Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life.

Purpose Of Review: Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia.

Proposing national diagnostic reference levels for electrophysiology studies and catheter ablation procedures in Bulgaria.

Introduction: The implementation of diagnostic reference levels (DRLs) is an essential tool for optimisation of the routine practice, better management of patient exposure while maintaining sufficient image quality. National DRLs for electrophysiology (EP) procedures are not available in our country.

Purpose: The main purpose of the study was to propose, for first time in Bulgaria, national DRLs (NDRLs) for EP studies and ablation procedures of two different levels of complexity.

Outcomes of early catheter ablation for ventricular tachycardia in adult patients with structural heart disease and implantable cardioverter-defibrillator: An updated systematic review and meta-analysis of randomized trials.

Aims: Catheter ablation (CA) for ventricular tachycardia (VT) can improve outcomes in patients with ischemic cardiomyopathy. Data on patients with non-ischemic cardiomyopathy are scarce. The purpose of this systematic review and meta-analysis is to compare early CA for VT to deferred or no ablation in patients with ischemic or non-ischemic cardiomyopathy.

Left free wall-sided Mahaim type fiber and A-V nodal reentry tachycardia: Unusual but not impossible combination.

A 52-year-old patient with previous catheter ablation of A-V nodal reentrant tachycardia (AVNRT) had a redo procedure for reported recurrence. During the study, AVNRT was not inducible, but a previously unrecognized left-sided Mahaim-type accessory pathway was diagnosed and ablated successfully.

Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating from the Para-Hisian area - QRS Morphology Change and Late Effect of the Ablation: Case Series.

Introduction: Radiofrequency catheter ablation of idiopathic ventricular arrhythmias originating in the para-Hisian region could be challenging because of a potential risk of iatrogenic atrioventricular block. Uncommonly, shift of the exit site during the ablation can be observed. Consequently, different approaches of radiofrequency catheter ablation of para-Hisian ventricular foci can be needed.

Present criteria for prophylactic ICD implantation: Insights from the EU-CERT-ICD (Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators in EUrope) project.

Background: The clinical effectiveness of primary prevention implantable cardioverter defibrillator (ICD) therapy is under debate. It is urgently needed to better identify patients who benefit from prophylactic ICD therapy. The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD) completed in 2019 will assess this issue.

Rationale and design of the EU-CERT-ICD prospective study: comparative effectiveness of prophylactic ICD implantation.

Aims: The clinical effectiveness of primary prevention implantable cardioverter defibrillator (ICD) therapy is under debate. The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD) aims to assess its current clinical value.

Methods And Results: The EU-CERT-ICD is a prospective investigator-initiated non-randomized, controlled, multicentre observational cohort study performed in 44 centres across 15 European Union countries.

Correlation between the sudden jump-like increases of the atrio-Hisian interval induced during burst atrial pacing and during programmed atrial stimulation in patients with atrioventricular nodal reentrant tachycardia.

Purpose: To study the correlation between the sudden prolongations of the atrio-Hisian (AH) interval with ≥50 ms during burst and programmed atrial stimulation, and to define whether the AH jump during burst atrial pacing is a reliable diagnostic criterion for dual AV nodal physiology.

Methods: Retrospective data on 304 patients with preliminary ECG diagnosis of AV nodal reentrant tachycardia (AVNRT), confirmed during electrophysiological study, was analyzed for the presence of AH jump during burst and programmed atrial stimulation, and for correlation between the pacing modes for inducing the jump. Wilcoxon signed-ranks test and Spearman's bivariate correlation coefficient were applied, significant was P-value <0.

The non-fluoroscopic navigation reduces significantly not only the fluoroscopic exposure during catheter ablation of the cavotricuspid isthmus but the total radiofrequency time as well.

Objective The non-fluoroscopic navigation (NFN) is known to reduce the fluoroscopic time during catheter ablation of various arrhythmias. We aimed to study the impact of NFN over several procedural parameters during radiofrequency (RF) catheter ablation of the cavo-tricuspid isthmus (CTI) in patients with CTI-dependent atrial flutter. Methods Data about 124 consecutive patients with CTI ablation performed were retrospectively collected.

The presence of extensive atrial scars hinders the differential diagnosis of focal or macroreentrant atrial tachycardias in patients with complex congenital heart disease.

Aims: Atrial tachycardias (ATs) frequently develop in patients with congenital heart defects (CHDs). This study aimed to evaluate the effects of extensive atrial scar formation on the total atrial activation time (TAAT) and its relation to the tachycardia cycle length (CL) to classify AT.

Methods And Results: Seventy-one patients were included and divided into two groups: patients without CHD (Group I, 35 patients) and with CHD (Group II, 36 patients).

Unusual site of origin of a non-automatic focal right ventricular tachycardia.

Focal right ventricular tachycardia is relatively uncommon. It usually arises from specific anatomic locations. A 59-year-old woman with a structurally normal heart and an automatic cardioverter-defibrillator implanted beforehand presented with drug-resistant incessant ventricular tachycardia for which 1786 anti-tachycardia pacing therapies and 119 shocks had been delivered.

