H. Abe (Kitakyushu, Japan)P. Adragao (Carnaxide, Portugal)G. Agnelli (Perugia, Italy)A. Ahmed (Riyadh, Saudi Arabia)A. Al-Ahmad (Riyadh, Saudi Arabia)F. Alamanni (Milan, Italy)P. Alboni (Cento-FE, Italy)A. Al-Fagih (Riyadh, Saudi Arabia)M. Al-Fayyadh (Riyadh, Saudi Arabia)O.R. Alfieri (Milan, Italy)E. Aliot (Vandoeuvre-lès-Nancy, France)A.S. Al-Khadra (Riyadh, Saudi Arabia)J. Almendral Garrote (Madrid, Spain)N. Al-Rawahi (Muscat, Oman)A. Alsheikh-Ali (Abu Dhabi, United Arab Emirates)E.U. Alt (Houston-TX, USA)V. Altamura (Rome, Italy)A.F. Amico (Copertino-LE, Italy)P. Ammann (St. Gallen, Switzerland)F. Ammirati (Rome, Italy)D. Andresen (Berlin, Germany)S. Anker (Berlin, Germany)G. Ansalone (Rome, Italy)F. Anselme (Rouen, France)S. Aquilani (Rome, Italy)O. Aquilina (Malta)E. Arbelo (Barcelona, Spain)G. Arena (Massa Carrara, Italy)A. Arenal-Maiz (Madrid, Spain)V. Arora (New Delhi, India)N. Aspromonte (Rome, Italy)A. Auricchio (Lugano, Switzerland)A. Auriti (Rome, Italy)A. Avella (Rome, Italy)G.H. Bardy (Seattle-WA, USA)S.S. Barold (Tampa-FL, USA)A. Barosi (Milan, Italy)D.K. Baruah (Visakhapatnam, India)J.G. Baust (Binghamton-NY, USA)F. Bellocci (Rome, Italy)D.G. Benditt (Minneapolis-MN, USA)S. Benussi (Milan, Italy)T. Berger (Innsbruck, Austria)E. Bertaglia (Mirano-VE, Italy)R. Bhardwaj (Shimla, India)F. Bianchi (Turin, Italy)S. Bianchi (Rome, Italy)L. Bianconi (Rome, Italy)A. Biffi (Rome, Italy)M. Biffi (Bologna, Italy)G. Bisleri (Brescia, Italy)J.J. Blanc (Brest, France)

P.E. Bloch-Thomsen (Hellerup, Denmark)C. Blomstrom Lundqvist (Uppsala, Sweden)L.V. Boersma (Nieuwegein, The Netherlands)M.G. Bongiorni (Pisa, Italy)L. Bontempi (Brescia, Italy)M. Borggrefe (Mannheim, Germany)G. Boriani (Bologna, Italy)G.L. Botto (Como, Italy)R. Bouhouch (Rabat, Morocco)S. Boveda (Toulouse, France)J. Brachmann (Coburg, Germany)G. Breithardt (Muenster, Germany)M. Brignole (Lavagna-GE, Italy)G. Buja (Padua, Italy)C.L. Byrd (Weston-FL, USA)J. Bytesnik (Prague, Czech Republic)H. Calkins (Baltimore-MD, USA)L. Calò (Rome, Italy)V. Calvi (Catania, Italy)D.S. Cannom (Los Angeles-CA, USA)F. Cantù (Bergamo, Italy)R. Cappato (Milan, Italy)A. Capucci (Ancona, Italy)C. Carbucicchio (Milan, Italy)M.D. Carlson (Sylmar-CA, USA)M. Cassese (Catanzaro, Italy)A. Castro (Rome, Italy)D. Catanzariti (Rovereto-TN, Italy)D. Cavaco (Lisbon, Portugal)J. Chen (Bergen, Norway)J.G. Chenarides (Pittsburgh, PA, USA)G.B. Chierchia (Brussels, Belgium)K.R.J. Chun (Hamburg, Germany)A. Ciccaglioni (Rome, Italy)J. Clementy (Bordeaux, France)F. Colivicchi (Rome, Italy)F. Coltorti (Bari, Italy)S.J. Connolly (Hamilton-ON, Canada)V.M. Conraads (Edegem, Belgium)D. Corrado (Padua, Italy)F. Crea (Rome, Italy)P.S. Cunha (Lisbon, Portugal)A. Curnis (Brescia, Italy)C. D’Ascia (Naples, Italy)J.C. Daubert (Rennes, France)D.W. Davies (London, UK)C. De Chillou (Nancy, France)P. De Filippo (Bergamo, Italy)Y. De Greef (Antwerp, Belgium)R. De Ponti (Varese, Italy)P. Defaye (Grenoble, France)J.C. Deharo (Marseille, France)FA

CULTY

P. Delise (Conegliano Veneto-TV, Italy)P. Della Bella (Milan, Italy)P.P. Delnoy (Zwolle, The Netherlands)T. Deneke (Cologne, Germany)L. Di Biase (Austin-TX, USA)M. Di Biase (Foggia, Italy)G. Di Pasquale (Bologna, Italy)M. Disertori (Trento, Italy)A. D’Onofrio (Naples, Italy)F. Dorticòs (La Habana, Cuba)F. Drago (Rome, Italy)M. Duytschaever (Bruges, Belgium)H. Ector (Leuven, Belgium)J.R. Edgerton (Plano-TX, USA)M. El Khuri (Beirut, Lebanon)N. El Sherif (Brooklyn-NY, USA)Z. Emkanjoo (Tehran, Iran)A. Epstein (Philadelphia, USA)C. Ermis (Antalya, Turkey)S. Ernst (London, UK)S. Faerestrand (Bergen, Norway)G.M. Fassini (Milan, Italy)L. Fauchier (Tours, France)S. Favale (Bari, Italy)F. Fedele (Rome, Italy)I. Fernandez Lozano (Madrid, Spain)S. Ficili (Rome, Italy)D.R. Fischell (Tinton Falls-NJ, USA)J.D. Fisher (New York-NY, USA)R. Fogari (Pavia, Italy)G. Forleo (Rome, Italy)N. Fragakis (Thessaloniki, Greece)P.A. Friedman (Rochester-MN, USA)F. Gaita (Asti, Italy)J.J. Garcia Guerrero (Badajoz, Spain)X. Garcia-Moll Marimon (Barcelona, Spain)M. Gasparini (Milan, Italy)J.C. Geller (Bad Berka, Germany)G.F. Gensini (Florence, Italy)A. Ghorbani-Sharif (Tehran, Iran)F. Giada (Mestre-VE, Italy)G. Giannola (Cefalù-PA, Italy)J. Gill (London, UK)A.M. Gillis (Calgary-AB, Canada)F. Giraldi (Milan, Italy)M. Godoy Yovanovich (Torrevieja, Spain)K. Goehl (Nuernberg, Germany)M.R. Gold (Charleston-SC, USA)B. Gorenek (Eskisehir, Turkey)M. Grimaldi (Acquaviva delle Fonti-BA, Italy)E. Gronda (Milan, Italy)S. Grossi (Turin, Italy)

J.M. Guerra (Barcelona, Spain)P. Guerra (Montreal, Canada)M.M. Gulizia (Catania, Italy)M. Haissaguerre (Bordeaux, France)F. Halimi (Le Chesnay, France)C. Hansen (Goettingen, Germany)B. Hansky (Bad Oeynhausen, Germany)R. Hatala (Bratislava, Slovakia)E. Hatzinikolaou-Kotsakou (Thessaloniki, Greece)R. Hauer (Utrecht, The Netherlands)G. Hindricks (Leipzig, Germany)K. Hirao (Tokyo, Japan)E. Hoffmann (Munich, Germany)H. Hogh Petersen (Copenhagen, Denmark)S.H. Hohnloser (Frankfurt, Germany)J.D. Hummel (Columbus-OH, USA)S. Iacopino (Catanzaro, Italy)M. Iacoviello (Bari, Italy)D. Igidbashian (Gorizia, Italy)K. Imai (Hiroshima, Japan)G. Inama (Crema, Italy)T. Ishikawa (Kanagawa, Japan)C.W. Israel (Frankfurt, Germany)A. Jaswal (New Delhi, India)C. Jazra (Bawcrieh, Lebanon)M. Jensen-Urstad (Stockholm, Sweden)B. John (Vellore, India)L.J.L.M. Jordaens (Rotterdam, The Netherlands)W. Jung (Villingen-Schwenningen, Germany)S.J. Kalbfleisch (Columbus-OH, USA)B.K. Kantharia (Houston-TX, USA)J. Kautzner (Prague, Czech Republic)A. Kazemi Saeid (Tehran, Iran)C. Kennergren (Goteborg, Sweden)U. Khanolkar (Goa, India)G. Klein (Hannover, Germany)D. Klug (Lille, France)Y. Kobayashi (Tokyo, Japan)J. Köbe (Muenster, Germany)O. Kowalski (Zabrze, Poland)V. Kumar (New Delhi, India)M. Kuniss (Bad Nauheim, Germany)T. Kurita (Osaka, Japan)M.T. La Rovere (Montescano-PV, Italy)F. Lamberti (Rome, Italy)M. Landolina (Pavia, Italy)G.A. Lanza (Rome, Italy)C.P. Lau (Hong Kong, Repubblic of China)C. Lavalle (Rome, Italy)J.Y. Le Heuzey (Paris, France)D. Lebedev (St. Petersburg, Russian Federation)B. Lemke (Luedenscheid, Germany)FA

CULTY

L. Leoni (Padua, Italy)G.V. Lettica (Ragusa, Italy)S. Levy (Marseille, France)T. Lewalter (Bonn, Germany)P. Lilla della Monica (Rome, Italy)C. Linde (Stockholm, Sweden)B.D. Lindsay (Cleveland-OH, USA)E.T. Locati (Milan, Italy)P. Loh (Utrecht, The Netherlands)V. Loiaconi (Rome, Italy)F. Lombardi (Milan, Italy)J.C. Lopshire (Indianapolis-IN, USA)M.L. Loricchio (Rome, Italy)M. Lowe (London, UK)A. Lubinski (Lodz, Poland)B. Luderitz (Bonn, Germany)M. Lunati (Milan, Italy)P. Mabo (Rennes, France)G. Maccabelli (Milan, Italy)A.P. Maggioni (Florence, Italy)G. Maglia (Catanzaro, Italy)R. Mango (Rome, Italy)A.G. Manolis (Athens, Greece)M. Mantica (Milan, Italy)R. Mantovan (Treviso, Italy)T. Maounis (Athens, Greece)G. Marenzi (Milan, Italy)G. Marinelli (Bologna, Italy)N. Marrazzo (Mercogliano-AV, Italy)D. Martin (Burlington-MA, USA)J.G. Martínez (Alicante, Spain)M. Martins Oliveira (Lisbon, Portugal)G. Mascioli (Bergamo, Italy)K. Matsumoto (Saitama, Japan)A. Mazzola (Teramo, Italy)A. Meijer (Eindhoven, The Netherlands)F. Mele (Rome, Italy)J.Q. Melo (Carnaxide, Portugal)P. Mitkowski (Poznan, Poland)M. Moghaddam (Tehran, Iran)G. Molon (Negrar-VR, Italy)L. Mont (Barcelona, Spain)A.S. Montenero (Milan, Italy)J. Moreno (Madrid, Spain)J. Morgan (Southampton, UK)P. Morina-Vazquez (Huleva, Spain)C. Moro-Serrano (Madrid, Spain)P. Mortensen (Aarhus, Denmark)A.J. Moss (Rochester-NY, USA)M. Munawar (Jakarta, Indonesia)C. Muneretto (Brescia, Italy)F. Musumeci (Rome, Italy)

C. Muto (Naples, Italy)Y. Nakazato (Tokyo, Japan)S. Nardi (Terni, Italy)A. Natale (Austin-TX, USA)G.F. Neri (Montebelluna-TV, Italy)G.A. Ng (Leicester, UK)T. Nitta (Tokyo, Japan)A. Nogami (Yokohama, Japan)E. Occhetta (Novara, Italy)K. Okishige (Yokohama, Japan)S. Orazi (Rieti, Italy)O. Oseroff (Buenos Aires, Argentina)A. Oto (Ankara, Turkey)I.E. Ovsyshcher (Beer-Sheva, Israel)D.L. Packer (Rochester-MN, USA)L. Padeletti (Florence, Italy)C. Pandozi (Rome, Italy)C. Pappone (Cotignola-RA, Italy)S. Paraskevaidis (Thessaloniki, Greece)J.W. Park (Hamburg, Germany)D. Pecora (Brescia, Italy)G. Pelargonio (Rome, Italy)G. Perego (Milan, Italy)N. Pérez Castellano (Madrid, Spain)D. Petrač (Zagreb, Croatia)M. Piacenti (Pisa, Italy)P. Pieragnoli (Florence, Italy)C. Pignalberi (Rome, Italy)C. Piorkowski (Leipzig, Germany)E.C.L. Pisanò (Lecce, Italy)D. Potenza (S.G. Rotondo-FG, Italy)A. Pozzolini (Fano-PU, Italy)C. Pratola (Ferrara, Italy)S.G. Priori (Pavia, Italy)C. Pristipino (Rome, Italy)A. Proclemer (Udine, Italy)A. Quesada (Valencia, Spain)S.M. Rafla (Alexandria, Egypt)A. Raviele (Mestre-VE, Italy)A.S. Revishvili (Moscow, Russian Federation)D. Reynolds (Oklahoma City-OK, USA)R.P. Ricci (Rome, Italy)M. Rinaldi (Turin, Italy)E. Rodriguez Font (Barcelona, Spain)F. Romeo (Rome, Italy)R. Rordorf (Pavia, Italy)E. Rowland (London, UK)R. Ruiz-Granell (Valencia, Spain)M. Russo (Rome, Italy)S.M.A. Sadrameli (Tehran, Iran)A. Sagone (Milan, Italy)S. Saksena (New Brunswick-NJ, USA)FA

CULTY

J.A. Salerno-Uriarte (Varese, Italy)V. Sanfins (Guimaraes, Portugal)T. Sanna (Rome, Italy)L. Santini (Rome, Italy)M. Santini (Rome, Italy)M. Santomauro (Naples, Italy)N. Saoudi (Monaco-MC, France)A. Sarkozy (Brussels, Belgium)B. Sarubbi (Naples, Italy)B. Sassone (Bentivoglio-BO, Italy)I. Savelieva (London, UK)A. Saxena (New Delhi, India)M. Scaglione (Asti, Italy)M.J. Schalij (Leiden, The Netherlands)D.L. Scher (Harrisburg-PA, USA)R. Schilling (London, UK)H. Schmidinger (Vienna, Austria)B. Schmidt (Frankfurt, Germany)B.M. Schumacher (Bad Neustadt, Germany)J.O. Schwab (Bonn, Germany)P.J. Schwartz (Pavia, Italy)L. Sciarra (Rome, Italy)P. Scipione (Ancona, Italy)K. Seidl (Ingolstadt, Germany)J. Seitz (Massy, France)G. Senatore (Cirié-TO, Italy)S. Sermasi (Rimini, Italy)K.K. Sethi (New Delhi, India)A.N. Shah (Elmhurst-NY, USA)D. Shah (Geneva, Switzerland)V.P. Sharma (Jalandhar, India)M. Shoda (Tokyo, Japan)T. Simmers (Breda, The Netherlands)B. Singh (New Delhi, India)K. Soejima (Kawasaki, Japan)G. Speciale (Rome, Italy)S. Spencker (Berlin, Germany)J. Sperzel (Bad Nauheim, Germany)P. Spirito (Genoa, Italy)G. Stabile (Naples, Italy)C. Stefanadis (Athens, Greece)P. Stefano (Florence, Italy)G. Steinbeck (Munich, Germany)D.M. Steinhaus (Kansas City-MO, USA)M. Sterlinski (Warsaw, Poland)C. Sticherling (Basel, Switzerland)F. Straube (Munich, Germany)K. Sugi (Tokyo, Japan)N.A. Sulke (Eastbourne, UK)R. Sutton (London, UK)R. Sweidan (Jeddah, Saudi Arabia)M. Taborsky (Olomouc, Czech Republic)

