Who needs a permanent pacemaker after transcatheter aortic valve implantation?

INTRODUCTION: We aimed to identify predictive factors for pacemaker requirement and determine the rate of pacemaker dependency in a single centre patient group. METHODS AND REULTS: Out of 116 patients, who underwent transcatheter aortic valve implantation at our institution. Absence of atrial fibrillation at time of procedure, pulmonary hypertension, obesity and severity of aortic valve stenosis were predictive for the need of permanent pacemaker implantation after transcatheter aortic valve implantation. CONCLUSION: Only persisting periprocedural and early-onset complete heart block were permanent and resulted in patients' pacemaker dependency. Definite predictors of persistence of conduction impairment are yet to be identified. We can predict only pacemaker dependency, but the real need of pacing in our risky patients with softer indications for permanent pacemaker after transcatheter aortic valve implantation cannot be clearly identified, essential in context of improving quality of their lives in avoiding symptomatic bradycardia, which can be intermittent, especially in such a group of elderly patients often with fragile and degenerate conduction system (Tab. 5, Ref. 34).

Prevalence of metabolic syndrome, insulin resistance, and microvascular angina pectoris in 500 consecutive patients referred to coronarography.

OBJECTIVE: This work was aimed to evaluate the prevalence of insulin resistance (IR) and metabolic syndrome in a large cohort of 40-60 years old patients with cardiovascular symptoms. METHODS: A total of 500 consecutive males and females referred to coronarography and coronary catheterization, because of spontaneous or after load precordial pain plus denivelisation of ST segment by electrocardiography, were included. Besides standard clinical examinations, ergometry, echocardiography, fundamental laboratory tests, and several other laboratory examinations were also performed, including oral glucose toleration test (OGTT), total and high-density lipoprotein (HDL) cholesterol, triglycerides, apoprotein A1 and B, apolipoprotein (a), uric acid, fibrinogen, plasminogen activator inhibitor-1 (PAI-1), cytokines (tumor necrosis factor α, TNFα, interleukin-1, IL-1, interleukin-6, IL-6), endothelin-1, as well as hormones (insulin, C peptide, leptin, growth hormone, cortisol). RESULTS: In 81.6% of patients, IR syndrome with compensatory hyperinsulinemia was found in a positive correlation with various symptoms of metabolic syndrome, including abdominal obesity, increased body mass index (BMI), dysglycemia, dyslipoproteinemia, coronary stenosis, decreased HDL level, and hypertension. Hirsutism with polycystic ovarian syndrome was found in 52% of examined women with IR. However, a normal coronary angiogram, called as a microvascular form of the angina pectoris (MIV-AP), was found in 14% of predominantly periclimacteric and benign hirsutic females with long-term disorders of menstrual cycle. Since these patients showed the same symptoms as their gender, age, BMI, and degree of coronary stenoses adjusted pairs with the macrovascular form (such as the same levels of several lipids, hormones and obesity measures), our data strongly support the view that MIV-AP might belong to the IR syndrome. CONCLUSIONS: Hyperinsulinemia and high prevalence of various symptoms of metabolic syndrome (MS) were found in high percentage of patients with after load precordial pain who were referred to coronarography. Similarly, in several women, MIV-AP was detected and its affiliation to MS suggested.

[Metastatic involvement of the heart and pericardium--MR case reports]. / Metastatické postihnutie srdca a perikardu-- MR kazuistiky.

Secondary metastatic tumors of the heart and pericardium are in comparison with primary cardiac tumors more common, but their overall prognosis is very poor. Metastases can occur in every part of the heart and pericardium. The most common source are tumors--lung cancer, breast cancer, melanoma and lymphoma. In this case report we described two patients with metastatic involvement of the heart. We are pointing out the possibilities of diagnostic imaging of cardiac tumors using echocardiography and magnetic resonance.

[Risk factors and prevention of sudden cardiac death in patients with ventricular tachycardia after myocardial infarct]. / Markery rizika a prevencia náhlej srdcovej smrti u pacientov s komorovou tachykardiou po infarkte myokardu.