Electrogram analysis at the His bundle region and the proximal coronary sinus as a tool to predict left atrial origin of focal atrial tachycardias.

Aims: Early activation at the His bundle (HB) region or proximal coronary sinus (CS) during focal atrial tachycardias (FATs) often necessitates biatrial mapping. Analysis of CS electrograms (EGMs) consisting of a near-field (N) component from CS musculature and a far-field (F) component from left atrial (LA) myocardium can uncover LA activation preceding right atrial (RA) activation. A similar pattern might be observed at the HB.

Selective slow pathway ablation using transseptal approach in a patient with surgically corrected partial atrioventricular canal defect and atrioventricular nodal reentrant tachycardia of the common type.

A 26-year-old woman with partial atrioventricular (AV) canal defect surgically closed with pericardial patch in a mode that the triangle of Koch had become part of the left atrium underwent successful slow pathway ablation for slow-fast AV nodal reentrant tachycardia. Transseptal approach was used because of the atypical post-operative anatomy. Transseptal catheter ablation of the slow pathway can be a reasonable and safe alternative in patients subjected to this type of operation.

Percutaneous coronary intervention for acute myocardial infarction in a single coronary artery anomaly.

We report on a case of an adult male patient with previously unknown coronary anomaly and acute myocardial infarction in the territory of the left anterior descending artery (LAD). The coronary angiography showed a single coronary artery with intertruncal course, arising from the right coronary sinus, and thrombotic occlusion of the LAD. Successful transradial percutaneous coronary intervention was done with implantation of an intracoronary stent in the occluded artery.

Bi-atrial and right atrial activation times help to differentiate focal from macroreentrant right atrial tachycardias.

Objective: The objective was to study atrial activation intervals and their relation to the tachycardia cycle length (TCL) as electrophysiologic parameters differentiating focal (FAT) from macroreentrant atrial tachycardias (MRAT) originating in the right atrium.

Methods: In 21 patients (8 men) with 30 successfully ablated right atrial tachycardias (15 focal) the endocardial activity during tachycardia was registered using multipolar catheters in the right atrium and the coronary sinus. Using this catheter configuration we measured the tachycardia cycle length (TCL), biatrial activation (BAA), right atrial activation (RAA), left atrial activation (LAA), as well as the proportion of those intervals to TCL.

Radiofrequency catheter ablation in a child with Wolff-Parkinson-White syndrome and congenitally corrected transposition of the great arteries.

The case is presented of a five-year-old boy with Wolff-Parkinson-White syndrome, who had undergone three surgical palliations because of congenitally corrected transposition of the great arteries, ventricular septal defect and pulmonary trunk near-atresia. Successful and uncomplicated radiofrequency catheter ablation of an accessory pathway located across the systemic atrioventricular valve ring was performed. The procedure was motivated by forthcoming corrective surgery, which would preclude venous access to the heart.

Ice mapping during tachycardia in close proximity to the AV node is safe and offers advantages for transcatheter ablation procedures.

Background: Ablation during ongoing orthodromic reentry tachycardia (AVRT) and atrioventricular nodal reentry tachycardia (AVNRT) is not recommended using radiofrequency energy when the arrhythmia substrate is located in close proximity to the atrioventricular (AV) node due to a significant risk for inadvertent AV block. The aim of the study is to test the feasibility of ice mapping during tachycardias involving arrhythmia substrate located in close proximity to the AV node.

Methods: This was a single-centre, prospective, randomized study.

Mid-term echocardiographic follow up of left ventricular function with permanent right ventricular pacing in pediatric patients with and without structural heart disease.

Background: Chronic right ventricular apical pacing may have detrimental effect on left ventricular function and may promote to heart failure in adult patients with left ventricular dysfunction.

Methods: A group of 99 pediatric patients with previously implanted pacemaker was studied retrospectively. Forty-three patients (21 males) had isolated congenital complete or advanced atrioventricular block.

Evolution of left ventricular function in paediatric patients with permanent right ventricular pacing for isolated congenital heart block: a medium term follow-up.

Aims: We aimed to assess the evolution of left ventricular (LV) systolic function in children with right ventricular apical (RVA) pacing for isolated congenital heart block (ICHB) and to identify possible predictors of LV function deterioration. Right ventricular apical pacing can be detrimental to LV function in a significant number of adults. Effects in children are still controversial.

Unusual Wenckebach phenomenon due to an atrial tachycardia arising from the apex of Koch's triangle in the presence of dual AV nodal physiology.

A case of a patient with narrow QRS tachycardia and without structural heart disease is presented. The electrophysiologic study revealed an atrial tachycardia in the presence of dual atrioventricular (AV) nodal physiology and AV block at suprahisian level, the latter two leading to an unusual Wenckebach periodicity. The entire septal area was mapped as was the coronary sinus (CS) os and the earliest atrial activation was found at the apex of Koch's triangle in close vicinity to the His bundle (HB).