H. Tada (Tsukuba-shi, Japan)M. Takagi (Osaka, Japan)S. Takatsuki (Tokyo, Japan)S. Themistoclakis (Mestre-VE, Italy)G. Theodorakis (Athens, Greece)L. Toivonen (Helsinki, Finland)C. Tondo (Milan, Italy)C. Torp-Pedersen (Hellerup, Denmark)L. Torracca (Ancona, Italy)S. Toscano (Colleferro-RM, Italy)T. Toselli (Ferrara, Italy)N. Trevisi (Milan, Italy)M. Tritto (Castellanza-VA, Italy)M. Tubaro (Rome, Italy)P. Turco (Cotignola-RA, Italy)G. Turitto (Brooklyn-NY, USA)V. Tuzcu (Little Rock-AR, USA)K. Uno (Tsuchiura, Japan)A. Vado (Cuneo, Italy)P.E. Vardas (Heraklion, Greece)N. Varma (Cleveland-OH, USA)V.P. Vassilikos (Thessaloniki, Greece)C. Vassilopoulos (Athens, Greece)G. Vergara (Rovereto-TN, Italy)R. Verlato (Camposampiero-PD, Italy)A. Verma (Ontario, Canada)E.G. Vester (Dusseldorf, Germany)G.Q. Villani (Piacenza, Italy)A. Vincenti (Monza-MI, Italy)M. Viscusi (Caserta, Italy)J. Vogt (Bad Oeynhausen, Germany)M. Volpe (Rome, Italy)H. Watanabe (Niigata, Japan)H. Wei (Beijing, Repubblic of China)M. Wieczorek (Duisburg, Germany)B.L. Wilkoff (Cleveland-OH, USA)C. Wolpert (Mannheim, Germany)J. Wright (Liverpool, UK)T. Yamane (Tokyo, Japan)N. Yazicioglu (Istanbul, Turkey)M. Zanobini (Monzino-MI, Italy)F. Zanon (Rovigo, Italy)G. Zanotto (Legnago-VR, Italy)P.A. Zartner (Sankt Augustin, Germany)G. Zingarini (San Sisto-PG, Italy)M. Zoni Berisso (Genoa, Italy)

FACULTY

FREE PAPERS

Tuesday, November 30

REMOTE MONITORING 2

CARDIAC IMPLANTABLE DEVICES REMOTE MONITORING MANAGEMENT EVALUATION:EXPERIENCE FROM ELECTROPHYSIOLOGY UNIT-SAN MATTEO HOSPITAL-PAVIA 2

M. Landolina, P. Lago, P. Sacchi, G. Beccagutti, F. Borghetti, S. Valsecchi, R. Busca, F. De Seta

IMPLANTABLE CARDIAC DEFIBRILLATOR PATIENT REMOTE MONITORINGFOLLOW-UP ECONOMIC AND MANAGERIAL EVALUATION 2

G. Molon, G. Vergara, F. Zanon, P. Delise, C. Perrone, A. Proclemer, M. Bertaglia, F. Borghetti, J. Comisso, G. Zanotto

RATIONALE OF IMPLANTABLE CARDIAC DEFIBRILLATORS PATIENTS REMOTE MONITORING 2A. Proclemer, G. Zanotto, L. Tomasi, M. Brieda, L. Leoni, R. Mantovan, R. Verlato, J. Comisso, F. Borghetti, G. Vergara

FOLLOW UP OF PATIENTS WITH PACE-MAKER AND ICD: ROLE OF CARE-LINK REMOTE MONITORING 3C. Amellone, M. Giuggia, G. Trapani, B. Giordano, G. Cirillo, L. Tognazzolo, B. Indino, G. Senatore

REMOTE MONITORING OF CARDIAC DEVICE PATIENTS: OUR EXPERIENCE 3V. Schirripa, A. Politano, M. Sgueglia, G. Panattoni, V. Romano, D.G. Della Rocca, A. Topa, L. Santini, G.B. Forleo, G. Magliano,L. Papavasileiou, F. Romeo

NEW ONSET OF ATRIAL ARRHYTHMIAS DETECTED THROUGH REMOTE MONITORINGIN PATIENTS TREATED WITH CARDIAC RESYNCHRONIZATION THERAPY 3

S. Iacopino, G. Colangelo, V. Aspromonte, I. Lo Cane, G. Fabiano, A. Talerico, S. Pellicano, D. Roccaro, M. Davinelli

ICD OUTCOME AND REMOTE CONTROL 4

MORBIDITY IN LONG TERM FOLLOW UP OF ICD IMPLANTED FOR PRIMARY PREVENTIONOF SUDDEN CARDIAC DEATH 4

W. Rauhe, L. Bertagnolli, F. Clari, I. Endrizzi, M. Manfrin, F. Pescoller, E. Raytcheva, M. Tomaino, W. Pitscheider

ELECTRICAL STORM IN BRUGADA SYNDROME: EFFICACY OF ORAL HYDROQUINIDINE TREATMENT 4L. Sciarra, G. Allocca, M. Rebecchi, E. Marras, L. De Luca, L. Zuccaro, M. Marziali, E. De Ruvo, E. Lioy, L. Corò, P. Delise, L. Calò

SAFETY AND EFFICACY OF MAGNETIC RESONANCE IMAGING (MRI) IN PM/ICD PATIENTS 4P. Lupo, G. De Ambroggi, S. Foresti, H. Ali, M. Pittalis, E. Bianco, T. Infusino, F. Secchi, F. Sardanelli, R. Cappato

THE POTENTIAL OF RISK OF MISDETECTION OR DELAYED DETECTION OF ADVERSE EVENTS WITHOUTA DAILY REMOTE CONTROL SYSTEM IN PATIENTS WITH CARDIAC RESYNCHRONIZATION THERAPY ICD 4

E. De Ruvo, E. Pisanò, R. Quaglione, L. Sciarra, L. De Luca, L. Iannucci, L.M. Zuccaro, M. Rebecchi, A. Sette, A. Fagagnini,M. Minati, S. Matera, F. Guarracini, F. Magliari, E. Lioy, A. Gargaro, L. Calò

HOMEGUIDE REGISTRY: MAY GAME THEORY BE A USEFUL TOOL TO QUANTIFY CLINICAL EFFICACYOF REMOTE MONITORING PATIENT MANAGEMENT WITH THE EXPECTED UTILITY CONCEPT? 5

G. Zanotto, G. Buja, L. Calò, A. Campana, R. Quaglione, G. Gasparini, V. Lettica, C. D’Ascia, L. Santini, N. Rovai, A. Gargaro, R.P. Ricci

THE ITALIAN HOMEGUIDE REGISTRY IN THE REMOTE MONITORING PRACTICE: ENROLMENT RATEAND PATIENT CHARACTERISTICS 5A. D’Onofrio, L. Calò, L. Morichelli, G. Buja, T. Toselli, I. Caico, L. Pavia, F. Caravati, V. Calzolari, G. Lolli, N. Rovai, D. Vaccari

CONTENTS

I

PREVENTION OF CARDIAC PACING TROUBLES 6

ALERT MESSAGES MANAGEMENT IN THE REMOTE MONITORING OF ICD AND PACEMAKER 6A. Folino, F. Chiusso, E. Marras, R. Mantovan, D. Vaccari, G. Boscolo, A. Vaglio, G. Gasparini, G. Zanotto, A. Megna, S. Iliceto, G. Buja

TOTAL REMOTE FOLLOW-UP PACEMAKER CLINIC 6M. Lord, M. Allain, M. Badra, J-F. Roux, F. Ayala-Paredes

CAN WE PREDICT AND PREVENT ADVERSE EVENTS RELATED TO HIGH-VOLTAGE IMPLANTABLECARDIOVERTER-DEFIBRILLATOR LEAD FAILURE? 6

R.P. Ricci, C. Pignalberi, B. Magris, S. Aquilani, V. Altamura, L. Morichelli, A. Porfili, L. Quarta, F. Saputo, M. Santini

INCIDENCE RATE AND PREDICTORS OF PERMANENT PACEMAKER IMPLANTATIONAFTER TRANSCATHETER AORTIC VALVE IMPLANTATION 6

S. Conti, E. Puzzangara, G.P. Pruiti, A. Di Grazia, C. Liotta, G.P. Ussia, C. Tamburino, V. Calvi

WENCKEBACH POINT PREDICTS VENTRICULAR PACING PERCENTAGE SO STABLE AV CONDUCTIONIN PATIENTS WITH SICK SINUS SYNDROME AND DUAL CHAMBER PACEMAKERS 7

F. Rocoma, M. Badra, J-F. Roux, F. Ayala-Paredes

STRAIGHT SCREW-IN ATRIAL LEADS “J POST-SHAPED” IN RIGHT APPENDAGE VS. J-SHAPED SYSTEMSFOR PERMANENT ATRIAL PACING: A SAFETY COMPARISON 7

F. Zoppo, G. Brandolino, F. Zerbo, E. Bacchiega, A. Lupo, E. Bertaglia

SUDDEN DEATH PREDICTORS 8

RISK STRATIFICATION IN ISCHEMIC CARDIOMYOPATHY AND MILD DEPRESSEDVENTRICULAR FUNCTION. PREVALENCE OF FQRS AND NON-NEGATIVE MTWA 8

C. Commisso, G. Pendenza, M. Porfirio, F. Guarracini, L. Sciarra, L. De Luca, E. E. de Ruvo, F. Nuccio, A. Sette, L.M. Zuccaro,M. Rebecchi, M. Minati, A. Fagagnini, S. Matera, E. Lioy, L. Calo’

B-TYPE NATRIURETIC PEPTIDE AS AN INDIPENDENT FACTOR OF SUDDEN CARDIAC DEATHAND APPROPRIATE ICD THERAPY IN ICD RECIPIENTS 8

L. Duro, R. Cioè, L. Santini, G.B. Forleo, G. Magliano, L. Papavasileiou, M. Sgueglia, V. Romano, F. Romeo

DIABETES MELLITUS AND RISK OF ARRHYTHMIA IN PATIENTSWITH IMPLANTABLE CARDIOVERTER DEFIBRILLATORS 8

D.G. Della Rocca, L.P. Papavasileiou, G. Panattoni, G.B. Forleo, L. Santini, G. Magliano, A. Giomi, A. Topa, C. Ticchi, F. Romeo

TREATMENT OF LEFT VENTRICULAR DYSFUNCTION WITH PROLONGED QTIN OBESE PATIENTS WITH DIABETES TYPE II 8

N. Siniscalchi, T. Cerciello, F. Oliviero, L.I. Siniscalchi, L. Misso

MORTALITY IN RECIPIENTS OF ICD IMPLANTED FOR PRIMARY PREVENTION OF SUDDEN CARDIAC DEATH 9W. Rauhe, L. Bertagnolli, F. Clari, I. Endrizzi, M. Manfrin, F. Pescoller, W. Pitscheider

REMOTE MONITORING OF PACEMAKER IN THE MANAGEMENT OF DEBILITATED ELDERLY PATIENTS 9A. Folino, R. Breda, J. Comisso, P. Calzavara, F. Borghetti, S. Iliceto, G. Buja

CONTENTS

II

ECHOCARDIOGRAPHY AND ARRHYTHMIAS 10

CLINICAL PRESENTATION AND LONG-TERM OUTCOME OF NON IMMUNE AND ISOLATED ATRIOVENTRICULARBLOCK WHEN CONGENITAL OR DIAGNOSED DURING CHILDHOOD: A FRENCH MULTICENTRIC STUDY 10

A. Baruteau, J.J. Schott, E. Villain, J.B. Thambo, F. Marcon, V. Gournay, F. Rouault, A. Chantepie, S. Guillaumont, F. Godart,C. Bonnet, A. Fraisse, J.M. Schleich, J.R. Lusson, Y. Dulac, J.C. Daubert, H. Le Marec, P. Mabo, V. Probst

ALTERED 2-D STRAIN MEASURES OF RIGHT BUT NOT OF LEFT VENTRICULAR FUNCTIONIN PATIENTS WITH BRUGADA SYNDROME 10

A. Puzzovivo, I. Nalin, F. Monitillo, V.E. Santobuono, M. Iacoviello, C. Forleo, V. Marangelli, S. Sorrentino, S. Favale

PREVALENCE OF CARDIAC ABNORMALITIES EVALUATED WITH COMPLETE ECHOCARDIOGRAPHICEXAM IN TRAINED YOUNG ATHLETES 10

F. Quaranta, F. Sperandii, F. Guarracini, E. De Ruvo, A. Parisi, L. Sciarra, A. Spataro, L. De Luca, E. De Marchis, M. Rebecchi, Z. Lazarevic,L.M. Zuccaro, A. Martino, E. Ciminelli, A. Fagagnini, C. Lanzillo, E. Lioy, L. Calò, F. Pigozzi

THROMBOLITIC TREATMENT OF LEFT ATRIAL THROMBUS GUIDED BY INTRACARDIACECHOCARDIOGRAPHY DURING CATHETER ABLATION FOR ATRIAL FIBRILLATION 10

A. Placci, C. Tomasi, F. Giannotti, M. Margheri

PREVALENCE OF VENTRICULAR REPOLARIZATION ABNORMALITIES IN TRAINED YOUNG ATHLETES 11F. Guarracini, F. Sperandii, E. De Ruvo, F. Quaranta, L. Sciarra, A. Spataro, L. De Luca, E. De Marchis, M. Rebecchi, Z. Lazarevic,L.M. Zuccaro, A. Martino, A. Fagagnini, M. Minati, M. Porfirio, C. Commisso, G. Pendenza, E. Lioy, F. Pigozzi, L. Calò

NEW FINDINGS IN LEFT INTRAVENTRICULAR DYSSYNCHRONY AT PATIENT WITH LEFT BUNDLE BRANCH BLOCK 11M. Zemlyanova, E. Suslina, I. Philippova, A. Semagin, J. Tracht, S. Khokhlunov

