Ablation of ventricular arrhythmias above semilunar valves.

Aritmije iz izgonskog trakta desne ili lijeve klijetke mogu imati svoje ishodište u supravalvularnim miokardnim ekstenzijama. Medikamentozna terapija je tradicionalno neuspješna, pa se kod simpomatskih slučajeva ili onih kod kojih se razvije aritmijom inducirana kardiomiopatija treba odlučiti za interventno rješenje. Za njihovu uspješnu eliminaciju ablacijom mapiranje i primjena radiofrekventne energije mora se učiniti iznad semilunarnih valvula, u regijama koje imaju specifične anatomske osobitosti. U ovom preglednom radu donosimo kratak osvrt na anatomsku podlogu ovih aritmija i intraproceduralne korake koji vode uspješnoj i sigurnoj ablaciji, kao i pregled vlastitog iskustva.Arrhythmias from the right and left ventricular outflow tract may stem from supravalvular myocardial extensions. Medical therapy has traditionally been unsuccessful, so in symptomatic cases or those in which arrhythmia-induced cardiomyopathy develop we should opt for an intervention. Mapping and use of radiofrequency energy has to be performed above semilunar valves for their successful elimination by ablation, in the regions that have specific anatomical features. This review article provides a brief overview of the anatomical substrate of these arrhythmias and intraprocedural steps that lead to successful and safe ablation, as well as an overview of our own experience

“Double fire” — a rare and commonly unrecognized arrhythmia.

Dvojna fiziologija provođenja atrioventrikularnim (AV) čvorom, odnosno prisutnost tzv. sporog puta, prema raznim studijama, elektrofiziološkim ispitivanjem se može dokazati u do čak 35% ljudi. Međutim, kod samo manjeg broja on ima i klinički značaj. Prikazujemo slučaj pacijentice s vrlo rijetkom elektrofiziološkom manifestacijom aktivnog sporog puta, dvostrukog odgovora ventrikula na jedan atrijski kompleks. Problem je uspješno rješen radiofrekventnom ablacijom. Ovakav način provođenja AV čvorom vjerovatno je i znatno češći nego što se opisuje u literaturi, ali se na žalost rijetko prepoznaje te je uglavnom refraktoran na medikamentoznu terapiju.Dual atrioventricular node (AV) pathway physiology or the presence of so-called slow conduction pathway is according to various studies demonstrable in up to 35% of normal people during electrophysiology study (EPS). In only a small number of them, it has a clinical significance. We present a case of a patient with a very rare electrophysiological manifestation of active slow pathway, double ventricular response to one atrial complex. The problem was successfully treated with radiofrequency ablation. This form of conduction via AV node is probably much more common than it was previously described in the literature, but unfortunately it is rarely recognized and is generally refractory to medical therapy

Kronične nezarazne bolesti kod hrvatskih branitelja u odnosu na opću populaciju: 25 godina nakon rata

Many published reports have documented an increased prevalence of chronic medical conditions among veterans, but there were only a few studies that compared these increases with the general population. The aim of this study was to determine differences in chronic medical conditions between Croatian war veterans and the general population. This study included two groups of subjects, i.e. 1453 participants who are Croatian war veterans and 1429 participants from the general population. Medical history, physical examination, laboratory tests and specific diagnostic procedures were taken during systematic physical examination in both groups. The prevalence of hypertension, diabetes, hyperlipidemia, hypothyroidism and hyperthyroidism, chronic obstructive pulmonary disease, coronary heart disease, malignancy, psychiatric diseases, cholelithiasis, nephrolithiasis, smoking and alcohol consumption was analyzed. Croatian war veterans were found to be more likely to develop hypertension than individuals in the general population (29.5% vs. 24.3%), as well as diabetes (7.3% vs. 3.8%), hyperlipidemia (56.4% vs. 27.3%), hyperthyroidism (3.1% vs. 0.8%), coronary heart disease (4.3% vs. 1 %), malignancy (4.1% vs. 2.2%), psychiatric diseases (15.4% vs. 1.1%), and alcohol consumption (53% vs. 29%). Significant difference was found in favor of the general population for hypothyroidism (14.3% vs. 8%). There were no differences in the prevalence of chronic obstructive pulmonary disease, cholelithiasis, nephrolithiasis, and smoking. Our findings confirmed the hypothesis of a higher prevalence of cardiovascular diseases, malignancy and psychiatric diseases among Croatian war veterans and emphasized the need of better control of their medical conditions.Povećana učestalost kroničnih bolesti među veteranima dokumentirana je kroz brojna istraživanja, no samo ih je nekoliko studija uspoređivalo s općom populacijom. Cilj ovog istraživanja bio je utvrditi razlike u pojavnosti kroničnih bolesti između hrvatskih branitelja i opće populacije. Ovo istraživanje obuhvatilo je dvije skupine ispitanika, 1453 hrvatskih branitelja i 1429 sudionika iz opće populacije. Anamneza, fizikalni pregled, laboratorijske pretrage i specifični dijagnostički postupci provedeni su tijekom sistematskog fizikalnog pregleda u obje skupine. Analizirana je učestalost hipertenzije, šećerne bolesti, hiperlipidemije, hipotireoze i hipertireoze, kronične opstruktivne plućne bolesti, koronarne bolesti, malignih bolesti, psihijatrijskih bolesti, kolelitijaze, nefrolitijaze, pušenja i konzumacije alkohola. Utvrđeno je da hrvatski branitelji imaju veću vjerojatnost za razvoj hipertenzije (29,5% prema 24,3%), dijabetesa (17,3% prema 3,8%), hiperlipidemije (56,4% prema 27,3%), hipertireoze (3,1% prema 0,8%), koronarne bolesti srca (4,3% naspram 1%), zloćudne bolesti (4,1% naspram 2,2%), psihijatrijske bolesti (15,4% naspram 1,1%) i češću konzumaciju alkohola (53% naspram 29%) nego pojedinci u općoj populaciji. Uočena je značajna razlika u korist opće populacije za hipotireozu (14,3% naspram 8%). Nije bilo razlika u učestalosti kronične opstruktivne plućne bolesti, kolelitijaze, nefrolitijaze i pušenja. Naši nalazi potvrdili su hipotezu o višoj učestalosti kardiovaskularnih bolesti, malignih i psihijatrijskih bolesti među hrvatskim braniteljima te naglasili potrebu bolje kontrole njihovog zdravstvenog stanja