UNLABELLED: The optimal therapeutic procedure for prevention of sudden cardiac death (SCD) after myocardial infarction involves identification of the patients with a high risk of malignant ventricular arrhythmias using non-invasive risk markers, invasive electrophysiological evaluation of high risk patients, selection of treatment (ICD, RFTA, antiarrhythmics) and evaluation of the effectiveness of treatment. The objective of this work is retrospective evaluation of the incidence of risk markers of sudden cardiac death and the importance of programmed ventricular stimulation for the prognosis of patients with malignant ventricular arrhythmias after myocardial infarction. RESULTS: 1. Retrospective analysis of 87 patients with ventricular tachycardia (VT) after myocardial infarction confirmed a high incidence of non-invasive risk markers. 2. For the long-term course a combination of the left ventricular ejection fraction (LVEF) < 0.40 + reduced heart rate variability (HRV) and abnormal ventricular potentials are most important (or dispersion of QT > 80 ms). The absence of ventricular extrasystoles on the Holter monitor does not predict the course without malignant arrhythmical episodes. 3. There is a statistically significant relation to the inducibility of BP during programmed ventricular stimulation with LVEF, persisting BP, RMS voltage of the terminal 40 ms (RMS40) and QT dispersion. 4. The inducibility of BP and persistence of inducibility on antiarrhytmic drugs in patients with LVEF < 40 is associated with a 14.8% incidence of SCD within four months after the first arrhythmic episode. The authors recommend to examine LVEF as the basis of risk stratification of SCD along with values of coronary reserve after myocardial infarction. In patients with LVEF (they recommend to examine Holter s monitor (assessment of HRV and analysis of ventricular arrhythmias) and mean ECG. Abnormal late ventricular potentials, reduced HRV or BP indicate programmed ventricular stimulation.

[Radiofrequency ablation of type I atrial flutter. Personal experience]. / Rádiofrekvencná ablácia atriálneho flutteru typ I. Nase skúsenosti.

The cause of Afl-I is macroentry in the right atrium. The critical site of reentry is the narrow anatomical space in the isthmic region between the posterior part of the annulus of the tricuspid valve and the vena cava inferior (isthmus TA-IVC). Radiofrequency ablation (RF) of the isthmus TA-IVC is successful on average in 90% of patients. The best criterium for evaluation of short-term and long-term effect of RF ablation is a two-way block of conduction in the TA-IVC insthmus, created by RF ablation. In case of a relapse it is possible to repeat ablation. Although a proarrhythmic effect of ablation is not assumed, the cause of the higher frequency of atrial fibrillation is not known. The authors present their own experience with the treatment of Afl-I by RF ablation of the TA-IVC isthmus in a group of 18 patients. RF ablation was successful in 83.3% patients of the group, no complications were recorded. Late relapses of Afl-1 in three patients were resolved by repeated RF ablation which was successful. The results are comparable with results in other departments. Based on their own experience the authors consider ablation treatment of Afl-1 a safe and effective therapeutic method in a selected group of patients.

[Management of ventricular tachycardia after acute myocardial infarct]. / Manazment komorovej tachykardie po akútnom infarkte myokardu.