ATRIAL AND AV NODAL TACHYCARDIA: ELECTROPHYSIOLOGY AND TREATMENT 12

NONINVASIVE MAPPING AND CATHETER ABLATION OF ATRIAL TACHYCARDIAS 12G. Simonyan, T. Dzhordzhikiya, O. Sopov, V. Kalinin, A. Revishvili

RADIOFREQUENCY CATHETER ABLATIONS FOR IDIOPATHIC ATRIAL TACHYCARDIAS - MORE THANTWO YEARS EXPERIENCE 12

A. Bulava, J. Hanis, D. Sitek, K. Rehouskova

SLOW PATHWAY POTENTIALS IN KOCH TRIANGLE 12T. Coppi, C. Lavalle, S. Ficili, M. Galeazzi, M. Russo, F. Venditti, A. Pandozi, G. Chiarelli, C. Pandozi, M. Santini

PALPITATIONS OCCUR MAINLY AT NIGHT IN ELDERLY PATIENTS WITH ATRIOVENTRICULAR NODALREENTRANT TACHYCARDIA 12

K. Blaszyk, W. Seniuk, M. Wasniewski, A. Gwizdala, A. Baszko, M. Popiel, S. Grajek

SIMULTANEOUS ENDOCARDIAL AND EPICARDIAL MAPPING OF CARDIAC VENTRICLES BASEDON THE INVERSE ELECTROCARDIOGRAPHY PROBLEM SOLUTION FOR PATIENTS WITH WPW SYNDROME 13

F.SH. Revishvili, V.V. Kalinin, O.S. Lyadzhina, G.YU. Simonyan, O.V. Sopov, E.A. Fetisova

CONTENTS

III

PHYSIOLOGICAL PACING 14

ANATOMICAL ATRIOVENTRICULAR REMODELING BY INTERATRIAL SEPTAL PACING 14S. Porcellini, G. Macca, P. Brioschi, A. Rimini, G. Tortora, S. Gilardi, T. De Santo, S. Biasi

NEW METHOD OF MYOCARDIAL CONTRACTILITY OPTIMIZATION DURINGIMPLANT DUAL-CHAMBER PACEMAKER 14

A. Tsyganov, M. Didenko, A. Bobrov, A. Fedyainova, G. Khubulava

HEMODYNAMIC MODIFICATIONS ASSESSED BY TRANSVALVULAR IMPEDANCE RECORDING 14E. Moro, G. Allocca, E. Zorzi, A. Cera, E. Marras, N. Sitta, P. Delise

DUAL-CHAMBER PACING MODES TO MINIMIZE RIGHT VENTRICULAR PACING:MEDIUM AND LONG-TERM CLINICAL OUTCOMES 14

N. Cabanelas, V.P. Martins, D. Durão, F. Valente, M. Alves, A. Francisco, P. Branco, G.F. Silva

PATIENTS WITH SURGICALLY CORRECTED CONGENITAL HEART DISEASE AND PACEMAKER:TWENTY YEARS FOLLOW-UP 15

A. Große, S. Raffa, M. Brunelli, K. Wauters, J.C. Geller

LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC FUNCTION IN PEDIATRIC PATIENTSWITH DEFINITIVE PACEMAKER 15

M. Cabrera Ortega, A.E. Gonzales Morejon, F. Dorticos

NEWS IN ATRIAL FIBRILLATION THERAPY 16

DIFFERENT IMAGE INTEGRATION MODALITIES TO GUIDE AF ABLATION:IMPACT ON PROCEDURAL AND FLUOROSCOPY TIMES 16

C. Pratola, E. Baldo, P. Artale, M. Bertini, L. Pirani, C. Cavazza, T. Toselli, R. Revelchion, R. Ferrari

TRANSCATHETER ABLATION OF ATRIAL FIBRILLATION: THE UTILITY OF THE NEW CARTO 3 MAPPING SYSTEM 16L. Sciarra, S. Dottori, L. De Luca, E. De Ruvo, P. Pitrone, C. Lanzillo, M. Minati, M. Rebecchi, L. Zuccaro, A. Fagagnini, E. Lioy, L. Calo’

EVALUATION OF ELECTRICAL ISOLATION OF PV OBTAINED BY CRYOBALLOON-ABLATIONFOR ATRIAL FIBRILLATION, USING ELECTROANATOMICAL VOLTAGE MAPPING 16

D. Catanzariti, M. Maines, C. Angheben, M. Centonze, G. Broso, G. Vergara

LATE ATRIAL TACHYCARDIA FOLLOWING PULMONARY VEINS ISOLATION:ANALYSIS OF SITES OF SUCCESSFUL DISCRETE ABLATION 16

F. Zoppo, G. Brandolino, F. Zerbo, E. Bertaglia

PERIODIC TRANSTELEPHONIC ECG MONITORING AND ASYMPTOMATIC RECURRENCES AFTER ABLATIONOF LONGSTANDING PERSISTENT ATRIAL FIBRILLATION 17

M. Fiala, V. Bulkova, J. Chovancik, J. Pindor, J. Gorzolka, H. Tolaszova, S. Krawiec, D. Vavrik, S. Kralovec, J. Brada, J. Januska

BENEFICIAL EFFECT OF ATORVASTATIN FOR PREVENTION ATRIAL FIBRILATION IN PACED PATIENTS 17E. Hatzinikolaou-Kotsakou, T.H. Beleveslis, G. Moschos, E. Reppas, M. Kotsakou, P. Latsios, K. Tsakiridis, S. Olalere

QUALITY OF LIFE IN PTS WITH SUSTAINED AF AND ADVANCED CHF SUBMITTED TO BIVENTRICULARPACEMAKER UPGRADE OR BIFOCAL RIGHT VENTRICULAR PACING OVER THE 12 MONTHS OF FOLLOW-UP 17

B. Malecka, A. Zabek, J. Lelakowski

TREATMENT OF ATRIAL FIBRILLATION WITH RADIOFREQUENCY ENERGY DURING OPEN HEART SURGERY 18F. Iezzi, R. Cini, P. Sordini, V. Loiaconi, M. Santini

CONTENTS

IV

Wednesday, December 1

ATRIAL FIBRILLATION: CLINICAL ISSUES 20

CIRCULATING PROGENITOR CELLS IN PATIENTS WITH PERSISTENT ATRIAL FIBRILLATION 20L. Perrotta, E. Sticchi, F. Cesari, P. Pieragnoli, G. Ricciardi, C. Fatini, S. Sacchi, L. Padeletti, G.F. Gensini, R. Abbate, A. Michelucci

IS THE PERSONALITY TYPE ASSOCIATED WITH LONE ATRIAL FIBRILLATION RECURRENCES RATE?:NEGATIVE AFFECTIVITY OF TYPE D PERSONALITY PREDICTS THE INCREASED RISK 20

E. Hatzinikolaou-Kotsakou, E. Reppas, T.H. Beleveslis, G. Moschos, M. Kotsakou, P. Latsios, K. Tsakiridis

LATE DETECTION OF ATRIAL FIBRILLATION IN A PATIENT WITH CRYPTOGENIC STROKE THROUGHAN IMPLANTABLE CARDIAC MONITOR 20

D. Cervellati, C. Brignola, C. Camanini, P. Vassallo, A. Cervellati

TEMPORAL DISTRIBUTION OF ATRIAL ARRHYTHMIC EPISODES: IMPLICATIONSFOR ATRIAL ARRHYTHMIAS MONITORING 20

A. Capucci, F. Censi, R. Quaglione, A. Castro, E. Capponi, P. Paoloni, G. Gasparini, G. Calcagnini, E. Mattei, P. Bartolini, G. Biancalana, A. Gargaro

DOES ONE SIZE FIT ALL? EFFECTIVENESS OF A WARFARIN DOSING REGIMEN IN THE OBESEAND MORBIDLY OBESE 21

A. Salacata, S. Keavey

AV NODE ELECTRIC BYPASS IN PATIENTS WITH REFRACTORY SYMPTOMATIC PERMANENTATRIAL FIBRILLATION: SINGLE CENTRE PROSPECTIVE STUDY 21

P. Ferrero, P. Defilippo, P. Ferrari, R. Brambilla, F. Cantù

HYBRID TREATMENT OF LONE PERSISTENT AF: A SAFE AND EFFECTIVE THERAPEUTICAL OPTION 21G. Bisleri, A. Curnis, L. Bontempi, C. Muneretto

CATHETER ABLATION OF ATRIAL AUTOMATIC TACHYCARDIA MISTAKENFOR INAPPROPRIATE SINUS TACHYCARDIA 22

C. Sardu, S.L. D’Ascia, V. Marino, V. Liguori, V. Marullo, V. Schiavone, C. D’Ascia

CARDIAC RESYNCHRONIZATION THERAPY: LONG TERM OUTCOME 22

RESULTS OF THE SURVEY ITHAQUE: MONITORING AND THERAPIES FOR SYSTOLIC HEART FAILURE 22CH. Leclercq, M. Hero

PREDICTORS OF ALL-CAUSE MORTALITY, VENTRICULAR ARRYTHMIAS AND CARDIAC HOSPITALIZATIONSIN PATIENTS IMPLANTED WITH CRT: DATA FROM THE ACTION-HF REGISTRY 22

L. Ottaviano, C.D. Dicandia, M. Mantica, L. Santangelo, G.Q. Villani, P. Pantaleo, P. Rossi, A. Perucca, E. Marangoni, G.L. Botto

THE EFFECTS OF CARDIAC RESYNCHRONIZATION THERAPY ON PATIENTSWITH MEDICALLY REFRACTORY HEART FAILURE 22

G. Panattoni, L.P. Papavasileiou, D.G. Della Rocca, F. Vecchio, V. Minni, C. Tota, M. Cesario, F. Paparoni, A. Di Molfetta, G.B. Forleo, L. Santini, F. Romeo

CARDIAC RESYNCHRONIZATION THERAPY IN ISCHEMIC PATIENTS WITH NARROW QRS:THE NARROW-CRT STUDY 23

C. Muto, R. Calvanese, M. Nastasi, P. Gallo, F. Solimene, R. Sangiuolo, L. Ascione, G. Carreras, L. Ottaviano, C. La Rosa, N. Marrazzo,M. Canciello, P. Guarini, R. Iengo, B. Tuccillo

CORRELATION BETWEEN INTRA-THORACIC IMPEDANCE AND IMPEDANCE CARDIOGRAPHYFOR THE DETECTION OF HEART FAILURE DETERIORATION:ALONG TERM STUDY 23

E. Moro, E. Zorzi, C. Marcon, G. Allocca, E. Marras, N. Sitta, P. Dovigo, P. Delise, A. Varbaro, S. Valsecchi

INTRAOPERATIVE SCREENING OF RIGHT VENTRICULAR PACING SITES IN HEART FAILURE PATIENTSUNDERGOING THE CARDIAC RESYNCHRONIZATION THERAPY 23

A. Tsyganov, M. Didenko, A. Bobrov, A. Fedyainova, G. Khubulava

LONG-TERM PACING AND SENSING FUNCTION OF CATHETER DELIVERED PACINGLEADSTO THE RIGHT VENTRICULAR POSTERIOR OUTFLOW TRACT IN CARDIAC RESYNCHRONIZATION THERAPY 24

H. Kristiansen, T. Hovstad, G. Vollan, S. Faerestrand

SINUS RHYTHM RECOVERY IN PATIENTS WITH CHRONIC ATRIAL FIBRILLATIONAND DILATED CARDIOMYOPATY WHO UNDERWENT CRT IMPLANT (SIBILLA STUDY) 24

P. Turco, A. D’Onofrio, G. Stabile, F. Solimene, V. La Rocca, C. Cavallaro, A. Iuliano, N. Marrazzo, F. Vecchione, S. De Vivo, C. Ciardiello, A. De SimoneCONTENTS

V

ICD APPROPRIATE AND INAPPROPRIATE INTERVENTIONS 25

SPECTRAL ANALYSIS OF SPONTANEOUS AND INDUCED VENTRICULAR FIBRILLATION IN PATIENTS WITHIMPLANTABLE DEFIBRILLATOR 25

M. Bernasconi, V.D.A. Corino, S. Mantovano, M. Marzegalli, M. Santini, M. Lunati, P. Defaye, J. Mermi, A. Proclemer,S. del Castillo-Arroys, A. Kloppe, L. Manotta, E. Santi, A. Marseglia, S. Cerutti

INAPPROPRIATE THERAPIES’ RATE IN A ICD’S RECIPIENTS POPULATION 25V. Romano, G. Panattoni, L. Duro, V. Schirripa, M. Sgueglia, G.B. Forleo, L. Santini, G. Magliano, L. Papavasileiou, F. Romeo

PREDICTIVE VALUE OF FRAGMENTED QRS IN ICD PATIENTS WITH LEFT VENTRICULAR DYSFUNCTIONIMPLANTED IN PRIMARY PREVENTION OF SUDDEN DEATH 25

D.G. Della Rocca, G.B. Forleo, L. Santini, L.P. Papavasileiou, G. Magliano, G. Panattoni, V. Romano, A. Viele, A. Politano, F. Romeo

CUMULATIVE RIGHT VENTRICULAR PACING AND OCCURRENCE OF VENTRICULAR TACHYARRHYTHMIASIN UNSELECTED ICD PATIENTS: RESULTS FROM THE FIRST REGISTRY 25

A. D’Onofrio, A. Bartoletti, E.M. Greco, M. Mezzetti, C. Tondo, M. Elia, A. Fazi, L. Dore, O. Piot, L. Padeletti

CORRELATIONS AMONG ARRHYTHMIAS, CLIMATIC VARIABLES AND AIR POLLUTIONIN PATIENTS WITH PACEMAKER AND ICD FOLLOWED BY REMOTE MONITORING 26

A. Folino, G. Zanotto, G. Neri, R. Mantovan, E. Marras, G. Gasparini, F. Di Pede, E. Bertaglia, A. Vaglio, G. Boscolo, G. Morani,R. Ometto, B. Martini, G. Scattolin, F. Zanon, S. Iliceto, G. Buja

EVENT-FREE SURVIVAL WITH IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS (ICD)AND LATE OCCURRENCE OF FIRST APPROPRIATE ICD THERAPY (RX) 26

F. Horlbeck, N. Liliegren, G. Nickenig, J.O. Schwab

CLINICAL EVALUATION OF A FULLY SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR (S-ICD) SYSTEM 26P. Lupo, H. Ali, S. Foresti, M. Pittalis, G. De Ambroggi, E. Bianco, T. Infusino, E. Renzullo, E. Daleffe, S. O’Connor, R. Cappato

ST MONITORING ALGORITHM: A NEW DIAGNOSTIC OPTION IN FUTURE ICD GENERATIONS 27L. Santini, D.G. Della Rocca, G.B. Forleo, G. Panattoni, L.P. Papavasileiou, G. Magliano, L. Duro, R. Cioè, M. Sgueglia, F. Romeo

CARDIAC PACING AUTOMATIC ALGORITHMS 28

THE AUTOMATIC ATRIAL CAPTURE MANAGEMENT: RESULTS OF THE CASA STUDY 28J.L. Rey, M. Hero

VENTRICULAR PACING RATE AND ATRIAL ARRHYTHMIAS ACCORDING TO INDICATION OF PACINGAND PROGRAMMING MVP™ FUNCTION AT 9 MONTHS FOLLOW-UP 28

