Quality of visualization of coronary venous system in 64-slice computed tomography.

BACKGROUND: Multi-slice computed tomography (MSCT) can be used to visualize the anatomy of the coronary venous system (CVS). A pre-procedural evaluation of target veins is a very important element of cardiac resynchronization. Thus, the quality of visualization of the CVS is of great importance. The aim of this study was to analyze the quality of visualization of CVS in MSCT. METHODS: In 220 subjects (129 male, average age 57.2 ± 11.8 years), a 64-slice CT (Aquilion 64, Toshiba, Japan) was performed. A scan with ECG-gating was performed using a slice thickness of 0.5 mm during a breath-hold. In each case, 3D volume rendering and 2D MPR reconstructions were created (Vitrea 2). The quality of visualization was graded independently by two cardiologists and a radiologist trained in MSCT on a 0-5 points scale for the coronary sinus and main veins [0 = not visible (lack of vein); 5 = visible as a smoothly bordered vascular structure]. RESULTS: The best visualization of the CVS was obtained for coronary sinus (4.10 ± 1.08), the worst for antero-lateral vein (2.11 ± 1.10). The average number of visible veins was 3.2 per case. Statistically, more veins were visible in older subjects - in the group aged 60+ the average number of visible veins was 3.6 ± 1.1 per case, whereas in those aged under 60 it was 2.9 ± 1.2 (p = 0.0001). There were no statistical gender differences in the quality of CVS visualization. CONCLUSIONS: The target veins for cardiac resynchronization therapy should be the lateral and postero-lateral, which are usually well visible. Such a strategy could increase the usefulness of MSCT.

Role of multi-slice computed tomography in the recognition of pericardial cyst.

A pericardial cyst is, according to the definition, a collection of fluid or blood in the pericardial space (inside the pericardial sac) around the heart. New visualization methods can help in the non-invasive diagnosis of pericardial cysts. Based on a presented case, we conclude that multi-slice computed tomography can have a great impact on the detection of pericardium diseases such as a pericardial cyst.

[Principles of the practices of electrocardiographic stress test in patients before and after pacemaker implantation]. / Zasady przeprowadzania elektrokardiograficznej próby wysilkowej u chorych przed i po wszczepieniu stymulatora serca.

Electrocardiographic stress test EKG is the basic, diagnostic test in the heart failure, it is also used for patients with implanted pacemaker.

The presence of endocardial leads may limit applicability of coronary CT angiography.

OBJECTIVES: Some indications that MSCT is necessary may be visible in patients with implanted pacemakers, CRTs and ICDs devices. Purpose. To evaluate whether the presence of endocardial leads influences the quality of visualization of the coronary arteries in MSCT. DESIGN: In 37 patients a 64-slice MSCT (Aquilion 64, Toshiba) was performed due to a suspicion of ischemic heart disease (33 patients) or suspicion of lead perforation (four patients). The control group consists of 35 patients. Influence of the leads was evaluated independently by two cardiologists. RESULTS: The total number of leads that were evaluated was 63. In 26 cases (41%) significant problems with the evaluation of coronary arteries occurred: LM-1 (2%) case, LAD-3 (5%) cases, LCx-4 (6%) cases, RCA-18 (28%) cases. The presence of a right ventricular lead did not influence the quality of the imaging of the left main coronary artery (LM) and its main branches (LAD and LCx). The main concerns were related to the RCA visualization-interpretable images in 18/63 (29%) of the analyzed leads. CONCLUSIONS: The presence of implanted endocardial leads may limit the applicability of coronary CT angiography in patients with implanted anti-arrhythmic devices.

[Identity of the cardiological rehabilitation with patients with implanted cardioverter-defibrillator]. / Odrebnosc rehabilitacji kardiologicznej u pacjentów po implantacji kardiowertera-defibrylatora.

Implantable cardioverter defibrylator - ICD saves people's life and it protections against sudden cardiac death. Myocardial infarction in the past is the most often factor of the sudden cardiac death risk. The controlled physical activity and psychologists therapeuthical sessions are very important in improvement of quality of life for patients who have implanted ICD.

Recurrence of ventricular arrhythmias in patients with non-ischaemic dilated cardiomyopathy: evidence-based predictors.

