous chamber tachycardia. External defibrillation was necessary due to recurrent tachyarrhythmias. A spasm developed when the RIA (radio immuno assay) was introduced during coronarography. The spasm started in the periphery of the artery and extended as far as the area of bifurcation with RD, with transitory closure of the artery and the development of chamber tachycardia. The patient fully recovered after the addition of Ca-blocker, nitrate depot and the withdrawal of the beta-blocker.

[Occurrence of an exceptional complication in an attempt to apply temporary pacemaking]. / Ojedinelá komplikace pri pokusu o zavedení docasné kardiostimulace.

The case study reports the case of a female patient who, during an admission exam in an area medical centre, presented with severe symptomatic bradyarrhythmia and the need for temporary external pacemaking. The first attempt to perform temporary transvenous pacemaking failed and was accompanied by a rare but serious iatrogenic complication which necessitated heart surgery. The case study is completed with illustrative figures.

[Long term results of cardiac resynchronisation therapy for patients with severe heart failure]. / Dlouhodobé výsledky srdecní resynchronizacní lécby u pacientu s tezkým srdecním selhaním.

INTRODUCTION: Cardiac resynchronisation therapy (CRT) has been shown to be a highly effective treatment strategy for patients with severe chronic heart failure (ChHF). OBJECTIVE OF STUDY: To determine the clinical response of patients to CRT, to measure morbidity and mortality for this population of patients, to determine causes and predictors of death. To test whether the parameters of tissue Doppler echocardiography are able to predict response to CRT. PATIENTS AND METHODS: Before and after implantation of the CRT and 12 months later, echocardiograph tests were carried out and relevant clinical data was recorded during the monitoring of patients. RESULTS: 102 patients (71 men, 31 women) with an average age of 71 +/- 9 years took part in the study. 68% patients had cardiac ischemia, 29% had idiopathic dilated cardiomyopathy. 75% patients were in functional class NYHA III, 25% NYHA IV. After a monitoring period of 711 +/- 329 days, 26 patients had died and 35 patients had been hospitalised. 34% of all hospitalisations were for acute exacerbation of ChHF. Patients with initial functional classification NYHA IV had a higher mortality rate in years one and two than patients in class NYHA III. The proportion of clinical responders was 64% after 12 months of CRT. In 58% of patients, a year of CRT produced a relative increase in the ejection fraction of the left ventricle (EF LV) of > or = 30%. 1/3 of patients had EF LV ? 45% with minimal symptoms of ChHF. The following were found to predict reverse remodelling of the left ventricle: less advanced state of the basic illness (EFLV > 23%, left ventricular end-diastolic diameter < 65 mm, left ventricular end-diastolic volume < 160 ml and left ventricular end-systolic volume < 120 ml) and interventricular mechanical delay > 45 ms. CONCLUSION: CRT is a safe method with a high success rate. There continues to be a problem with identifying responders. Symptoms of less advanced heart disease and interventricular delay were identified as sensitive predictors of the response to treatment.

[The influence of targeted intervention on the incidence of risk factors of cardiovascular diseases at medical staff]. / Vliv cílene intervence na výskyt rizikových faktoru kardiovaskulárních onemocnení u zdravotnických zamestnancu.

INTRODUCTION: The work addresses the targeted intervention of cardiovascular diseases at medical staff. SET AND METHODICS: During 2002-2004 years, within the scope of preventive examination, there was made targeted prevention of risk factors of cardiovascular diseases (CVD) at the big hospital employees at the Centre of preventive care of employees and in the department of preventive cardiology of Ist Internal Clinic of LF UP and FN Olomouc. According to the effective tables, there was stated a CVD risk of these employees. The employees received a personal individual letter which informed them of the level of CVD risk and proposed a targeted intervention of risk factors. The part of the set--427 employees of the average age of 38.93 years (SD 11.39), 69 men (M) of the average age of 40 years (SD 12.47) and 358 women (F) of the average age of 38.7 years (SD 11.18) was examined another time during 2004-2005 years. The methodics of second examination was the same as at the first examination, only the questionnaire was complemented by the questions related to the knowledge of the CVD risk stated at previous examination. RESULTS: There occurred statistically significant decrease of LDL cholesterol in the set (from 2.87 mmol/l to 1.23 mmol/l, p < 0.0001) and BMI decrease (from 24.35 to 24.16, p < 0.05) and at the same time statistically significant increase of total cholesterol (from 5.09 mmol/l to 5.27 mmol/l, p < 0.05) and triglycerides (from 1.27 mmol/l to 3.01 mmol/l, p < 0.0001). There was no significant change in other RFs (BP, WHR, HDL cholesterol, moving activity). The influence on RF of smoking was statistically significant (23 employees quitted smoking, 10 employees started, p < 0.05). 53 F (14.80%) and 3 M (4.34%) know their cardiovascular risk, 235 F (65.64%) and 53 M (76.81%) do not know their cardiovascular risk. CONCLUSION: The work approved the influence of targeted intervention on the incidence of cardiovascular diseases risk factors and at the same time low level of knowledge of one's own individual risk, despite of targeted intervention.