J.L. Rey, M. Hero

EVOLUTION OF THE GAIN IN SPONTANEOUS CONDUCTION BETWEEN ATRIO-VENTRICULARDELAY HYSTERESIS ALGORITHMS AND A NEW PACING MODE 28

P. Le Franc, M. Hero

AMOUNT OF RIGHT VENTRICULAR PACING IN THE FIRST THREE MONTHS AFTER DEVICE IMPLANTATION:A PREDICTOR OF OUTCOMES AFTER THREE YEARS 29

N. Cabanelas, V.P. Martins, D. Durão, F. Valente, M. Alves, A. Francisco, R. Silva, G.F. Silva

EARLY DETECTION OF SILENT ISCHAEMIA THROUGH INTRATHORACIC FAR-FIELD ELECTROCARDIOGRAMS 29A. Fagagnini, L.M. Zuccaro, L. Sciarra, E. de Ruvo, L. De Luca, M. Rebecchi, M. Minati, S. Matera, F. Guarracini, M. Porfirio,G. Pendenza, L. Sangiovanni, M. Sforza, F. Stirpe, A. Masia, R. Pavese, A. Pollastrelli, A. Sciahbasi, E. Lioy, L. Calò

RV THRESHOLD BEHAVIOUR AT LONG TERM: AUTOMATIC VERIFICATION OFSTIMULATIONWARRANTS SUPERIOR SAFETY! 29

M. Biffi, A. Mazzotti, B. Gardini, V. Mantovani, G. Massaro, M. Ziacchi, M. Salomoni, M. Balbo, F. Bonfatti, G. Boriani

CONTENTS

VI

SYNCOPE: NON INVASIVE DIAGNOSIS 30

BENEFICIAL EFFECTS OF TILT TRAINING IN PREVENTING NEUROCARDIOGENIC SYNCOPE:WHAT ARE THE POSSIBLE MECHANISMS? 30

S. Laranjo, M. Oliveira, C. Tavares, V. Geraldes, V. Silva, S. Santos, E. Oliveira, I. Rocha, R. Ferreira

WHICH IS THE MAIN DETERMINANT OF HYPOTENSION IN TILT INDUCED VASOVAGAL SYNCOPE?THE ROLE OF THE ARTERIAL AND VENOUS SYSTEM 30

G. Nigro, V. Russo, M. Iovino, V. Gionti, M.L. Rosato, L. Armetta, F. Colimodio, V. Giordano, M.G. Russo, P. Golino, R. Calabro’

UTILITY OF AN EXTERNAL LOOP RECORDER IN DIAGNOSING PATIENTS WITH SPORADIC PALPITATIONSOR SYNCOPE 30

A. Sette, E. De Ruvo, L. De Luca, C. Lanzillo, L. Sciarra, C. Commisso, F. Sebastiani, V. Iuianella, M. Rebecchi, L M. Zuccaro,A. Fagagnini, M. Minati, F. Guarracini, M. Porfirio, A. Martino, S. Matera, L. Calò

THE USE OF REMOTE CONTROL FOR IMPLANTABLE LOOP RECORDER IN MANAGEMENT OF SYNCOPE UNIT 31R. Colaceci, M. Bocchino, M.G. Romano, N. Danisi, G. Pighini, L. La Rocca, F. Ammirati

SINGLE-CENTER EXPERIENCE OF LOOP RECORDER IMPLANTATION IN PATIENTSWITH UNEXPLAINED SYNCOPE AND WITHOUT PALPITATIONS OR SIGNIFICANT CARDIAC ABNORMALITIES 31

G. Capella, S. Gilardi, V. Silvestri, R. Melloni, R. Fornerone, R. Seregni

THE DIAGNOSTIC VALUE OF ADENOSINE IN THE INVESTIGATION OF POTENTIAL SICK SINUSSYNDROME IN PATIENTS WITH SYNCOPE/PRESYNCOPE 31

N. Fragakis, A. Antoniadis, P. Kyriakoy, G. Navrozidis, G. Katsaris, P. Geleris

BRUGADA SYNDROME 32

SUCCESSFUL MANAGEMENT OF ELECTRICAL STORM USING ORAL QUINIDINE IN CILOSTAZOLINEFFECTIVE BRUGADA SYNDROME PATIENTS 32

K. Higuchi, K. Hirao, O. Inaba, A. Yagishita, Y. Tanaka, M. Kawabata, H. Hachiya, M. Isobe

RIGHT VENTRICLE MAPPING IN PATIENS WITH BRUGADA SYNDROME 32S. Ficili, M. Galeazzi, C. Lavalle, M. Russo, G. Chiarelli, L. Santini, F. Amati, F. Mele, C. Pandozi, M. Santini

ELECTROANATOMIC RIGHT VENTRICULAR MAPPING IN PATIENTS WITH BRUGADA SYNDROME:ALTERATIONS AND POSSIBLE CORRELATIONS WITH PROGNOSIS 32

L. Sciarra, L.M. Zuccaro, E. De Ruvo, G. Allocca, E. Marras, L. De Luca, M. Rebecchi, A. Fagagnini, M. Marziali, A. Sette, C. Lanzillo,M. Minati, E. Lioy, P. Delise, L. Calò

THE ROLE OF TWELVE LEADS ECG HOLTER MONITORING TO DIAGNOSE BRUGADA SINDROMEBY REVEALING SPONTANEOUS COVED TYPE ELECTROCARDIOGRAM 32

L. Sciarra, M. Marziali, E. De Ruvo, L. De Luca, E. Marras, G. Allocca, L.M. Zuccaro, M. Rebecchi, A. Martino, M. Minati, M. Porfirio,A. Fagagnini, E. Lioy, P. Delise, L. Calo’

RIGHT VENTRICLE HISTOLOGICAL FINDINGS IN PATIENTS WITH BRUGADA SYNDROMEINDUCIBLE DURING THE ELECTROPHYSIOLOGICAL STUDY 33

M. Russo, S. Ficili, C. Pandozi, M. Galeazzi, C. Lavalle, C. Bernardi, L. Santini, R. Mango, F. Amati, G. Novelli, F. Romeo, M. Santini

BRUGADA SYNDROME TREATED WITH AN ENTIRELY SUBCUTANEOUS IMPLANTABLECARDIOVERTER-DEFIBRILLATOR SYSTEM 33

E. De Maria, L. Bonetti, G. Patrizi, J. Scrivener, A. Montin, G. Zuccon, S. Capelli

CONTENTS

VII

CARDIAC RESYNCHRONIZATION THERAPY: TECHNICAL AND CLINICAL ISSUES 34

LONG-TERM ELECTROPHYSIOLOGIC FUNCTION OF RIGHT VENTRICULAR LEAD IN HIGH POSTERIORSEPTAL VERSUS APICAL LEAD PLACEMENT IN CARDIAC RESYNCHRONIZATION THERAPY 34

H. Kristiansen, T. Hovstad, G. Vollan, S. Faerestrand

ASSESSMENT OF MYOCARDIAL VIABILITY WITH GATED SPECT IN PREDICTING RESPONSETO CARDIAC RESYNHRONIZATION THERAPY 34

D. Zizek, M. Cvijic, L. Lezaic, I. Zupan

QUADRIPOLAR LEADS IN CRT IMPLANTS FOR CS STIMULATION: ADVANTAGES? 34A. Curnis, L. Bontempi, A. D’Aloia, M. Cerini, A. Lipari, N. Berlinghieri, C. Pagnoni, N. Ashofair, M. Mutti, F. Vassanelli, L. Dei Cas

TRIPLE- SITE CRT PACING IN PATIENTS WITH NAROW QRS: A PILOT STADY IN 12 PATIENTS? 35Z. Calovic, V. Jovanovic, G. Nikcevic, M. Saviano, E. Kallergis, G. Vicedomini, V. Santinelli, C. Pappone, G. Milasinovic

SAFETY OF CARDIAC RESYNCHRONIZATION IMPLANTATION IN OCTOGENARIANS35 35M. El-Chami, M. Hoskins, M. Kanitkar, D. Delurgio, J. Langberg, A. Leon

APPLICATION OF THE SEATTLE HEART FAILURE MODEL IN PATIENTS ON CARDIAC RESYNCHRONIZATION THERAPY 35L. Perrotta, G. Ricciardi, P. Pieragnoli, G. Pontecorboli, M. Chiostri, T. De Santo, F. Bellocci, N. Vitulano, M. Emdin, G. Mascioli,A. Michelucci, M.C. Porciani, L. Padeletti

CATHETER ABLATION OF ATRIAL FIBRILLATION: TECHNIQUES AND MAPPING SYSTEMS 36

ESOPHAGEAL EFFECT OF CRYOABLATION FOR PAROXYSMAL ATRIAL FIBRILLATION 36Z. Chitovova, A. Humera, J. Skoda, J. Petru, L. Sediva, S. Kralovec, F. Holy, V. Reddy, P. Neuzil

EVALUATING THE PULMONARY VEIN ANATOMICAL VARIABILITY BY MAGNETIC RESONANCE IMAGINGIN PATIENTS UNDERGOING ATRIAL FIBRILLATION ABLATION: AN ITALIAN REGISTRY 36

R. De Lucia, E. Bertaglia, F. Gaita, R. Verlato, M. Paolucci, M. Del Greco, C. Pratola, E. Soldati, M.G. Bongiorni

CARTO 3 AND CARTO RMT IN LEFT ATRIAL MAPPING AND ABLATION: COMPARISON OF TWO TECHNOLOGIES 36S. Grossi, F. Bianchi, A. Sibona Masi, S. Lebini, M.R. Conte

RESULTS OF THE FIRST ITALIAN REGISTRY ON ENSITE NAVX ATRIAL FIBRILLATION ABLATION PROCEDURES(IRON-AF): 1-YEAR PROCEDURAL OUTCOMES 37

M. Mantica, E. Menardi, N. Trevisi, M. Faustino, F. Perna, M. Santamaria, G. Carreras, A. Pappalardo, C. Pandozi, G. De Martino, E. Romano

AF ABLATION AND CRITICAL MASS: ROLE OF ATRIAL DEBULKING A PILOT STUDY 37C. Lavalle, S. Grossi, C. Pandozi, F. Bianchi, S. Dottori, A. Gramondo, M. Russo, M. Galeazzi, S. Ficili, M. Santini

EFFECTIVENESS AND RELIABILITY OF A SIMPLIFIED APPROACH FOR THREE-DIMENSIONALIMAGE-INTEGRATION USING AN ELECTROANATOMIC MAPPING SYSTEM 37

E. Soldati, G. Zucchelli, R. De Lucia, S. Viani, L. Paperini, A. Di Cori, L. Segreti, L. Misuraca, M.G. Bongiorni

GENETIC ARRHYTHMIAS 38

CLINICAL CHARACTERISTICS OF 4 CZECH FAMILIES WITH CATECHOLAMINERGIC POLYMORPHIC 38VENTRICULAR TACHYCARDIA AND PILOT RESULTS OF MUTATIONAL ANALYSIS OF RYR2 GENE

T. Novotny, P. Kubus, P. Vit, I. Andrsova, A. Florianova, I. Valaskova, J. Kadlecova, R. Gaillyova, E. Svandova, J. Spinar

DOES HIGH-FREQUENCY RIGHT VENTRICULAR PACING INFLUENCE ATRIAL FIBRILLATION INCIDENCEIN MYOTONIC DYSTROPHY TYPE 1 PATIENTS? 38

G. Nigro, V. Russo, V. Gionti, M.L. Rosato, V. Giordano, L. Armetta, F. Colimodio, M.G. Russo, P. Golino, R. Calabro’

OUTCOMES OF EVALUATION OF RELATIVES WITH A FAMILY HISTORY OF YOUNG SUDDEN CARDIAC DEATH;NEARLY AS MANY ICDS REMOVED AS IMPLANTED 38

J. Caldwell, N. Moreton, N. Khan, L. Kerzin-Storrar, K. Metcalfe, W. Newman, C. Garratt

CLINICAL CHARACTERISTIC OF 28 CZECH FAMILIES WITH GENETICALLY CONFIRMED DIAGNOSISOF LONG QT SYNDROME 39

I. Andrsova, T. Novotny, J. Kadlecova, R. Gaillyova, A. Florianova, A. Bittnerova, M. Sisakova, P. Vit, J. Spinar

THE CLINICAL SIGNIFICANCE OF FAMILIAL HEART BLOCK 39M. Yahalom, N. Roguin, R.S. Kaiyal, J. Bornstein, R. Farah

PECULIAR ELECTROANATOMIC AND ELECTROPHYSIOLOGIC FEATURES OF ARRHYTHMOGENIC RIGHTVENTRICULAR CARDIOMYOPATHY PATIENTS WITH CLINICAL VENTRICULAR TACHYCARDIA 39

P. Santangeli, A. Dello Russo, M. Casella, G. Pelargonio, F. Bellocci, S. Bartoletti, M. Pieroni, M. Zucchetti, F. Tundo, G. Fassini,C. Carbucicchio, L. Di Biase, A. Natale, C. TondoCONTENTS

VIII

IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS: TECHNICAL ISSUES 40

DO PATIENT CHARACTERISTICS INFLUENCE THE DECISION TO PERFORM DEFIBRILLATION TESTINGAT THE TIME OF ICD IMPLANT? DATA FROM SAFE-ICD STUDY 40

G. Ciaramitaro, M. Brignole, G. Mascioli, C. Tomasi, A. Del Rosso, A. Reggiani, G. Giudici, L. Chiodi, M. D’Acri, S. Favale

PROLONGED BURST - A NEW METHOD FOR ICD TESTING DURING IMPLANTATION 40J. Lukl, D. Marek, M. Marcian, P. Schneiderka

DEFIBRILLATION TESTING AT IMPLANT: RESULTS FROM THE FIRST STUDY 40P. Scipione, A. D’Onofrio, G. Ricciardi, P. Pieragnoli, I. Rubino, S. Argnani, D. Gorini, O. Piot, L. Padeletti

FIRST EXPERIENCES WITH NEW ICD AND DEFIBRILLATION LEADS: THE 4-SITE SYSTEM 40G. Forleo, L. Santini, A. D’Onofrio, C. Cavallaro, L. Bontempi, F. Caravati, I. Caico, F. Zanon, G. Pastore, D. Vaccari, S. Vitadello,A. De Simone, V. La Rocca, F. Cantù, P. De Filippo, F. Sebastiani, L. De Luca,G. Pelargonio, M. Narducci, A. Curnis

NO CONTACT ARRAY ELECTROANATOMICAL MAPPING DURING CRT-D IMPLANT: A SINGLE CENTEREXPERIENCE OF TEN PATIENTS WITH A CLINICAL AND ECHOCARDIOGRAPHICS 2-YEARS FOLLOW-UP 41