BACKGROUND: Ventricular arrhythmia (VA) is the most frequent cause of sudden death among patients with non-ischaemic dilated cardiomyopathy (DCM). AIM: To identify the important VA risk factors in patients with DCM. METHODS AND RESULTS: Eighty-five DCM patients (73 males, mean age 54 years) with DCM and implantable cardioverter defibrillators (ICD) were followed for 21+/-19 months after ICD implantation. The mean follow-up was 21 months. Data from 55 patients with VA recorded in the ICD memory and requiring ICD intervention during follow-up were compared with 30 patients without arrhythmia. Cox regression analysis identified the following univariate predictors of VA: alcoholic aetiology of DCM (0.05), diuretic treatment (0.003), history of cardiac arrest (0.03), right ventricular diastolic diameter (0.001). Both ACE inhibitor (ACEI) and statin treatments were associated with a tendency towards decreased risk of VA. Multivariate logistic analysis identified four predictors as significantly related to VA: alcoholic aetiology (HR 4.8, p=0.008), ACEI treatment (HR 0.4, p=0.01), diuretic treatment (HR 2.6, p=0.015), and statin treatment (HR 0.1, p=0.03). CONCLUSIONS: The majority of patients with DCM and ICD have recurrences of VA. Alcoholic aetiology of DCM is associated with an increase in the incidence of arrhythmias. Treatment with ACEI and statins is associated with a reduction of arrhythmias.

Optimal image reconstruction intervals for noninvasive visualization of the cardiac venous system with a 64-slice computed tomography.

The purpose of the study was to evaluate in which phase of the cardiac cycle visualization of the cardiac veins could achieve the highest possible quality. In 138 patients (aged 56.6 +/- 10.6; 58F) with a suspicion of CAD, a 64-slice CT (Toshiba Aquilion) was performed. In each case ten 3D volume rendering reconstructions were created from 0 to 90% R-R intervals (step 10%) using a 0.5 mm slice thickness (reconstructions 2.0 mm). An arbitrary score of the quality of images was introduced. In 82 (59.4%) patients optimal image quality was noted at the 40% phase, in 28 (20.3%) at the 30% phase and finally in 14 (10.1%) at the 50% phase. These 3 phases (30/40/50%) were the best option for 124 (89.8% of all) patients. In the rest of the patients the best visualization was obtained in other phases as follows: 60 and 80% for 4 patients (2.9%); 70% for 3 patients (2.3%) and at the 0, 10, 20% one patient at each phase (0.7%). The optimal phases of the cardiac cycle for the visualization of the cardiac venous system are 30 or 40%. Less frequently, an alternative could be the 50% phase.

Changes in the mental and physical components of the quality of life for patients six months after pacemaker implantation.

BACKGROUND: The additional purpose for pacemaker implantation, beyond treating arrhythmias and conduction disturbances, is to improve the quality of life (QoL) of the patient. Most previous research has shown this purpose to have been achieved. However, the question as to whether all mental and physical components improve QoL to the same degree is still valid. The purpose of this study is to evaluate changes in the primary mental and physical areas of QoL in patients six months after they have had a pacemaker implanted. METHODS: Ninety eight patients with atrioventricular blocks (AVB) and 100 patients with sinus node dysfunction (SND) who were qualified for pacemaker implantation were included in this study. Every patient had a DDD(R)-type pacemaker with bipolar screw-in leads implanted. The ventricular lead was positioned in the right ventricular outflow tract. QoL was evaluated twice: three to five days before implantation and six months afterwards - the MLWHF questionnaire was used. RESULTS: A very high statistical improvement in QoL (p approximately 0,0000) - reduced number of points was found in all five areas of QoL in patients with SND and in four areas in patients with AVB. In the 'anxiety/depression area' in patients with AVB, the average number of points was higher (p = 0.3871), so QoL was worse. CONCLUSIONS: Implanting a pacemaker improves QoL in patients with AVB and SND. In patients with AVB, anxiety/depression is made more intense.

A user-friendly method of cardiac venous system visualization in 64-slice computed tomography.

BACKGROUND: Previsualization of the cardiac venous system is very important for some techniques, for example, cardiac resynchronization therapy (CRT). The aim of this study was to propose a new, user-friendly method of cardiac venous system visualization in 64-slice computed tomography (CT). METHODS: In 112 patients (66 M) aged 58 +/- 11 standard deviation, a 64-slice CT with a retrospective electrocardiogram gating was performed due to a suspicion of ischemic heart disease. Special attention was paid to the requirements for image reconstruction useful for CRT. RESULTS: In 74% of the patients, it was possible to obtain similar images to those during the CRT implantation procedure within anterior-posterior, left anterior oblique, and right anterior oblique views. The coronary sinus was clearly visible in all cases, the ostium measured 12.9 +/- 5.9 mm, and the angle of entrance 99 +/- 12 degrees. In all patients it was possible to demonstrate more than one vein; in 95%, at least one vein was clearly visible in the target area. Among the target veins, the posterolateral vein was visible most frequently (78%) in the cases as well as the lateral vein (78%). CONCLUSION: The proposed scheme in 64-slice computed tomography enables images to be generated similar to the intraoperative fluoroscopy, which can be useful in techniques where previsualization of the cardiac venous system is recommended.