The MCP-1 -2518 (A to G) single nucleotide polymorphism is not associated with myocardial infarction in the Czech population.

Monocyte chemoattractant protein (MCP)-1 is the key chemokine in the process of atheroslerotic vascular inflammation. Examining already reported association between coronary artery disease (CAD) and the SNP A/G in the MCP-1 gene (position -2518), 139 Czech patients with CAD manifested as myocardial infarction (MI) and 359 unrelated healthy control (C) subjects were genotyped by PCR-SSP. Genotype and allele frequencies were not different in MI and C groups (allele G: MI, 20.5%; C, 23.8%, OR = 0.8, P > 0.05). No differences were detected when the patients were subdivided based on sex or the age of MI first occurrence. Further, no relationship was observed between circulating MCP-1 levels and carriage of the G allele. The data do not support a role for the MCP-1 -2518 single nucleotide polymorphism in susceptibility to CAD manifested by myocardial infarction.

Serum levels of the MCP-1 chemokine in patients with ischemic stroke and myocardial infarction.

Chemokine-driven migration of inflammatory cells has been implicated in pathogenesis of atherosclerosis-associated conditions such as ischemic stroke and myocardial infarction. In this study, a candidate chemokine, monocyte chemoattractant protein (MCP)-1, was investigated in patients with both aforementioned manifestations of atheroslerotic inflammation. MCP-1 levels in serum were determined by ELISA in 40 healthy, control subjects (C), 40 patients with ischemic stroke (IS), and in 64 patients with myocardial infarction (MI). Statistical analysis utilised Mann-Whitney test, Fisher's exact test, and Spearman's rank correlation (P < .05). In comparison to control subjects (C; median/interquartile range: 239/126 pg/mL), MCP-1 serum levels were increased in both investigated patient cohorts (IS: 384/370, P < .001; MI: 360/200, P < .002). There was a substantial variability of MCP-1 serum levels, especially in the IS group. No relationship was observed between chemokine levels and atherosclerosis risk factors (hypertension, diabetes, smoking, and alcohol consumption), and MCP-1 was also not related to age or gender. Elevation of MCP-1 in circulation of patients with atherosclerosis-associated complications implicates this CC chemokine ligand (CCL)2 in inflammatory processes, which contribute to pathogenesis of myocardial infarction and ischemic stroke. Further investigations, including patient stratification, are however necessary to evaluate if MCP-1 can be utilised for clinical management of patients with these diseases.

[Cardiac arrhythmias. Diagnostic and therapeutic decision-taking]. / Srdecní arytmie diagnostické a terapeutické rozhodování.

Last 40 years of growing knowledge of the mechanisms of cardiac arrhythmias has unambiguously demonstrated therapeutic superiority of non-pharmacological treatment over antiarrhythmic drugs, which are in these days rather used in acute phase or moderate forms of tachyarrhythmias. Diagnosis of bradyarrhythmias relies mainly on bradycardia symptoms, bradycardia detection on the surface ECG and their mutual time correlation. Electrophysiological study stands aloof in these cases. Permanent cardiac stimulation dominates unequivocally in the therapy of bradyarrhythmias. Electrophysiological study has taken a unique place in the tachycardia therapy, since it allows inducing reproducibly tachyarrhythmia and by means of its mapping to determine its course. Thus, a completely new, "intracardiac" view on the arrhythmia mechanism has evolved and considerably weakened the diagnostic importance of the surface ECG. Radiofrequency catheter ablations represent a rapidly evolving causal therapeutic modality of tachyarrhythmias, especially in the absence of structural heart disease. Significantly decreased left ventricular ejection fraction combined with tachycardia symptoms should raise suspicion of life threatening ventricular arrhythmias, which are nowadays successfully treated by implantation of a cardioverter-defibrillator.