C. Pratola, T. Toselli, M. Bertini, R. Revelchion, P. Artale, R. Ferrari

BROKEN LEADS WITH PROXIMAL ENDINGS IN THE CARDIOVASCULAR SYSTEM - SERIOUS CONSEQUENCESAND EXTRACTION DIFFICULTIES 41

A. Andrzej Kutarski, B. Malecka, R. Pietura

SPECIAL LEADS 42

IMPLANTATION OF A NOVEL QUADRIPOLAR LEFT VENTRICUALR LEAD AND CRT-D SYSTEM CAPABLEOF DELIVERING LONG-TERM MULTISITE PACING 42

A. Shetty, S. Duckett, J. Bostock, D. Roy, S. Hamid, C. Bucknall, N. Patel, C. Rinaldi

J POST-SHAPING OF STRAIGHT ATRIAL LEADS SCREWED INTO THE RIGHT APPENDAGE:AN ALTERNATIVE LEAD PLACEMENT APPROACH FOR PERMANENT ATRIAL PACING 42

F. Zoppo, G. Brandolino, F. Zerbo, A. Lupo, E. Bacchiega, E. Bertaglia

HEMODYNAMIC SENSOR IN STYLET CHANNEL - ACUTE HUMAN EXPERIMENT 42D. Tomasic, B. Ferek-Petric, S. Brusich

VIDEOTHORACOSCOPIC IMPLANTATION OF THE LEFT VENTRICULAR PACING LEADFOR CARDIAC RESYNCHRONIZATION THERAPY 42

A. Droghetti, A. Reggiani, M.C. Bottoli, P. Pepi, A. Fusco, C. Bonadiman, R. Casarotto, W. Mosaner, A. Vicentini, G. Muriana

LONG-TERM PERFORMANCE OF ENRHYTHM MRI SURESCAN SYSTEM IN PATIENTSWITH STANDARD PACING INDICATION 43

L. Santini, M. Santini, S. Iacopino, L. Calò, L. Piraino, R. Verlato, C. Svetlich, G. Morani, R. Ricci, S. Aquilani, G. Forleo,F. Sciotto, M.G. Bongiorni

DOES STEROID ELUTION HAVE AN EFFECT ON TISSUE HEALING AFTER RADIOFREQUENCY ENERGY EXPOSURE:IMPLICATIONS FOR MRI SCAN ONPATIENTS WITH CARDIAC LEADS 43

P. Yang, N. Kirchhof, J. Golnitz, K. Stokes, R. McVenes

CONTENTS

IX

Thursday, December 2

IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS: INDICATIONS AND PROGRAMMING 45

GENDER DISCRIMINATION IN SELECTION OF ICD RECIPIENTS 45A. Jaswal, A. Saxena, R. Singhal

MADIT II VS SCD-HEFT: HOW MANY PATIENTS WE NEED TO TREAT TO SAVE A LIFE? 45G. Panattoni, D.G. Della Rocca, L.P. Papavasileiou, L. Santini, G.B. Forleo, G. Magliano, A. Politano, V. Schirripa, V. Romano, F. Romeo

SAFETY OF HIGH RATE CUTOFF ICD PROGRAMMING IN PRIMARY PREVENTION OF SUDDEN CARDIAC DEATH 45N. Clementy, B. Pierre, N. Zannad, O. Marie, L. Fauchier, D. Babuty

ICD INTERVENTIONS IN OLD PATIENTS IMPLANTED FOR SUDDEN CARDIAC DEATH PRIMARY PREVENTION 45A. Andriani, F. Giusti, M. Liccardo, D. Carretta, F. Alfano, P. Gallo, P. Nocerino, P. Guarini

ICD THERAPY FOR PRIMARY PREVENTION OF SUDDEN CARDIAC DEATH:HIGH INCIDENCE OF SYNCOPE DURING APPROPRIATE ICD INTERVENTIONS 46

W. Rauhe, L. Bertagnolli, M. Manfrin, I. Endrizzi, M. Tomaino, W. Pitscheider

ALL-CAUSE MORTALITY IN CURRENT PRACTICE ACCORDING TO DEVICE INDICATIONS:DATA FROM THE ACTION-HF REGISTRY 46

P. Nocerino, A. D’Onofrio, G. Molon, R. Verlato, T. Toselli, C. Storti, D. Pecora, G.P. Gelmini, M. Mantica, G.L. Botto

IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY IN BRUGADA SYNDROME:LONG TERM FOLLOW-UP OF PROPHYLACTIC IMPLANTATION 46

V. Kamperidis, S. Paraskevaidis, V. Vassilikos, K.N. Tsilonis, S. Theofilogiannakos, L. Mantziari, G. Dakos, G. Stavropoulos, I. Styliadis

DOES CEPHALIC OR SUBCLAVIAN VEIN APPROACH IMPACT ON DYSFUNCTION RATE OF ICD LEADS? 47V. Romano, L. Duro, M. Sgueglia, L. Santini, G. Magliano, G.B. Forleo, L.P. Papavasileiou, F. Romeo

HOW TO FORESEE AND TO MANAGE CRT RESPONSE 48

WHICH BASELINE PARAMETERS CAN HELP TO PREDICT THE RESPONSE AFTER CARDIACRESYNCHRONIZATION THERAPY? 48

K. Goscinska-Bis, R. Gardas, M. Gibinski, B. Grzegorzewski, W. Kargul, J. Wilczek

NON RESPONDERS TO CRT: BASELINE CLINICAL CHARACTERISTICS 48M. Brambatti, S. Molini, S. Guardiani, F. Guerra, A. Giovagnoli, A. Romandini, G. Pupita, M.V. Matassini, M. Marchesini, A. Capucci

LEFT ATRIAL REVERSE REMODELLING AS SUCCESSFUL RESULT AFTER CARDIAC RESYNCHRONIZATION THERAPY 48L. Rossi, A. Malagoli, E. Casali, G. Rusticali, G.Q. Villani

V-V DELAY INTERVAL OPTIMIZATION IN CRT USING ECHOCARDIOGRAPHY COMPAREDTO QRS WIDTH IN SURFACE ECG 48

D. Ragab, R. Elhussini, A. Nawar, A. Abdelaziz

SUPER-RESPONDERS AFTER CARDIAC RESYNCHRONIZATION THERAPY IMPLANTS:RESULTS OF A SINGLE CENTER STUDY 49

F. Morandi, D. Pecora, M. Campana, C. Cuccia

GEOMETRIC DISTANCE BETWEEN LEADS FOR BIVENTRICULAR STIMULATION AS PREDICTOROF CRT RESPONSE 49

G. Covino, M. Volpicelli, P. Belli, G. Ratti, P. Tammaro, C. Provvisiero, L. Auricchio, P. Capogrosso

UPGRADE OF CRT NON RESPONDERS: NOVELL ”CRT+” PACING THERAPY 49Z. Calovic, G. Nikcevic, V. Jovanovic, G. Vicedomini, V. Santinelli, C. Pappone, G. Milasinovic

THE EFFECTIVENESS OF CRT CANNOT OVERWHELM WORSENING OF END-STAGE CARDIOMYOPATHY 50H. Ino, T. Tsuda, K. Hayashi, N. Fujino, M. Yamagishi

CONTENTS

X

HEART FAILURE MONITORING AND TREATMENT 51

THE ROLE OF AETIOLOGY IN PATIENTS UPGRADED FROM RIGHT VENTRICULAR PACINGTO CARDIAC RESYNCHRONIZATION THERAPY 51

M. Morales, U. Startari, L. Panchetti, M. Piacenti

THE EFFECT OF HEART FAILURE ETIOLOGY ON THE EFFECT OF PACEMAKER UPGRADEIN PATIENTS WITH PERMANENT ATRIAL FIBRILLATION AND ADVANCED HEART FAILURE 51

B. Malecka, A. Zabek, J. Lelakowski, A. Maziarz, J. Bednarek, M. Pasowicz, P. Podolec

INTRA-THORACIC IMPEDANCE AND ULTRASOUND COMET-TAIL IN HEART FAILURE MONITORING 51M. Maines, D. Catanzariti, C. Angheben, S. Valsecchi, J. Comisso, G. Vergara

INTRA-THORACIC IMPEDANCE ALERT: CLINICAL USEFULNESS IN PATIENTS WITH HEART FAILUREAND NO INDICATION TO RESYNCHRONIZATION THERAPY 52

L. Leoni, G. Molon, M. Santini, W. Rahue, D. Facchin, L. Tomasi, V. Calvi, S. Iacopino, A. Curnis, A. Varbaro, G. Imbimbo

EFFECTS OF ACE-INHIBITORS PLUS ANGIOTENSIN RECEPTOR BLOCKERS IN EARLY PHASEOF ACUTE MYOCARDIAL INFARCTION 52

N. Siniscalchi, F. Oliviero, A. Del Gatto, T. Cerciello, L.I. Siniscalchi, L. Misso

CARDIAC RESYNCHRONIZATION THERAPY: TECHNOLOGY AND OUTCOME 53

THREE-DIMENSIONAL DYNAMIC POSITION ASSESSMENT OF THE CORONARY SINUS LEADIN CARDIAC RESYNCRHONIZATION THERAPY: METHODS AND FIRST CLINICAL EXPERIENCES 53

C. Tomasi, C. Corsi, D. Turco, S. Severi, S. Argnani, M. Margheri

AN OBSERVATIONAL REGISTRY ON EFFICACY AND SAFETY OF THE RIGHT VENTRICULAROUTFLOW TRACT FOR ICD LEADS: RESULTS OF THE EFFORT REGISTRY 53

G. Mascioli, G. Gelmini, A. Reggiani, V. Giudici, A. Spotti, A. Mocini, R. Marconi, F. Ruffa, G. Zanotto

EPICARDIAL LEAD IMPLANTS WITH VIDEO-THORACOSCOPIC TECHNIQUE 53A. Reggiani, A. Droghetti, G. Martini, G. Muriana, R. Zanini

SINGLE CENTER EXPERIENCE OF CARDIAC RESYNCHRONISATION THERAPY (CRT-P/CRT-D)OF FIVE YEARS (2005-2009) - A DEMOGRAPHIC PROFILE 53

R. Singhal, A. Jaswal, A. Saxena

BENEFITS OF CRT IN ELDERLY HEART FAILURE PATIENTS 54E. Casali, M. Liccardo, P. Gallo, F. Franchi, P. Nocerino, G. Sibilio, P. Guarini

CATHETER ABLATION OF ATRIAL FIBRILLATION: WHEN AND HOW? 55

PREDICTORS OF SINUS RHYTHM RESTORATION AND LONG-TERM MAINTENANCE BY ABLATIONOF LONGSTANDING PERSISTENT ATRIAL FIBRILLATION 55

M. Fiala, M. Sknouril, R. Nevralova, V. Bulkova, J. Chovancik, J. Gorzolka, J. Pindor, D. Vavrik, S. Krawiec, M. Dorda, O. Jiravsky, J. Januska

TIMING AND FEATURES PREDICTING SUCCESS OF CATHETER ABLATION OF ATRIAL FIBRILLATION 55E. Menardi, A. Vado, G. Rossetti, E. Racca, M. Bobbio

BENEFIT FROM ABLATION OF LONGSTANDING PERSISTENT AF IS BETTER THANIN PAROXYSMAL AF 2-YEAR EVALUATION OF QUALITY OF LIFE 55

V. Bulkova, M. Fiala, D. Wichterle, J. Chovancik, J. Simek, S. Havranek, J. Gorzolka, J. Pindor, H. Tolaszova, J. Brada, K. Ivanova

ALTERATIONS IN ATRIAL EXCITATION PATTERNS FOLLOWING CIRCUMFERENTIAL PULMONARY VEINS ISOLATION 55V. Vassilikos, G. Dakos, I. Chouvarda, S. Paraskevaidis, I. Chatzizisis, G. Stavropoulos, N. Maglaveras, I. Styliadis

IS THE PRESENCE OF ABNORMALITIES OF THE P WAVE IN LEAD V1 NECESSARILY INDICATIVEOF THE EXISTENCE OF BLOCK OF INTERATRIAL CONNECTIONS LOCATED IN PROXIMITY OF FOSSA OVALE? 56

P. Pieragnoli, G. Ricciardi, L. Perrotta, G. Mascia, L. Padeletti, A. Michelucci

EARLY EXPERIENCE OF RESPIRATORY EFFECT REDUCTION ON FAST ANATOMICAL 3D MAPPING 56E. De Ruvo, S. Dottori, M. Rebecchi, L. De Luca, L. Sciarra, L.M. Zuccaro, A. Faganini, G. Sabino, P. Terrosu, M. Minati, F. Guarracini,M. Porfirio, F. Sebastiani, R.V. Iulianella, C. Commisso, A. Sette, F. Nuccio, C. Lanzillo, E. Lioy, L. Calò

CONTENTS

XI

CARDIAC PACING IMPLANTATION AND PROGRAMMING 57

SUPRACLAVICULAR VEIN APPROACH TO OVERCOME IPSILATERAL SUBCLAVIAN VEIN OBSTRUCTIONWHEN IMPLANTING PACEMAKER-ICD LEADS 57

D. Antonelli, N.A. Freedberg, Y. Turgeman

ROADMAP FLOUROSCOPY FOR PLACEMENT OF PACEMEAKER AND ICD LEADS 57A. Salacata, S. Keavey

PERIOPERATIV ORAL ANTICOAGULANT THERAPY DURING PACEMAKER AND DEFIBRILLATOR IMPLANTATIONS 57G. Bencsik, R. Pap, A. Makai, L. S·ghy, G. Klausz, T. Forster

THE FACTORS ASSOCIATED WITH REOPERATION AFTER DE NOVO PACEMAKER IMPLANTATION 57C. Suga, T. Hirahara, Y. Sugawara, J. Ako, S. Momomura, T. Kurata

ATRIO-VENTRICULAR SEARCH HYSTERESIS ALGORITHM MINIMIZES RIGHT VENTRICULAR PACINGIN PATIENTS IMPLANTED WITH A DUAL CHAMBER PACEMAKER: RESULTS FROM A PROSPECTIVE STUDY 58

P. Le Franc, J. Casassus, G. Kaltofen, K. Bel Hadj, O. Bizeau, E. Espaliat, A. Guillemot, P. Pepi, E. Mouton, L. Coutrot, O. Thomas

IMPACT ON VENTRICULAR PACING OF AN ATRIO-VENTRICULAR SEARCH HYSTERESIS ALGORITHMACCORDING TO IMPLANT INDICATIONS IN PACEMAKER RECIPIENTS 58

M. Maines, P. Le Franc, G. Vergara, D. Catanzariti, A. Reggiani, P. Pepi, M. Pasqualini, D. Pozzetti, P. Belli, C. Provvisiero, G. Saint-Cricq,P. Berdague, M. Abinader, U. Appl, L. Coutrot, O. Thomas

IMPLANTABLE DEVICES REMOTE CONTROL 59

ACCEPTANCE AND SATISFACTION OF PATIENTS WITH IMPLANTED DEVICES REMOTE MONITORING 59L. Morichelli, A. Sassi, L. Quarta, A. Porfili, N. Cadeddu, F. Saputo, S. Aquilani, M. Magris, V. Altamura, C. Pignalberi, R.P. Ricci, M. Santini