BACKGROUND: Risk stratification of malignant ventricular tachyarrhythmias and sudden cardiac death after myocardial infarction is essentially important for high risk patients identification, who require specific therapeutic procedures. Non-invasive risk markers--LVEF, late potentials LP, Q-T dispersion, decreased heart rate variability (HRV) and baroreflex sensitivity (BRS)--and ventricular tachycardia inducibility have low positive predictive value. The appropriate combination and consecutiveness which will provide most precise identification of patients threatened by sudden arrhythmic death, applicable to all patients after myocardial infarction, is being analysed. METHODS: In a group of 87 patients after myocardial infarction suffering from ventricular tachycardia retrospective assessment of sudden cardiac death risk markers incidence was performed. RESULTS: 1. The most frequent risk marker was LVEF 0.40 (48.3%), abnormal LP (84.9%), DQT 80 ms and decreased HRV (73.1%) and their combinations. 2. Patients with inducible ventricular tachycardia (62.1%) had lower LVEF in comparison with non-inducible ventricular tachycardia patients (0.42 +/- 0.11 vs 0.51 +/- 0.01, p = 0.002), higher QT dispersion (85.0 +/- 30.5 ms versus 63.6 +/- 30.7 ms, p = 0.003). 3. In patients with recurrent malignant ventricular tachyarrhythmias and sudden cardiac death occurring during the follow-up is sustained inducible ventricular tachycardia with antiarrhythmic therapy and induction of ventricular tachycardia during native state significantly more frequent. LVEF is significantly reduced, FQRS on SAECG is significantly prolonged, DQT is significantly higher. CONCLUSION: On the basis of the results and data from literature the authors recommend LVEF assessment in all patients after myocardial infarction and further stratification in patients with left ventricular dysfunction.

[Dispersion of the Q-T interval after myocardial infarct]. / Disperzia intervalov Q-T po infarkte myokardu.

Non-homogenity of ventricular myocardial repolarization is a substrate for the reentry mechanism of ventricular arrhythmias. It is manifestant by dispersion of Q-T and Q-Tc intervals on the standard ECG curve. The authors studied the possibility of using the dispersity of Q-T and Q-Tc intervals in clinical practice. They evaluated the dispersion of these intervals within the set of 21 patients after myocardial infarction with sustained ventricular tachycardia, and compared it with the dispersion within the control set of 17 patients after myocardial infarction without an arrhythmic episode. By means of comparison, they have discovered that: 1) the dispersion of Q-T and Q-Tc intervals is significantly higher in patients with ventricular tachycardia: Q-T (mean +/- SE) 82.8 +/- 7.8 msec vs 42.2 +/- 4.8 msec, Q-Tc 93.0 +/- 10.2 msec vs 47.1 +/- 4.8 msec, p > 0.001, 2) the dispersion of Q-Tc when higher than 60 msec is an optimum discrimination value for the prognosis of sudden arrhythmic death after myocardial infarction (sensitivity 81%, specificity 76%) and 3) the dispersion of Q-T and Q-Tc intervals has no relation to the function of the left ventricle. Therefore the authors consider the dispersion of Q-T and Q-Tc intervals as being a useful marker of malignant ventricular arrhythmia which could be included into the algorithm of assessment of the risk of sudden arrhythmic death after myocardial infarction.

[Treatment of paroxysmal ventricular tachycardia]. / Moznosti liecby paroxyzmálnej komorovej tachykardie.

The authors present a retrospective evaluation of the risk stratification and therapy of 53 patients with ventricular tachycardia. They present the diagnostical algorithm used for the detection of risk of sudden death. The most frequently used drug in the set of patients was amiodarone in monotherapy or in combination with other drugs. Sotalol was used for both, its antiarrhythmic nature, and for its ability to reduce the defibrillation threshold in patients with an implanted automatic implantable cardiovertor-defibrillator (AICD). Antiarrhythmic drugs of class I in monotherapy were used in patients with non-coronary causes of ventricular tachycardia and with normal left ventricular function. The authors, on the basis of sudden death of three patients with low ejection fraction of the left ventricle which were recorded even despite Holter apparatus and electophysiologically confirmed supression of ventricular tachycardia, recommend to consider in this group of patients the primary AICD implantation. (Tab. 4, Fig. 2, Ref. 13.)

[The head-up tilt test with nitroglycerin provocation in the diagnosis of vasovagal syncope]. / "Head-up tilt" test s provokáciou nitroglycerínom v diagnostike vazovágovej synkopy.

The study compares the diagnostical values of "head-up tilt" tests both with or without nitroglycerin the provocation. On the basis of the comparison of a group of 60 patients and 20 healthy people we can state that the "head-up tilt" test with the provocation by nitroglycerin is appropriate for the statement of diagnosis of the cardioinhibitory type of vasovagal syncopes. (Tab. 4, Ref. 14.)