Influence of DDD rate response pacing with integrated double sensors on physical efficiency and quality of life.

AIMS: The aim of this study was to evaluate whether the use of a double sensor gives additional benefits for patients in improving physical efficiency as well as quality of life (QoL) as compared to the accelerometer sensor alone. METHODS AND RESULTS: The presented research is a prospective, randomized, single-blind clinical trial. Double-sensor (accelerometer and minute-ventilation) pacemakers (Guidant, Pulsar Max DR) were implanted in 20 patients with sinus node dysfunction (SND) and chronotropic incompetence. After randomization, patients were placed in one of two groups: 1, only the accelerometer sensor was activated; 2, both sensors were activated. After a 3-month follow-up, an initial cardio-pulmonary exercise test was performed, after which the patients were placed in the opposite group for a further 3 months. Finally, the second tests were performed. In 75% of the patients an improvement in QoL was observed in the double-sensor group (P = 0.0242) when compared with the single-sensor group. The addition of a ventilating sensor had no influence on the duration of exercise test (A: 11 +/- 3.19 vs. B: 11 +/- 2.92 P = 1.0000). The parameters of cardio-pulmonary exercise tests recorded in situations A and B before exertion, and 6 minutes after exertion were not statistically different. CONCLUSION: The use of double-sensor pacemakers does not improve physical efficiency; however, it does improve QoL.

Totally epicardial cardiac resynchronization therapy system implantation in patients with heart failure undergoing CABG.

BACKGROUND: Systolic dyssynchrony is present in a considerable number of patients with heart failure (HF) undergoing coronary artery bypass grafting (CABG). Surgical revascularization offers an optimal setting for totally epicardial cardiac resynchronization therapy (CRT) system implantation. AIM: To assess the efficacy of totally epicardial CRT implantation during CABG, in patients with HF. METHODS: Twenty three patients with HF and dyssynchrony underwent totally epicardial CRT system implantation during CABG. This randomised, single-blind, cross-over study compared clinical and echocardiographic parameters during two periods: 3 months of active CRT (CRT+) and 3 months of inactive CRT (CRT-) pacing. RESULTS: Twenty two patients underwent randomisation and completed both study periods. In the CRT+ group more patients improved by two NYHA classes (p=0.028), had a longer 6-minute walk test distance (p=0.047) and better quality of life (p=0.003) compared with the CRT- group. Echocardiography revealed an improved LV ejection fraction (p<0.001), smaller LV end-systolic volume (p=0.04), reduced mitral regurgitation (p=0.026) and improved LV synchrony in the CRT+ group compared with the CRT- group. CONCLUSION: CRT delivered by a totally epicardial system implanted during CABG is associated with additional improvement of clinical and echocardiographic parameters in patients with HF and systolic dyssynchrony.

Mortality in patients with heart failure treated with cardiac resynchronisation therapy. A long-term multi-centre follow-up study.