THE REMOTE CONTROL IN THE MANAGEMENT OF HEART FAILURE AND ARRHYTHMIAS IN PATIENTSWITH IMPLANTABLE CARDIAC DEVICES 59

S. Aquilani, L. Morichelli, A. Porfili, L. Quarta, C. Pignalberi, B. Magris, V. Altamura, R.P. Ricci, M. Santini

A REMOTE MONITORING EXPERIENCE WITH HEART FAILURE PATIENTS IMPLANTED WITH ICDAND CRT-D DEVICES CO-MANAGED BY PHYSICIANS AND NURSES 59

A. Locatelli, V. Giudici, P. Neri, B. Casiraghi, S. Gilardi, L. Viscardi, P. Rocca, C. Malinverni, M. Tomaselli, A.M. Durante, M.T. Villa, M. Pisoni

CLINICAL UTILITY OF REMOTE MONITORING BY IMPLANTABLE CARDIOVERTER DEFIBRILLATORIN A GROUP OF PATIENTS WITH CHRONIC HEART FAILURE 59

V.E. Santobuono, M. Iacoviello, F. Nacci, M. Anaclerio, G. LuzzI, A. Puzzovivo, F. Monitillo, F. Quadrini, R. Memeo, S. Favale

LATITUDE PATIENT MANAGEMENT SYSTEM: A USEFUL TOOL IN THE MANAGEMENTOF HEART FAILURE PATIENTS WITH CRT-D DEVICES 60

L. Zuccaro, M. Sforza, A. Martino, E. De Ruvo, L. De Luca, L. Sciarra, S. Matera, M. Minati, M. Rebecchi, A. Fagagnini, E. Lioy, L. Calo’

REMOTE CONTROL OF PM PATIENT FROM START-UP TO CLINICAL PRACTICE: A SINGLE CENTER EXPERIENCE 60S. Baccillieri, P. Turrini, A. Cattin, M. Martignon, D. Marangon, D. Canovese, M. Bernardi, A. Libralon, A. Menegazzo, E. Caliari, J. Comisso, R. Verlato

CATHETER ABLATION OF VENTRICULAR TACHYCARDIA 61

VENTRICULAR TACHYCARDIA ABLATION TARGETING ENDOCARDIAL AND EPICARDIAL LATE POTENTIALS 61P. Vergara, N. Trevisi, F. Baratto, F. Petracca, A. Ricco, G. Maccabelli, P. Della Bella

VT ABLATION: EVOLUTION OF PATIENTS, SUBSTRATE ASSOCIATED TO VT AND PROCEDURES IN THE LAST YEARS 61C. Lavalle S. Ficili, M. Russo, M. Galeazzi, T. Coppi, G. Chiarelli, F. Venditti, C. Pandozi, M. Santini

SUBSTRATE MAPPING AND ABLATION OF VENTRICULAT TACHYCARDIA IN RECIPIENTSOF IMPLANTABLE DEFIBRILLATOR IN PRIMARY PREVENTION 61

B. Pezzulich, R. Maggio, F. Gugliotta

ROLE OF INTRACARDIAC ECHOCARDIOGRAPHY AS ELECTROANATOMICAL MAPPING INTEGRATIONFOR VENTRICULAR TACHYCARDIA ABLATION 61

E. Soldati, A. Di Cori, G. Zucchelli, L. Segreti, L. Paperini, S. Viani, R. De Lucia, L. Misuraca, M.G. Bongiorni

FLUOROSCOPY-FREE RIGHT VENTRICULAR MAPPING AND ABLATION OF PREMATURE VENTRICULARCONTRACTIONS ORIGINATING FROM THE RIGHT VENTRICULAR OUTFLOW TRACT: A PILOT STUDY 62

E. De Ruvo, S. Dottori, A. Fagagnini, L. Sciarra, L. De Luca, Lm. Zuccaro, M. Rebecchi, Rv. Iulianella, F. Sebastiani, A. Martino,M. Minati, S. Matera, F. Guarracini, G. Pendenza, M. Porfirio, G. Navone, F. Nuccio, A. Sette, E. Lioy, L. Calo’

VENTRICULAR TACHYCARDIA UNIT: AN EFFECTIVE MODEL FOR ADVANCED VT TREATMENT 62F. Baratto, F. Petracca, G. Maccabelli, N. Trevisi, C. Bisceglia, M. Cireddu, P. Della Bella

CONTENTS

XII

BENEFITS OF ICD REMOTE CONTROL 63

INTEGRATED MANAGEMENT OF A CARDIOLOGY OUTPATIENT CLINIC THROUGH THE USE OF REMOTEMONITORING SYSTEMS OF THE PATIENT WITH THE IMPLANTED DEVICE: THE SOCIAL IMPACT 63

L.M. Zuccaro, M. Sforza, L. La Rocca, L. San Giovanni, F. Stirpe, S. Matera, L. De Luca, L. Sciarpa, E. De Ruvo, M. Rebecchi, L. Calò

IMPACT OF REMOTE MONITORING SYSTEM OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORSON QUALITY OF LIFE 63

G. Panattoni, M. Sgueglia, V. Schirripa, A. Politano, A. Giomi, L.P. Papavasileiou, L. Santini, G.B. Forleo, G. Magliano, F. Romeo

REMOTE MONITORING OF ICDS AND CARDIAC CRT-D DEVICES: LATITUDE SYSTEM EVALUATION 63L. Zuccaro, M. Sforza, L. De Luca, L. Sciarra, M. Rebecchi, E. De Ruvo, F. Guarracini, A. Martino, F. Stirpe, A. Fagagnini, E. Lioy, L. Calo’

HOMEGUIDE REGISTRY: RATIONALE, OBJECTIVES, DESIGN, TIME SCHEDULING 63R.P. Ricci, L. Morichelli, D. Vaccari, G. Zanotto, M. Brieda, A. Curnis, F. Di Pede, F. Ammirati, E. Marras, D. Melissano, A. Gargaro, A. D’Onofrio

THE REMOTE CONTROL OF IMPLANTABLE DEVICES: ORGANIZATIONAL IMPACTAND RESOURCE CONSUMPTION CARDIOLOGY OUTPATIENT CLINICS 64

L. Morichelli, A. Porfili, L. Quarta, A. Sassi, N. Cadeddu, F. Saputo, C. Pignalberi, B. Magris, V. Altamura, S. Aquilani, R.P. Ricci, M. Santini

FOLLOW-UP OF IMPLANTABLE DEVICES: NEW MANAGEMENT WITH REMOTE MONITORING SYSTEM 64R. Colaceci, M. Bocchino, M.G. Romano, N. Danisi, G. Pighini, L. La Rocca, F. Ammirati

UPDATE IN ENDOCARDIAL AND EPICARDIAL MAPPING 65

CARTOSOUND UTILIZATION IN ABLATION PROCEDURES: TWO YEAR EXPERIENCE OF A SINGLE CENTRE 65C. Pratola, L. Pirani, P. Artale, C. Cavazza, M. Bertini, E. Baldo, T. Toselli, R. Ferrari

“NEAR ZERO” FLUOROSCOPIC EXPOSURE IN SUPRAVENTRICULAR ARRHYTHMIA ABLATION USINGTHE ENSITE NAVX™ MAPPING SYSTEM 65

M. Casella, A. Dello Russo, G. Pelargonio, A. Scarà, S. Bartoletti, M. Moltrasio, P. Santangeli, S. Riva, P. Zecchi, A. Natale, C. Fiorentini, C. Tondo

A NEW 3D MAPPING SYSTEM FOR CATHETER ABLATION OF VENTRICULAR ARRHYTHMIAS 65L. De Luca, L. Sciarra, E. De Ruvo, P. Pitrone, S. Dottori, M. Rebecchi, L. Zuccaro, C. Lanzillo, A. Fagagnini, F. Guarracini, F. Pigozzi,F. Quaranta, E. Lioy, L. Calò

FLUOROSCOPIC TIME REDUCTION IN CATHETER ABLATION FOR SIMPLE SVT COMPARING CARTO-XPAND CARTO3 NAVIGATION SYSTEMS 66

F. Solimene, C. Marrazzo, G. Donnici, G. Shopova, A. Natalizia, P. Pitrone

DETERMINATION OF OCCURRENCE DEPTH OF AN ECTOPIC SOURCE IN CASE OF VENTRICULAREXTRASYSTOLE BASED ON NONINVASIVE ENDOCARDIAL AND EPICARDIAL MAPPING 66

A. SH. Revishvili, V.V. Kalinin, O.S. Lyadzhina, G.YU. Simonyan, O.V. Sopov, E.A. Fetisova

KOCH TRIANGLE ACTIVATION IN PATIENTS WITH AND WITHOUT AVNRT 66M. Galeazzi, S. Ficili, M. Russo, C. Lavalle, S. Dottori, B. Verbo, T. Coppi, G. Chiarelli, F. Venditti, A. Pandozi, C. Pandozi, M. Santini

CONTENTS

XIII

Friday, December 3

NO MAPPING CATHETER ABLATION OF ATRIAL FIBRILLATION 68

FIVE YEARS AFTER ABLATION WITH CRYOBALLOON; WHO IS THE BEST PATIENT 68A. Berkowitsch, T. Neumann, M. Kuniss, S. Zaltsberg, D. Pajietnew, T. Eckhard, H.F. Pitschner

CRYOABLATION OF PAROXYSMAL ATRIAL FIBRILLATION 68S. Ficili, C. Lavalle, M. Galeazzi, M. Russo, A. Pandozi, G. Chiarelli, T. Coppi, C. Pandozi, M. Santini

EVALUATION OF ELECTRICAL PV ISOLATION OBTAINED WITH CRYOBALLOONBY ELECTRO-ANATOMICAL VOLTAGE MAPPING WITH CARTO SYSTEM 68

G. Arena, C. Bartoli, V.M. Borrello, M. Ratti, C. Andriani, V. Molendi, R. Tongiani, N. Gigli, M. Mazzini, S. Berti

CONTRAST REAL-TIME INTRACARDIAC ECHOCARDIOGRAPHY IN SUPPORTING AF CRYOABLATIONOF PV. A RANDOMIZED STUDY 69

M. Maines, D. Catanzariti, C. Angheben, C. Cirrincione, G. Broso, G. Vergara

ISOLATION OF THE PV N OBTAINED WITH A NOVEL PHASED RF /DUTY CYCLE MAPPINGAND ABLATION CATHETER: PRELIMINARY EXPERIENCE 69

F. Solimeno, C. Paolillo, G. Donnici, G. Shopova, N. Marrazzo, P. Rubino

PV MAPPING AND ISOLATION USING A NOVEL PHASED RF/DUTY CYCLE CATHETERWITH NAVX MAPPING SYSTEM 69

G.B. Forleo, L. Santini, F. Romeo, A. Avella, A. Pappalardo, F. Laurenzi, P.G. De Girolamo

ELECTROPHYSIOLOGICAL FINDINGS AT RE-DO PROCEDURES IN PATIENTS WITH PREVIOUS PV ABLATIONWITH PHASED/DUTY CYCLE MULTIELECTRODE CATHETER 70

S. Baccillieri, P. Turrini, A. Di Marco, A. Stendardo, P.G. Piovesana, V. Scarabeo, F. Campisi, E. Mantovani, R. Verlato, E. Ceoldo

A NOVEL TECHNIQUE OF PV ISOLATION APPROACH WITH PHASED RF/DUTY CYCLE TECHNOLOGY:ASSESSMENT OF THE RESULTS DURING THE LEARNING CURVE 70

R. Verlato, S. Baccillieri, P. Turrini, A. Di Marco, A. Stendardo, P.G. Piovesana, V. Scarabeo, F. Campisi, E. Mantovani, E. Ceoldo

OPTIMIZING CARDIAC RESYNCHRONIZATION THERAPY 71

CRT: A NUMERICAL MODEL TO PERSONALIZE BIV PROGRAMMING 71A. Di Molfetta, L. Santini, L. Fresiello, G.B. Forleo, M. Sgueglia, C. Tota, M. Cesario, D. Sergi, G. Ferrari, F. Romeo

CAN NON SUSTAINED VT’S PREDICT CARDIAC RESYNCHRONIZATION THERAPY NON-RESPONDERS? 71L.P. Papavasileiou, F. Vecchio, A. Topa, G. Panattoni, D.G. Della Rocca, V. Minni, A. Di Molfetta, F. Paparoni, M. Cesario,C. Tota, L. Santini, G.B. Forleo, G. Magliano, F. Romeo

CLINICAL BENEFITS OF CARDIAC RESYNCHRONIZATION THERAPY IN OVER 75 YEARS OLD PATIENTS 71R. Memeo, F. Quadrini, V.E. Santobuono, L. Nuzzi, P. Palmisano, G. Luzzi, M. Anaclerio, F. Nacci, S. Favale

FRAGMENTED QRS IN CARDIAC RESYNCHRONIZATION THERAPY PATIENTS 71S. Sacchi, G. Mascia, M. Pennesi, L. Perrotta, A. Paoletti Perini, G. Ricciardi, P. Pieragnoli, M. Chiostri, M.C. Porciani,A. Michelucci, L. Padeletti

CARDIAC MEMORY IN HUMANS: VECTOCARDIOGRAPHIC QUANTIFICATION INCARDIAC RESYNCHRONIZATION THERAPY 72

L. Perrotta, C. Fantappie’, G. Ricciardi, P. Pieragnoli, M. Chiostri, S. Valsecchi, M.C. Porciani, A. Michelucci, F. Fantini, L. Padeletti

CONCORDANCE IN TIME BETWEEN SONR AND HEART SOUND 72A. Tassin, A. Kobeissi, L. Vitali, G. Gaggini, F. Treguer, P. Ritter, A. Furber, JM. Dupuis

LEFT VENTRICULAR PACING WITH A NEW QUADRIPOLAR TRANSVENOUS LEAD FOR CRT:EARLY RESULTS OF A PROSPECTIVE COMPARISON WITH CONVENTIONAL IMPLANT OUTCOMES 72

G.B. Forleo, L. Santini, L.P. Papavasileiou, D.G. Della Rocca, G. Panattoni, G. Magliano, V. Romano, M. Sgueglia, A. Di Molfetta, F. Romeo

IS IT POSSIBLE, WITH A REMOTE MONITORING SYSTEM, TO INCREASE THE RESPONSETO THE BIVENTRICULAR PACING THERAPY AND IMPROVE THE MENAGEMENT OF PATIENTSWITH ADVANCED HEART FAILURE? 73

A. Curnis, L. Bontempi, A. Lipari, F. Vassanelli, C. Pagnoni, N. Ashofair, M. Cerini, L. Dei CasCONTENTS

XIV

LEAD EXTRACTION 74

NON-INFECTIVE INDICATIONS FOR LEAD EXTRACTION - COMMON PRACTICE 74A. Andrzej Kutarski, B. Malecka

ENDOVASCULAR LEADS EXTRACTION: DO EXIST PREDICTIVE PARAMETERS FOR ADVERSE EVENTS? 74L. Bontempi, A. Curnis, E. Vizzardi, M. Cerini, A. Lipari, C. Pagnoni, N. Ashofair, M. Mutti, F. Vassanelli, L. Dei Cas