[Autonomic nervous system tests in the classification of patients at risk for sudden cardiac death]. / Testovanie autonómneho nervového systému pri stratifikovaní chorých ohrozených náhlou srdcovou smrtou.

The authors present an insight into the role of the nervous system in relation to the risk of sudden cardiac death. They present the basic diagnostic possibilities provided by examination of the autonomous nervous system, namely heart rate variability and baroreflex sensitivity. Reduced heart rate variability and the depression of baroreflex sensitivity represent independent risk markers of sudden heart death. Their role in complex risk stratification of patients endangered by sudden cardiac death especially after myocardial infarction and with congestive heart failure. (Fig. 5, Tab. 2, Ref. 24.)

[Prevention of polymorphous ventricular tachycardia in patients with congenital long QT interval syndrome]. / Moznosti prevencie polymorfnej komorovej tachykardie u pacientov s kongenitálnym syndrómom dlhého QT intervalu.

Patients with the Romano-Ward long QT interval syndrome run a high risk of sudden cardiac death. Beta-blockers of the sympathetic nerve are effective treatment. Some patients die suddenly despite this treatment. The treatment of choice is a combination of beta-blockers of the sympathetic nerve and cardiostimulation. The authors describe a group of their own five patients from three families with the Romano-Ward syndrome. The course was favourable. The stimulation rate needed for normalization of the QT interval and a favourable clinical development was 78 +/- 6 imp./min. Based on data in the literature and their own experience the authors recommended combined treatment with beta-blockers and cardiostimulation in patients with the Romano-Ward syndrome, if monotherapy with beta-blockers is not effective.

[Microvascular angina pectoris and insulin resistance]. / Mikrovaskulárna angina pectoris a inzulínová rezistencia.

The authors examined 29 patients with the syndrome of microvascular angina pectoris. In 12 patients (41.4%) they recorded hyperinsulinaemia as a manifestation of insulin resistance. The body weight, HDL cholesterol level, LDL cholesterol and triglycerides did not differ significantly in the two groups and were at the upper borderline of the range of reference values. The authors analyze mechanisms common to the pathophysiology of the syndrome of microvascular angina pectoris and the syndrome of insulin resistance.

[Corneal endothelium after radical keratotomy]. / Sródblonek rogówki po keratotomii radialnej.

Corneal endothelium was examined in 37 patients with a contact endothelial specular microscope before and after radial keratotomy. The mean percent of cell loss was 0.9% one month and 2.5% six months after surgery.

[Use of transconjunctival cryoapplication in chronic pars planitis with involvement of peripheral retina and choroid]. / Zastosowanie krioaplikacji przezspojówkowej w przewleklych zapaleniach czesci plaskiej ciala rzeskowego z zajeciem obwodu siatkówki i naczyniówki.

The transconjunctival cryoapplication was performed in 8 patients (13 eyes) with the recurrent pars planitis and the simultaneous involvement of peripheral retina and choroid. Before the surgery, the peripheral fundus of the eye was examined with the Goldmann three-mirror lens and afterwards, the cryoapplication of lesions was performed. The topical treatment, dexamethasone and indomethacin drops, followed the surgery only. In all cases the inflammation disappeared but the macular edema and vitreal exudation regressed slowly. The considerable improvement of visual acuity was achieved in 8 eyes (61%). So far, the results of the observations are satisfactory and they entitle the authors to carry on the application of the treatment mentioned above.

[Critical evaluation of the treatment of diabetic retinopathy based on personal experience]. / Krytyczna ocena leczenia retinopatii cukrzycowej w oparciu o material wlasny.

The authors present the results of analysis of the treatment of 184 patients (360 eyes) with diabetic retinopathy; it comprises as well the out-patients as the in-patients divided into 4 groups in dependence on the changes and the treatment applied (laser focused photocoagulation, panretinal photocoagulation, cryopexy) the majority of patients reported to the hospital with an advanced proliferative diabetic retinopathy and this allowed only the performance of a panretinal photocoagulation and in a part of cases only cryopexy. The attention is called to the necessity of an early detection of pathological changes and of an early treatment.