BACKGROUND: Benefits of cardiac resynchronisation therapy (CRT) for survival in selected congestive heart failure (CHF) patients have been acknowledged by the 2005 ESC guidelines. AIM: To analyse mortality in CRT pacing only (CRT-P) patients during at least one-year follow-up. METHODS: This was a prospective, multi-site, at least one-year observational study on mortality and mode of death in patients who received CRT-P due to commonly accepted indications. One-year follow-up data (or earlier death) were available for 105 patients (19 females, 86 males) aged 60.6+/-9.8 years (35-78). Baseline NYHA class was 3.2+/-0.4 (3-4). Coronary artery disease (CAD) was the underlying aetiology of CHF in 57 (54%) patients and 48 (46%) patients had CHF due to non-coronary factors. RESULTS: Mean follow-up duration was 730 days (360-1780), median 625. There were 21 (20%) deaths: 5 (24%) sudden cardiac deaths (SCD), 13 (62%) deaths due to heart failure (HFD) and 3 (14%) other deaths. Thirteen (62%) patients died within the first year of observation. All SCD occurred in this period. Mean time to death was 303+/-277 days (19-960) to HFD - 339+/-313 days (19-960) and to SCD - 208+/-127 days (31-343). There were no significant differences between survivors and non-survivors with respect to left ventricular ejection fraction (LVEF) (25+/-10 vs. 20+/-8%), 6-minute walk test (6 min WT) (276+/-166 vs. 285+/-163 m) and LV diastolic diameter (LVEDD) (71+/-9 vs. 78+/-10 mm) (all NS). The SCD and HFD patients had similar age (62.0+/-5.4 vs. 56.6+/-13.2 years), gender (80 vs. 83% males), NYHA class (3.1+/-0.2 vs. 3.5+/-0.3), LVEF (22+/-9 vs. 17+/-5%), LVEDD (86+/-10 vs. 79+/-9 mm), 6 min WT (270+/-142 vs. 292+/-188 m) (NS). In 4 patients from the SCD group CHF was of non-coronary aetiology and only in 1 patient from the HFD group (p=0.003). The values of LVEF, LVEDD and NYHA class in HFD patients who died during the first year after implantation, compared with those who died later, were similar. CONCLUSIONS: Sudden cardiac death probability in the studied CRT-P population was the highest during the first year after implantation. Afterwards, the risk of HFD started to increase. Thus, in all patients eligible for CRT prophylactic defibrillation function should be considered.

[Vasovagal syncope--standards of management, clinical and diagnostic problems]. / Omdlenia wazowagalne--standardy postepowania, problemy kliniczne i diagnostyczno-terapeutyczne.

Although vasovagal syncope is the most frequent cause of loss of consciousness, the ability of diagnostic and therapy is still weak. The most important diagnostic method in vasovagal syndrome is the tilt test. The number of clinical trials of the effective treatment of vasovagal syncope is still small. This article attempts to summarize the most important clinical problems connected with vasovagal syncope and includes present guidelines of European Society of Cardiology. The treatment of vasovagal syndrome is mainly based on tilt training and non-pharmacological methods. Presently, there is a lack of evidence for the efficiency of pharmacological treatment. Cardiac pacing should be limited as a choice to a very small group of patients affected by severe cardioinhibitory type of vasovagal syndrome.

Totally epicardial cardiac re-synchronization therapy system implantation in patients with heart failure undergoing CABG--description of 3 cases.

INTRODUCTION: Systolic dyssynchrony as an indication for cardiac re-synchronization therapy is present in a considerable subset of patients with congestive heart failure undergoing surgical coronary revascularisation. Coronary artery bypass grafting offers an optimal setting for totally epicardial cardiac re-synchronization system implantation. AIM: To assess the feasibility and safety of totally epicardial cardiac re-synchronization system implantation in patients with ischaemic heart disease and heart failure undergoing coronary artery bypass grafting. METHODS: Three male patients with coronary artery disease and postinfarction functional class III congestive heart failure underwent a combined procedure of on-pump surgical coronary revascularisation and totally epicardial cardiac re-synchronization system implantation (all three leads implanted epicardially). In all patients intraventricular dyssynchrony was revealed in preoperative echocardiography. RESULTS: There was no perioperative morbidity or mortality. The mean total time required for cardiac re-synchronization system implantation was 17.3+/-2.3 minutes. We obtained excellent pacing and sensing parameters at implant (left ventricular pacing thresholds: 0.8, 0.5, 0.5 V at 0.5 ms; left ventricular sensing thresholds: 17, 15, 20 mV, respectively in consecutive patients). After 12 months pacing and sensing parameters remained stable. Significant improvement in 6-minute walk test distance, functional class and echocardiographic parameters (left ventricular ejection fraction, intraventricular dyssynchrony) was observed in all patients. CONCLUSIONS: Totally epicardial cardiac re-synchronization system implantation is safe and can be regarded as an important supplement to surgical coronary revascularisation in the still growing population of patients with severe heart failure and systolic dyssynchrony, which can be used for the optimisation of treatment results.

Intracardiac electrogram method of VV-delay optimization in biventricular pacemakers.

Ventricle to ventricle (VV) delay optimization can provide an additional benefit to cardiac resynchronization therapy, but the methods currently used for optimization are time consuming and operator-dependent. We present two cases of VV-delay optimization with the use of a new intracardiac electrogram method. (Cardiol J 2007; 14: 305-310).