Acute ischemia as a complication by transoesophageal echocardiography.

Transoesophageal echocardiography (TEE) is a safe procedure with a low complication rate. We present a patient with severe coronary artery stenosis or disease who developed acute coronary ischemia of the anterior wall as a complication of TEE procedure. The possible mechanism can be stress during the procedure.

[Endothelial injury and activation of the coagulation cascade during radiofrequency catheter ablation]. / Endoteliální poskození a aktivace koagulacní kaskády behem radiofrekvencní katétrové ablace.

GOAL OF STUDY: To identify the extent of systemic activation of the coagulation cascade and to evaluate thrombogenic effect of the radiofrequency catheter ablation. METHODS AND RESULTS: Markers of activation of the coagulation cascade (D-dimers [DD]), markers of activation of the fibrinolytic system (tissue plasminogen activator [t-PA] and its inhibitor [PAI-1]), and markers of endothelial damage (von Willebrand factor [vWf]) were monitored in 50 patients undergoing catheter ablation. Levels of these substances were identified in time T0--at the beginning of the examination, T1--after finishing diagnostic part of the electrophysiological study, T2--after finishing all applications of radiofrequency energy, and T3--24 hours after T2. Levels of vWf were significantly elevated in time T1 compared to values in T0 (p < 0.001) and were further elevating after finishing the procedure in time T2 (p < 0.05). Levels of t-PA were also elevated in time T1, however after application of the radiofrequency energy, further increase in T2 was nonsignificant. Concentrations of PAI-1 were in time T2 significantly lower compared to T1 values (p < 0.001). Levels of DD were significantly elevated during entire procedure and elevated levels persisted even 24 hours later (p < 0.001). Levels of vWf a t-PA in time T2 correlated with total time of application of radiofrequency energy. Significantly higher activation of the coagulation cascade was identified, in patients undergoing isolation of pulmonary veins compared to patients undergoing catheter ablation of other arrhythmias. In the subgroup of patients treated with anticoagulation before the intervention elevation of DD levels in times T1 and T2 was lower compared to patients who did not undergo any treatment (p < 0.05). CONCLUSION: The radiofrequency catheter ablations activate the coagulation cascade. Moreover, application of the radio frequency energy increases systemic thrombogenic state and this effect "depends on the dose". A risk group make patients undergoing catheter isolation of pulmonary veins.

[Acute myocardial infarct as a result of external compression caused by an expanding pulmonary adenocarcinoma]. / Akutní infarkt myokardu jako dusledek zevní komprese prorustajícího adenokarcinomu plic.

The case report describes a rare cause of acute myocardial infarction. 68-years old man with the cancer triplicity (follicular and papillar carcinoma of the thyroid gland, Grawitz tumor, bronchogenic carcinoma with generalization) was admitted to the intensive care unit for the sudden onset of chest pain, positivity of cardioselective enzymes and signs of cardiogenic shock. Echocardiographic examination proved diaphragmatic akinesis with low left ventricular ejection fraction about 30%. The acute coronary angiogram revealed unimportant atherosclerotic narrowing of the left coronary artery and a long significant stenosis in the proximal portion of the right coronary artery untypical for atherosclerotic lesion suspicious of extramural compression. A pathological vascularization to the extramyocardial region was documented during right coronary angiogram. The patient was treated conservatively and finally transferred to the pulmonary disease department, where he died of progression of the cancer disease two months later. Postmortem examination found spreading of the bronchogenic adenocarcinoma to the pericardium along the course of the right coronary artery, but neither direct infiltration of the vessel wall by the tumor nor atherosclerotic disease of the proximal portion of the right coronary artery were proved. These findings together with the coronary angiogram demonstrate a rare cause of the myocardial infarction due to the extramural compression by the malignant tumor.

[Effect of beta radiation brachytherapy in the treatment of restenosis of coronary stents]. / Efekt brachyterapie beta zárením v lécbe restenózy v koronárním stentu.