Preporuke za postupanje kod bolesnika sa srčanim implantabilnim elektroničkim uređajima koji su podvrgnuti magnetskoj rezonanci - Radna skupina za aritmije i elektrostimulaciju Hrvatskoga kardiološkog društva

For many years, magnetic resonance imaging (MRI) was contraindicated in patients with cardiac implantable electronic devices (CIED). Today, there is a growing amount of evidence that MRI can be performed safely in the majority of patients with CIEDs. Firstly, there are devices considered MRI conditional by manufacturers that are available on the market and secondly, there is clear evidence that even patients with MRI non-conditional devices can also undergo MRI safely. Protocols have been developed and recommendations from different cardiac and radiologic societies have been published in recent years. However, the majority of physicians are still reluctant to refer these patients to MRI. Therefore, this document is published as a joint statement of the Croatian Working Group on Arrhythmias and Cardiac Pacing and Department of Radiology, Sestre milosrdnice University Hospital Centre to guide and ease the management of patients with CIED undergoing MRI. Also, we propose a unified protocol and checklist that could be used in Croatian hospitals.Magnetska rezonanca (MR) dugo je bila kontraindicirana dijagnostička metoda kod bolesnika sa srčanim implantabilnim elektroničkim uređajima (CIED). Danas imamo dovoljno dokaza da se MR može sigurno učiniti kod većine bolesnika s CIED. Prvo, postoje uređaji koji mogu biti podvrgnuti MR prema preporukama proizvođača, a drugo, postoje jasni dokazi da većina uređaja koji nisu označeni kao sigurni za MR od proizvođača također mogu biti podvrgnuti MR. Tijekom godina razvijeni su brojni protokoli kardioloških i radioloških društava, međutim, dio liječnika i dalje oklijeva kod postavljanja indikacije za MR u ove skupine bolesnika. Stoga je Radna skupina za aritmije i elektrostimulaciju srca Hrvatskoga kardiološkog društva u suradnji s radiolozima KBC Sestre milosrdnice pripremila preporuke za postupanje s bolesnicima s CIED koji su podvrgnuti MR

Chronic Medical Conditions in Croatian War Veterans Compared to the General Population: 25 Years after the War

Many published reports have documented an increased prevalence of chronic medical conditions among veterans, but there were only a few studies that compared these increases with the general population. The aim of this study was to determine differences in chronic medical conditions between Croatian war veterans and the general population. This study included two groups of subjects, i.e. 1453 participants who are Croatian war veterans and 1429 participants from the general population. Medical history, physical examination, laboratory tests and specific diagnostic procedures were taken during systematic physical examination in both groups. The prevalence of hypertension, diabetes, hyperlipidemia, hypothyroidism and hyperthyroidism, chronic obstructive pulmonary disease, coronary heart disease, malignancy, psychiatric diseases, cholelithiasis, nephrolithiasis, smoking and alcohol consumption was analyzed. Croatian war veterans were found to be more likely to develop hypertension than individuals in the general population (29.5% vs. 24.3%), as well as diabetes (7.3% vs. 3.8%), hyperlipidemia (56.4% vs. 27.3%), hyperthyroidism (3.1% vs. 0.8%), coronary heart disease (4.3% vs. 1 %), malignancy (4.1% vs. 2.2%), psychiatric diseases (15.4% vs. 1.1%), and alcohol consumption (53% vs. 29%). Significant difference was found in favor of the general population for hypothyroidism (14.3% vs. 8%). There were no differences in the prevalence of chronic obstructive pulmonary disease, cholelithiasis, nephrolithiasis, and smoking. Our findings confirmed the hypothesis of a higher prevalence of cardiovascular diseases, malignancy and psychiatric diseases among Croatian war veterans and emphasized the need of better control of their medical conditions