FACTORS AFFECTING SURVIVAL FOLLOWING LEAD EXTRACTION IN PATIENTSWITH CARDIAC DEVICE INFECTION 74

F. Viganego, S. O’Donoghue, Z. Eldadah, M. Shah, M. Rastogi, J. Mazel, E.V. Platia

LARGE SINGLE CENTER EXPERIENCE IN TRANSVENOUS CORONARY SINUS LEAD REMOVAL:PROCEDURAL OUTCOMES, TECHNICAL IMPLICATIONS AND PREDICTORS OF MECHANICAL DILATATION 75

A. Di Cori, E. Soldati, L. Segreti, G. Zucchelli, R. De Lucia, L. Paperini, S. Viani, A. Boem, D. Levorato, M.G. Bongiorni

PERCUTANEOUS EXTRACTION OF OVER 1 000 PERMANENTLY IMPLANTED LEADS IN 590 PTS.USING MECHANICAL SYSTEMS - EFFECTIVENESS AND COMPLICATIONS 75

A. Andrzej Kutarski, M. Czajkowski, R. Pietura, M. Grabowski, B. Malecka

TRANSVENOUS REMOVAL OF PACING AND DEFIBRILLATING LEADS: 13 YEARS OFEXPERIENCE IN A SINGLE CENTER 75

M.G. Bongiorni, E. Soldati, G. Zucchelli, L. Segreti, A. Di Cori, R. De Lucia, S. Viani, L. Paperini, D. Levorato, A. Boem

FEASIBILITY AND MID-TERM OUTCOME OF CARDIAC RESYNCHRONIZATION THERAPYAFTER CORONARY SINUS LEAD EXTRACTION: TERTIARY REFERRAL CENTRE EXPERIENCE 76

G. Zucchelli, G. Solarino, I. Fabiani, E. Soldati, A. Di Cori, L. Segreti, G. Coluccia, R. De Lucia, S. Viani, L. Paperini, A. Boem, M.G. Bongiorni

TRANSVENOUS EXTRACTION OF IMPLANTABLE CARDIOVERTER DEFIBRILLATOR LEADS:FEASIBILITY, SAFETY AND DETERMINANTS OF SUCCESS IN A SINGLE CENTER EXPERIENCE 76

L. Segreti, E. Soldati, G. Zucchelli, A. Di Cori, R. De Lucia, L. Paperini, S. Viani, D. Levorato, A. Boem, M.G. Bongiorni

CARDIAC PACING AND ICD PROGRAMMING AND FOLLOW-UP 77

CUMULATIVE BURDEN OF RIGHT VENTRICULAR PACING IN SINUS NODE DYSFUNCTIONVS ATRIOVENTRICULAR BLOCK PATIENTS: MID-TERM OUTCOMES FROM THE NATURE REGISTRY 77

G. Molon, A. Vicentini, D. Vaccari, A. Pezzotta, J.C. Deharo

DUAL-CHAMBER PACEMAKER REPROGRAMMING IN CLINICAL PRACTICE:RESULTS FROM A LARGE COHORT OF THE NATURE REGISTRY 77

A. Vicentini, D. Vaccari, G. Molon, E. Favero, J.C. Deharo

CRT OPTIMIZATION BY SONR OR STANDARD METHODS: RESULTING CLINICALRESPONSE RATE FROM THE RANDOMIZED CLEAR STUDY 77

R.P. Ricci, M. Lunati, L. Padeletti, S. Orazi, A. Capucci, S. Cerisano, P. Ritter

FREQUENT VV AND AV DELAYS OPTIMIZATION IN CRT PATIENTS IMPROVESCLINICAL RESPONSE RATE: RESULTS FROM THE RANDOMIZED CLEAR STUDY 78

D. Vaccari, G.Q. Villani, R.P. Ricci, M. Lunati, L. Padeletti, P. Ritter

COMPARISON BETWEEN OPTIMIZED CRT PATIENTS BY SONR OR CLINICAL PRACTICE:NYHA CLASS EVALUATION 78

S. Orazi, R.P. Ricci, M. Lunati, L. Padeletti, A. Capucci, S. Cerisan, P. Ritter

REMOTE FOLLOW-UP IN PATIENT WITH IMPLANTABLE DEVICE: A SINGLE EXPERIENCE 78G. Giunta, L. La Rocca, L. Marruncheddu, P. Franciosa, F. Fattorini, E. Crisuolo, C. Straccio, A. Ciccaglioni, F. Fedele

DEGREE AND SEVERITY OF SLEEP BREATHING DISORDERS CORRELATEWITH THE BURDEN OF VENTRICULAR TACHYARRHYTHMIAS IN ICD PATIENTS 79

G. Mantovani, E. Aime’, C. Gentilini, M. Lorini, C. Storti, M. Longobardi, E. Moro, F. Anselme

ICD MODEL SELECTION ACCORDING TO PRIMARY OR SECONDARY PREVENTION INDICATIONS:PRELIMINARY OUTCOMES FROM THE FIRST REGISTRY 79

M. Piacenti, P. Scipione, E. Dovellini, A. Proclemer, S. Cerisano, R. Manfredini, O. Pensabene, F. Frascarelli, O. Piot, L. Padeletti

CONTENTS

XV

POSTERS - CARDIAC PACING

1 SIGNAL AVERAGED ELECTROCARDIOGRAPHY: A BETTER INDICATOR OF LEFT VENTRICULAR ENLARGEMENT 81M. Alasti, B. Omidvar, M. Haghjoo, A. Alizadeh, M.H. Nikoo, H.R. Bonajdar

2 PHRENIC STIMULATION THRESHOLD AND BODY POSITION: IMPLICATIONS FOR LV PACINGOUTPUT PROGRAMMING 81M. Biffi, B. Gardini, A. Mazzotti, V. Mantovani, G. Massaro, M. Ziacchi, M. Balbo, F. Bonfatti, M. Salomoni, G. Boriani

3 AUTOMATIC CAPTURE VERIFICATION IS SUPERIOR TO FIXED-OUTPUT STIMULATION:ENHANCED PACEMAKER LONGEVITY OVER A 10-YEARS FOLLOW UP 81M. Biffi, A. Mazzotti, B. Gardini, V. Mantovani, G. Massaro, M. Ziacchi, M. Balbo, F. Bonfatti, M. Salomoni, G. Boriani

4 IMPLANTATION OF TWO-CHAMBER AND BIVENTRICULAR PACEMAKERS:VECTORCARDIOGRAPHIC DIAGNOSTICS OF STIMULATION LEADS LOCALIZATION 81V. Zalevsky, G. Knyshov, Y. Bilynskyi, V. Lazoryshynets, R. Vitovskyi, B. Kravchuk, K. Rudenko, O. Trembovetska, V. Beshliaga, M. Dyrda,M. Myroshnyk, L. Tokarska

5 USEFULNESS OF QRS DURATION MEASURED IMMEDIATELY AFTER IMPLANTATION TO PREDICT RESPONSETO CARDIAC RESYNCHRONIZATION THERAPY 82F. Quadrini, R. Memeo, V.E. Santobuono, P. Palmisano, L. Nuzzi, G. Luzzi, M. Anaclerio, F. Nacci, S. Favale

6 IDENTIFYNG OPTIMAL LEFT VENTRICLE LEAD POSITION USING A NEW CORONARY GUIDEWIREWITH TEMPORARY PACING CAPABILITIES AND NON-INVASIVE HEMODYNAMIC ACUTE MONITORING 82A. D’Onofrio, C. Cavallaro, S. De Vivo, A. Vecchione, M. Cavallaro, S. Camerale, M. Ionno, A. Garagaro, P. Caso

7 CRT BY LV PACING SYNCHRONIZED WITH INTRINSIC RV CONDUCTION 82G. Neri, S. Vittadello, G. Masaro, D. Vaccari, A. Barbetta, F. Di Gregorio

8 LONG-TERM EVALUATION OF CARDIAC RESYNCHRONIZATION THERAPY: BENEFIT PREDICTORS 83C. Pignalberi, F. Saputo, B. Magris, S. Aquilani, V. Altamura, R.P. Ricci, M. Santini

9 THE PROBLEM OF NON-RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY:A SINGLE CENTER EXPERIENCE 83S. Maffè, A. Perucca, P. Paffoni, U. Parravicini, P. Dellavesa, A.M. Paino, M. Bielli, L. Cucchi, F. Zenone, N. Franchetti Pardo, F. Signorotti, M. Zanetta

10 THE RELATIONSHIP OF NON-SUSTAINED VENTRICULAR ARRHYTHMIAS AND MAJOR EVENTS IN CRT-D PATIENTS 83F. Vecchio, L.P. Papavasileiou, A. Topa, G. Panattoni, D.G. Della Rocca, A. Di Molfetta, V. Minni, M. Cesario, C. Tota, F. Paparoni,L. Santini, G.B. Forleo, G. Magliano, F. Romeo

11 USE OF IMPLANTABLE CARDIOVERTER DEFIBRILLATOR AND CARDIAC RESYCHRONIZATION THERAPYIN HIGH RISK PATIENTS: AN ITALIAN SURVEY STUDY ON 220 CARDIOLOGY DEPARTMENTS 83G. Inama, C. Pedrinazzi, M. Landolina, F. Olna, L. Inama, M. Zoni. Berisso

12 ARE THE RESULTS OF THE SCD-HEFT TRIAL APPLICABLE IN OUR CLINICAL SETTING? 84J. Martínez, P. Peñafiel, I. Garrido, F. Pastor, J.J. Sánchez, G. De La Morena, D. Pascual, A. García, M. Valdés

13 COMPLICATIONS DEVICE LONGEVITY AND PATIENT SURVIVAL IN THE SWEDISH PACEMAKER AND ICD REGISTRY 84F. Gadler, C. Linde

14 ICD PRICING IN THE REAL-LIFE SCENARIO: UP-FRONT COST OR DAILY COST? 84M. Biffi, B. Gardini, A. Mazzotti, G. Massaro, M. Ziacchi, F. Bonfatti, M. Salomoni, M. Balbo, V. Mantovani, G. Boriani

15 PRACTICE PATTERNS AND EFFICACY OF IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IMPLANTATIONSIN A TERTIARY CENTER OF NORTHERN GREECE 85K. Tsilonis, V. Vassilikos, A. Vosnakidis, L. Mantziari, S. Paraskevaidis, G. Dakos, G. Stavropoulos, G. Efthimiadis, S. Mochlas, G. Louridas,G. Parcharidis, I. Styliadis

16 TRIGGERS AND OUTCOME OF ACCELERATED VENTRICULAR TACHYARRHYTHMIA IN PATIENTS WITHIMPLANTABLE CARDIOVERTER DEFIBRILLATOR 85C. Schukro, L. Leitner, J. Siebermair, T. Pezawas, G. Stix, J. Kastner, M. Wolzt, H. Schmidinger

17 OUTCOME IN ISCHEMIC CARDIOMYOPATHY PATIENTS RECIPIENTS OF IMPLANATBLECARDIOVERTER-DEFIBRILLATOR 85K. Polymeropoulos, P. Ioannidis, E. Keklikoglou, D. Papakonstantinou, J. Zarifis

18 SUBCUTANEOUS ICD IMPLANTATION 85G. Zuccon, V. Ardente, M. Bencivenni, E. Algeri, S. Russo, D. Baldazzi, A. MontinCONTENTS

XVI

19 CLINICAL OUTCOME OF DUAL CHAMBER PACING AND RECURRENCE OF SYNCOPE IN14 CARDIOINHIBITORY SYNCOPE PATIENTS 86A. Yaminisharif, R. Yaminisharif, G. Davoodi, A. Kazemisaeed, A. Vasheghani-Farahani, A. Shafiee

20 INTRAOPERATIVE DEFIBRILLATION EFFICACY OF THE SINGLE COIL ICD-LEAD SPRINT QUATTRO SECURE S 6935 86L. Binner, G. Grossmann, D. Walcher, P. Stiller, W. Rottbauer, S. Stiller

21 LONG-TERM CHANGES IN INTRACARDIAC IMPEDANCE IN CARDIAC RESYNCHRONIZATION THERAPY PATIENTS 86F. Gadler, N. Holmstrom, S-E Hedberg, A Karlsson, C Valzania, M.J. Eriksson

22 EIGHT PATIENTS UNDERGOING PERMANENT RIGHT BIFOCAL STIMULATION 87M. Marini, P. Baraldi, A. Montin, G. Zuccon, A. Andraghetti

23 COMPARISON OF METHODS IN REDUCING RIGHT VENTRICULAR PACING AND ITS CLINICAL IMPLICATIONS:IS THE DIFFERENCE WORTH IT? 87V. Gourineni, K Wong, M Hyder, E Tiffany-Ellis, R Davoudi

24 A VARIATION OF CARDIAC FUNCTION BY THE DIFFERENCE OF QRS DURATION IN THE VENTRICULAR PACING 87M. Shima, Y. Deguchi, D. Fujibayashi, T. Hashida

25 PERMANENT PACING VIA A LEFT VENTRICULAR LEAD IN A PATIENT WITH AN ARTIFICIAL TRICUSPID VALVE 87L. Binner, J. Homann, S. Stiller, D. Walcher

26 CAR DRIVING IS SAFE FOR PATIENTS IMPLANTED WITH AN ICD 88C. Pignalberi, C. Lavalle, L. Morichelli, A. Porfili, L. Quarta, A. Sassi, A. Aquilani, B. Magris, V. Altamura, R.P. Ricci, M. Santini

27 DOES CURRENT CLINICAL PRACTICE MATCH CLASS I INDICATIONS FOR ICD IMPLANTATION?DATA FROM THE SAFE-ICD STUDY 88V. Giudici, A. Locatelli, E. Occhetta, G. Comerci, R. Sangiuolo, M. Sassara, G.P. Gelmini, S. Orazi, A. Talarico, F. Accardi, M. Gasparini

28 VALUE OF REMOTE MONITORING IN IMPROVING EFFICIENCY OF SCHEDULED IN-OFFICE ICD FOLLOW-UPS 88G. De Meyer, Y. De Greef, B. Schwagten, E. Schepers, D. Stockman

29 CRT-D MALFUNCTION DUE TO SCATTERED RADIATION DETECTED BY HOME MONITORING 88E. Marras, F. Chiusso, G. Allocca, N. Sitta, P. Delise

30 HOME MONITORING EFFECTIVENESS TO PREVENT NAPPROPRIATE SHOCKS IN PATIENTSWITH IMPLANTABLE CARDIOVERTER DEFIBRILLATORS (ICDS) 89C. Puntrello, V. Lettica, G. Pizzimenti, G. Deblasi, E. Pizzimenti

31 INTEGRATION OF LATITUDE REMOTELY TRANSMITTED DATA INTO AN EMR SYSTEM USING FILEMAKERPRO SOFTWARE: PROCEDURE AND ALGORHYTMS 89G. Pupita, S. Molini, S. Borio, J. Ellis, M. Brambatti, S. Guardiani, A. Capucci