Brachytherapy currently represents the only treatment method for in-stent restenosis (ISR) confirmed in randomised clinical studies. In a group of 46 patients, selected for brachytheraphy on the bases of clinical signs of restenosis accompanied with development or deterioration of angina pectoris and with angiography results showing significant in-stent restenosis, we used a beta radiation system BetaCath NOVOSTE. This therapy was safe. Results of acute angiography were positive in 91% of patients. Clinical restenoses within 6 month of clinical monitoring occurred in 8.6% of patients. Due to impairment of more arteries in the majority of patients from the sample, following revascularisation of nontarget vessels was necessary in 19.6% of patients. We haven't observed late thrombosis. It was probably eliminated by prolonged administration of a combination of aspirin and clopidogrel. Dosimetry results during brachytherapy showed that doses of radiation both for a surgeon and a patient corresponded to a fraction of doses received from an x-ray apparatus during fluoroscopy and acquisition. Both an edge restenosis and a diffuse restenosis were identified in stenoses of patients with in-stent restenosis. Brachytherapy with beta radiation seems to be an efficient method for treatment of coronary in-stent restenosis.

[Long-term effect of catheter ablation of ventricular tachycardia in adult patients with previous surgery of congenital heart defects. 2 case reports]. / Dlouhodobý efekt katétrové ablace komorové tachykardie u dospelých pacientu s predchozí operací vrozené srdecní vady. Dve kazuistiky.

Two case reports of catheter ablation of sustained monomorphic ventricular tachycardia in two adult patients after previous surgical correction of congenital heart disease are reported. In both patients catheter ablation led to long-term elimination of ventricular tachycardia during follow-up period of 38 and 20 months.

[Treatment of atrioventricular accessory pathways using catheter ablation: analysis of immediate and long-term results at the end of the learning curve period]. / Lécba sínokomorových prídatných drah katétrovou ablací: analýza bezprostredních a dlouhodobých výsledku v období po ukoncení ucební fáze.

UNLABELLED: Immediate and long-term results of catheter ablation of atrioventricular accessory pathways (AP) are presented. METHOD: One hundred and seventy-one patients aged 41.8 +/- 14.4 years underwent catheter ablation of 179 AP. Right and left AP occurred simultaneously in 3 patients; thus 65 ablation procedures for 57 rights AP in 57 patients were compared with 125 ablation procedures for 122 left AP in 117 patients. RESULTS: Including repeated procedures ablation was successful in 116 (99%) patients with left AP and in 57 (100%) patients with right AP. First catheter ablation failed in 4 (7%) patients with right AP and in 4 (3.4%) patients with left AP (p = NS). Two of these patients with left AP and all 4 pts with right AP had successful reablation. AP conduction recurred after successful ablation in 7 (12.3%) patients with right AP and in u 5 (4.1%) patients with left AP (p = 0.1). Three patients with right AP did not undergo another ablation, other 9 patients with AP recurrence had successful reablation. Procedure time during left AP ablation was shorter (159.6 +/- 70.7 vs. 183.4 +/- 75.6 min.; p = 0.02) and number of RF current deliveries was lower during left AP ablation (9.3 +/- 8.5 vs. 13.3 +/- 11.8; p = 0.008) compared to right AP ablation. Fluoroscopy time during left AP ablation (22.4 +/- 19.1 min.) did not significantly differ from that during right AP ablation (20.9 +/- 17.1 min.). Concealed AP was present in 13 (22.8%) patients with right AP and in 59 (48.4%) patients with left AP (p = 0.002). Anatomico-functional variant of AP occurred in 5 (8.8%) patients with right AP and in 4 (3.3%) patients with left AP (p = NS). Atrial fibrillation complicated ablation procedure in 9 (15.8%) patients with right AP and in 7 (5.7%) patients with left AP (p = NS). During 30.3 +/- 17 (2-60) months follow-up period tachyarrhythmia associated with the presence of an AP occurred in 3 patients with right AP and in 1 patient with unsuccessful ablation of left AP. None of these patients underwent repeated ablation. CONCLUSION: Successful ablation of AP can be achieved successfully in 100%. Catheter ablation of right AP is generally more difficult and primary ablation failure and AP conduction recurrence is nonsignificantly more often. Irregularity of the tricuspid annulus, instability of the ablation catheter, presence of the conduction system, higher occurrence of anatomico-functional AP variants and sustained atrial fibrillation during the ablation procedure represent the main causes of this finding.