Preporuke za postupanje kod bolesnika sa srčanim implantabilnim elektroničkim uređajima koji su podvrgnuti magnetskoj rezonanci - Radna skupina za aritmije i elektrostimulaciju Hrvatskoga kardiološkog društva

For many years, magnetic resonance imaging (MRI) was contraindicated in patients with cardiac implantable electronic devices (CIED). Today, there is a growing amount of evidence that MRI can be performed safely in the majority of patients with CIEDs. Firstly, there are devices considered MRI conditional by manufacturers that are available on the market and secondly, there is clear evidence that even patients with MRI non-conditional devices can also undergo MRI safely. Protocols have been developed and recommendations from different cardiac and radiologic societies have been published in recent years. However, the majority of physicians are still reluctant to refer these patients to MRI. Therefore, this document is published as a joint statement of the Croatian Working Group on Arrhythmias and Cardiac Pacing and Department of Radiology, Sestre milosrdnice University Hospital Centre to guide and ease the management of patients with CIED undergoing MRI. Also, we propose a unified protocol and checklist that could be used in Croatian hospitals.Magnetska rezonanca (MR) dugo je bila kontraindicirana dijagnostička metoda kod bolesnika sa srčanim implantabilnim elektroničkim uređajima (CIED). Danas imamo dovoljno dokaza da se MR može sigurno učiniti kod većine bolesnika s CIED. Prvo, postoje uređaji koji mogu biti podvrgnuti MR prema preporukama proizvođača, a drugo, postoje jasni dokazi da većina uređaja koji nisu označeni kao sigurni za MR od proizvođača također mogu biti podvrgnuti MR. Tijekom godina razvijeni su brojni protokoli kardioloških i radioloških društava, međutim, dio liječnika i dalje oklijeva kod postavljanja indikacije za MR u ove skupine bolesnika. Stoga je Radna skupina za aritmije i elektrostimulaciju srca Hrvatskoga kardiološkog društva u suradnji s radiolozima KBC Sestre milosrdnice pripremila preporuke za postupanje s bolesnicima s CIED koji su podvrgnuti MR

Differences in activated clotting time and total unfractionated heparin dose during pulmonary vein isolation in patients on different anticoagulation therapy

Background: Periprocedural pulmonary vein isolation (PVI) anticoagulation requires balancing between bleeding and thromboembolic risk. Intraprocedural anticoagulation is monitored by activated clotting time (ACT) with target value >300 s, and there are no guidelines specifying an initial unfractionated heparin (UFH) dose. Methods: We aimed to assess differences in ACT values and UFH dosage during PVI in patients on different oral anticoagulants. We conducted an international, multi-center, registry-based study. Consecutive patients with atrial fibrillation (AF) undergoing PVI, on uninterrupted anticoagulation therapy, were analyzed. Before transseptal puncture, UFH bolus of 100 IU/kg was administered regardless of the anticoagulation drug. Results: Total of 873 patients were included (median age 61 years, IQR 53-66; female 30%). There were 248, 248, 189, 188 patients on warfarin, dabigatran, rivaroxaban, and apixaban, respectively. Mean initial ACT was 257 ± 50 s, mean overall ACT 295 ± 45 s and total UFH dose 158 ± 60 IU/kg. Patients who were receiving warfarin and dabigatran compared to patients receiving rivaroxaban and apixaban had: (i) significantly higher initial ACT values (262 ± 57 and 270 ± 48 vs. 248 ± 42 and 241 ± 44 s, p < .001), (ii) significantly higher ACT throughout PVI (309 ± 46 and 306 ± 44 vs. 282 ± 37 and 272 ± 42 s, p < .001), and (iii) needed lower UFH dose during PVI (140 ± 39 and 157 ± 71 vs. 171 ± 52 and 172 ± 70 IU/kg). Conclusion: There are significant differences in ACT values and UFH dose during PVI in patients receiving different anticoagulants. Patients on warfarin and dabigatran had higher initial and overall ACT values and needed lower UFH dose to achieve adequate anticoagulation during PVI than patients on rivaroxaban and apixaban