[Determination of the end-point of the radiofrequency linear lesion in the subeustachian isthmus and its relation to treatment of atrial flutter and fibrillation. Acute and long-term results in 90 patients]. / Hodnocení cílového momentu radiofrekvencní lineární léze na subeustachovském mustku a jeho vztah k lécbe flutteru a fibrilace síní. Akutní a dlouhodobé výsledky u 90 pacientu.

UNLABELLED: Complete subeustachian isthmus (isthmus) block created with radiofrequency (RF) linear lesion eliminates type I. atrial flutter (AFL). The end-point of the procedure is measurable. PATIENTS AND METHOD: Ninety patients (21 F) aged 57.6 +/- 12.5 years underwent RF catheter ablation for AFL. Twenty patients had significant structural heart disease (SHD). Atrial fibrillation (AF) was previously documented in 34 (37.8%) patients. Complete isthmus block served as the end-point of the procedure. RESULTS: Following the first ablation procedure complete isthmus block was achieved in 81 (90%) patients and incomplete isthmus block in 7 (7.8%) patients. First procedure failed in 2 (2.2%) patients. AFL recurred in 6 (6.8%) patients, in 4 (4.9%) out of 81 patients with complete isthmus block and in 2 (28.5%) out of 7 patients with incomplete isthmus block. After repeated successful ablation and creation of complete isthmus block in these 6 patients and in 1 patient with previous ablation failure, complete isthmus block was achieved in 84 (93.3%) patients, incomplete isthmus block in 5 (5.6%) patients and ablation was unsuccessful in 1 patient. During 21 +/- 10.6 (6-45) month follow-up since the last ablation AFL did not recur in any of 89 (98.9%) patients with complete or advanced incomplete isthmus block. AF occurred in 39 (43.3%) patients. Incidence of AF was significantly higher in patients without SHD and with AF previously documented or induced (group 2) (25/43; 58.1%) compared to patients without SHD and no AF documented or induced (group 1) (6/27; 22.2%) (p < 0.01). AF occurred in 40% patients with SHD (group 3), which did not significantly differ from any of the former two groups of patients. In this group AF occurred in 10 out of 12 (83.3%) patients with AF documented prior to ablation, which was significantly more compared to 1 (12.5%) patient out of 8 without documented AF (p < 0.01). CONCLUSION: Complete conduction block over the subeustachian isthmus during catheter ablation has a clearly measurable end-point and represents effective method in permanent cure of AFL. Clinical benefit is reduced by AF, particularly in patients, in whom the arrhythmia was documented prior to ablation. In these patients catheter ablation of AFL can be considered a first step to combined treatment with previously ineffective antiarrhythmic drugs and with other ablation strategies.

[Electrophysiologic parameters determining the success of radiofrequency ablation of atrioventricular reentry tachycardia]. / Elektrofyziologické parametry urcující úspesnost radiofrekvencní ablace atrioventrikulárních reentry tachykardií.

The main objective was to assess electrophysiological parameters which may be important for effective radiofrequency ablation of accessory atrioventricular pathways. In a group of 66 patients a total of 490 applications of radiofrequency current were made, incl. 68 which led to successful severing of the accessory pathways. The ablations were successful in 65 patients (98.5%). The potential of the accessory pathways was present in effective ablations in 19 cases of 68 applications (28%), while in ineffective ablations it was present in 13 cases of 421 applications (3%, p < 0.001). Stability of the electrogram was found in all 68 effective ablations (100%), while in ineffective ablations a stable electrogram was found in 248 cases of 323 applications (77%, p < 0.001). In unstable electrograms the ablation was not effective in any of the patients. The V-delta interval was significantly longer in successful ablations (16 +/- 14.2 ms) than in unsuccessful ones (3 +/- 19.4 ms, p < 0.001). The ventriculoatrial interval was in successful ablations significantly shorter (57.5 +/- 22.5 ms) than in unsuccessful ones (74.5 +/- 20.9 ms, p < 0.001). In 90% applications the ventriculoatrial interval was less than 70 ms. Of 10 evaluated parameters the potential of the accessory pathway, stability of the electrogram, V-delta interval (equal or < or = 0) and short ventriculoatrial intervals (equal to or < or = 70 ms) proved important parameters for successful ablation of accessory pathways.