32 CLINICAL AND COST-SAVING BENEFITS OF DAILY REMOTE MONITORING IN PACEMAKER PATIENTSWITH AMBULATING INABILITY 89M. Marini, C. Capparuccia

33 AUTONOMIC DYSFUNCTION IN AIDS PATIENTS RECEIVING ANTIRETROVIRAL THERAPY 89W. Wongcharoen, K. Keanprasit, A. Phrommintikul, N. Chattipakorn

34 ATRIOVENTRICULAR BLOCK AND VENTRICULAR FIBRILLATION IN PATIENT WITH NONCOMPACTIONOF THE VENTRICULAR MYOCARDIUM 90A. Placci, C. Tomasi, F. Giannotti, G. Bellanti, M. Margher

35 ATRIAL FIBRILLATION INCIDENCE IN PACEMAKER PATIENTS WITHOUT TACHYARRHYTHMIA HISTORY 90K. Polymeropoulos, E. Keklikoglou, P. Ioannidis, D. Papakonstantinou, G. Tsinopoulos, E. Delvizi, J. Zarifis

36 RELATION BETWEEN FIRST HEART SOUND AND FIRST SONR SIGNAL AMPLITUDE 90A. Tassin, A. Kobeissi, L. Vitali, G. Gaggini, F. Treguer, P. Ritter, A. Furber, J.M. Dupuis

37 THE IMPACT OF STORED ELECTROGRAMS ON PACEMAKER LONGEVITY 91C. Perri, S. Turner, A. Costa-Vitali, C. Lau, B. Goldman, E. Crystal

38 LEAD POSITIONING IN DEFINITIVE SEPTAL INTER-VENTRICULAR PACING 91B. Deriouich, M. Hero

39 COMPARISON PER-OPERATIVE AND INTRA-INDIVIDUAL VENTRICULAR PACING BETWEEN APEXAND SEPTO-BASAL POSITIONNING 91B. Deriouich, M. HeroCONTENTS

XVII

40 COMPARISON PER-OPERATIVE AND INTRA-INDIVIDUAL WIDTHS OF VENTRICULAR PACING COMPLEX,BETWEEN APEX AND SEPTO-BASAL POSITIONNING 91B. Deriouich, M. Hero

41 CHANGES OF PACING AND DEFIBRILLATION PARAMETERS IN RIGHT VENTRICULAR SEPTALPACING SITE - ONE YEAR FOLLOW-UP 92T. Minarik, D. Brecka, K. Grussmannova, M. Taborsky

42 LONG-TERM EVALUATION OF DIRECT HIS-BUNDLE PACING 92C. Pignalberi, R.P. Ricci, S. Aquilani, B. Magris, V. Altamura, M. Santini

43 ROUTINE USE OF ICE (INTRACARDIAC ECHOCARDIOGRAPHY) DURING LEAD EXTRACTION 92J. Petru, L. Sediva, J. Skoda, J. Kupec, P. Neuzil, F. Holy, J. Brada, K. Holdova, L. Plevkova, S. Kralovec

44 INITIAL RESULTS FROM THE LEAD EXTRACTION DEVICE EVALUATION AND RESULTS DATABASE(LEADER DATABASE) 92R.H.M. Schaerf, E.K. Bowser, B.E. Norlander

45 APOTENTIALLY DANGEROUS HAVING CLASS 3 INDICATIONS LEAD EXTRACTION.NOT ALL PATIENT NEEDS OPEN-HEART CARDIAC SURGERY 93A. Andrzej Kutarski, M. Czajkowski, R. Pietura, A. Tomaszewski

46 EXTRACTED LEADS’ BREAKAGE. ONE MORE OPTION OF MANAGEMENT 93A. Andrzej Kutarski, R. Pietura, M. Czajkowski

47 SYSTEMATIC BACTERIOLOGICAL LAB EXAMINATIONS FOLLOWING INFECTED ENDOCARDIAL LEADEXTRACTION USING STANDARD OR MODIFIED MECHANICAL SINGLE-SHEATH DILATATION TECHNIQUE 94G.M. Calvagna, R. Evola, A. Gargaro, N. Rovai

48 EPIDEMIOLOGICAL PROFILE OF INFECTIVE ENDOCARDITIS: REGARDING 158 CASES 94S. Fadili, N. Baady, A. Assaidi, Z. Elhonsali, A. Bennis

49 A NOVEL BENEFICIAL METHOD TO INSERT A PACING LEAD 94D. Fujibayashi, Y. Deguchi, M. Ishi, M. Shima, T. Hashida, M. Amino, K. Yoshioka, T. Tanabe

50 RISK FACTORS OF SUBCLAVIAN VENOUS OCCLUSION AFTER PACEMAKER IMPLANTATION 94T. Hashida, Y. Deguchi, M. Shima, D. Fujibayashi, M. Amino, K. Yoshioka, Y. Ikari

51 STRAIGHT SCREW-IN ATRIAL LEADS “J POST-SHAPED” IN RIGHT APPENDAGE VERSUS J-SHAPEDPASSIVE FIXATION: A PROCEDURAL SAFETY COMPARISON 95F. Zoppo, F. Zerbo, A. Lupo, E. Bacchiega, G. Brandolino, E. Bertaglia

52 PERMANENT EPICARDIAL PACING IN PEDIATRIC AND CONGENITAL HEART DISEASE’S PATIENTS 95M. Cabrera Ortega, E. Selman-Houssein Sosa, A. Naranjo Ugalde

53 HIGH SENSING INTEGRITY COUNTER MIMICKING LEAD FAILURE IN AN ICD / CCM OPTIMIZER PATIENT 95J. Michaelsen, J. Wilcox, W. Grofle-Heitmeyer

54 LEAD’S LIGATURE FAILURE AND OVERMUCH OF LEAD’S LENGTH IN RIGHT HEART - CAN WE OBSERVE IT ONLY? 96A. Andrzej Kutarski, B. Malecka

55 A DIFFICULT CARDIOVERTER-DEFIBRILLATOR IMPLANTATION IN A PATIENT WITH PERSISTENTLEFT SUPERIOR VENA AND RIGHT SUPERIOR VENA CAVA ATRESIA: A CASE REPORT 96I. De Crescenzo, M. Viscusi, M. Brignoli, D. Di Maggio, C. Sardu, P. Golino

56 PERMANENT PACING IN PATIENTS WITH PROLONGED ASYSTOLE AT THE HEAD UP TILT TEST 96F. Smurra, I. Scarfò, L. Santini, A. Viele, V. Romano, G.B. Forleo, L.P. Papavasileiou, G. Magliano, A. Capria, F. Romeo

57 PACEMAKER IMPLANTATION IN PATIENTS ON VITAMINE K ANTAGONIST: THE ELECTRA 2008 SURVEY 97J. Taïeb, M. Guenoun, M. Hero, R. Morice, C. Barnay

58 INFORMED CONSENT OF PATIENTS BEFORE PACEMAKER IMPLANTATION IN FRANCE:THE ELECTRA 2008 SURVEY 97M. Guenoun, J. Taïeb, M. Hero

59 MODALITIES OF PACEMAKER IMPLANTATION IN CLINICAL PRACTICE: THE ELECTRA 2008 SURVEY 97M. Guenoun, J. Taïeb, M. Hero

60 FOLLOW-UP OF PATIENTS IMPLANTED BY PACEMAKER IN FRANCE: THE ELECTRA 2008 SURVEY 98J. Taïeb, M. Guenoun, M. HeroCONTENTS

XVIII

POSTERS - CARDIAC ELECTROPHYSIOLOGY

1 COMPARISON OF LEFT ATRIUM RADIUS VALUES AGAINST ENERGY LEVELS NEEDED FOR A SUCCESSFULELECTRICAL CARDIOVERSION AT PATIENTS WITH NONVALVULAR ATRIAL FIBRILLATION 99B. Akdemir, A.R. Gulcan, S. Karakas, S. Koc, M. Ucar, I. Nizam, R.E. Altekin, H. Yilmaz, N. Deger, C. Ermis

2 DETECTION OF SUPRAVENTRICULAR ARRHYTHMIAS IN PATIENTS WITH RECENT CRYPTOGENETIC STROKEWITH AN IMPLANTABLE LOOP-RECORDER 99V. Giudici, A. Locatelli, B. Casiraghi, R. Grandi, G.B. Antongiovanni, P. Scopelliti, M. Tespili, A. Brambilla

3 FIBRILLATORY WAVE AMPLITUDE ON SURFACE ECG AS A PREDICTOR OF SINUS RHYTHM MAINTENANCEAFTER ELECTRICAL CARDIOVERSION 99G. Marchetti, A. Zaniboni, V. Castaldini, D. Franzè, V. Volzone, S. Urbinati

4 PREDICTION OF ATRIAL FIBRILLATION DEVELOPMENT IN HYPERTENSIVE PATIENTS WITHNORMAL LEFT ATRIAL DIMENSION USING P WAVE WAVELET ANALYSIS 99G. Dakos, V. Vassilikos, I. Chatzizisis, I. Chouvarda, H. Karvounis, S. Paraskevaidis, L. Mantziari, G. Stavropoulos, N. Maglaveras, I. Styliadis

5 STRATEGIES IN TRANS-THORACIC ELECTRICAL CARDIOVERSION OF ATRIAL FIBRILLATION IN CAMPANIA:THE SCARICA REGISTER 100A. Campana, F. Franculli, L. Santangelo, F. Candelmo, R. Sangiuolo, A. Catalano, S.L. D’Ascia, M. De Michele

6 EFFECT OF “MPV” (MEAN PLATELET VOLUME) VALUE ON SUCCESS OF CARDIOVERSION AT PATIENTSWITH NONVALVULAR ATRIAL FIBRILLATION 100B. Akdemir, A. Yanikoglu, B. Çaglar, E. Kaya, I. Nizam, I. Basarici, A. Belgi Yildirim, I. Demir, M. Kabukcu, S. Yalçinkaya, C. Ermis

7 ELECTROVIEW 3D MAPPING SYSTEM: A NEWLY AVAILABLE THREEDIMENSIONAL MAPPING SYSTEMTO PERFORME ATRIAL ARRHYTHMIAS 100M. Rebecchi, L. Sciarra, E. De Ruvo, L. De Luca, L.M. Zuccaro, R. Iulianella, C. Commisso, M. Minati, A. Fagagnini, F. Guarracini,S. Matera, M. Porfirio, G. Pendenza, E. Lioy, L. Calo’

8 AUTONOMIC DENERVATION IN RIGHT ATRIUM FOR PATIENTS AFFECTED BY VAGAL-PAROXYSMALATRIAL FIBRILLATION 101M. Rebecchi, L. Sciarra, E. De Ruvo, L. De Luca, L.M. Zuccaro, M. Porfirio, M. Minati, A. Fagagnini, G. Pendenza, F. Guarricini,F. Pigozzi, E. Lioy, L. Calo’

9 THROMBOGENICITY AFTER CLOPIDOGREL AND ASPIRIN ADMINISTRATION DURING RADIOFREQUENCY ABLATION 101K. Polymeropoulos, V. Vassilikos, S. Paraskevaidis, T. Karamitsos, J. Styliadis

10 PRKAG3 POLYMORPHISMS ASSOCIATED WITH SPORADIC WOLFF-PARKINSON-WHITE SYNDROMEIN TAIWANESE PEOPLE 101K. Weng, K. Hsieh, L. Ger

11 A STRANGE CASE OF LEFT POSTEROMEDIAL ATRIOVENTRICULAR ACCESSORY PATHWAY:APPARENT ABSENCE OF PREEXICITATION DUE TO MARKED ATRIAL CONDUCTION DELAY 101D. Malaspina, R. De Ponti, M. Pala, G. Guenzati, M. Bernasconi, M. Marzegalli

12 RADIOFREQUENCY CATHETER ABLATION OF ATRIOVENTRICULAR REENTRANT TACHYCARDIAFROM A LEFT ANTEROSEPTAL ACCESSORY PATHWAY IN DEXTROCARDIA WITH COMPLETE SITUS INVERSUS 102S. Iacopino, I. Lo Cane, G. Colangelo, V. Aspromonte, G. Fabiano, A. Talerico, P. Sorrenti, G. Campagna, S. Pellicano, M. Salierno

13 LATE PAROXYSMAL ATRIOVENTRICULAR BLOCK 2:1 IN PATIENT WITH PREVIOUS EFFECTIVEABLATION OF A RIGHT POSTEROSEPTAL ACCESSORY PATHWAY 102S. Iacopino, G. Colangelo, V. Aspromonte, I. Lo Cane, G. Fabiano, A. Talerico, P. Sorrenti, G. Campagna, S. Pellicano

14 IS THERE ANY DIFFERENCES BETWEEN CAVOTRICUSPID CONDUCTION IN PATIENTSWITH AND WITHOUT TYPICAL ATRIAL FLUTTER? 102S. Misikova, B. Stancak, E. Komanova, P. Spurny, O. Olexa

15 A NOVEL MULTIELECTRODE CATHETER FOR ABLATION OF RIGHT ATRIAL FLUTTER 103G. De Meyer, Y. De Greef, D. Stockman, B. Schwagten

16 CRYOBALLOON ABLATION OF ATRIAL FIBRILLATION: ACUTE AND LONG TERM RESULTS 103A. Pappalardo, A. Avella, G.B. Forleo, F. Laurenzi, P.G. De Girolamo, M. Mansour, C. Tondo

17 A COMMON INFERIOR PULMONARY TRUNK DETECTED BY MAGNETIC RESONANCE IMAGING AFFECTSATRIAL FIBRILLATION ABLATION STRATEGY: CASE REPORT 103R. De Lucia, E. Soldati, G. Zucchelli, A. Di Cori, L. Segreti, M.G. Bongiorni

18 IMAGE INTEGRATION-GUIDED EXTENSIVE ENCIRCLING PULMONARY VEIN ISOLATION:A PROSPECTIVE, RANDOMIZED STUDY 103Y. Tanaka, H. Hachiya, O. Inaba, A. Yagishita, K. Higuchi, M. Kawabata, K. HiraoCONTENTS

XIX

19 MAZE PROCEDURE CONFINED TO LEFT ATRIUM ONLY WITH BIPOLAR RADIOFREQUENCY ABLATION INPATIENTS WITH PERMANENT AND PERSISTENT ATRIAL FIBRILLATION UNDERGOING CARDIAC SURGERY 104G. Marchetti, G. Marinelli, R. Di Bartolomeo, P. Grazi, P. Passarelli, R. Roncuzzi, A. Zaniboni, S. Urbinati

20 RARE CASE OF SYNCOPE: 42 SECOND PAUSE DURING TILT TABLE TEST 104X. Amley, L. Mastrine, V. Valentino, Y. Greenberg

21 COMPARISON OF TWO PROTOCOLS FOR HEAD-UP TILT TESTING IN PATIENTS WITH NORMAL HEARTAND RECURRENT UNEXPLAINED SYNCOPE 104M. Alasti, B. Omidvar, M.H. Nikoo

22 SLEEP-DISORDERED BREATHING, ATRIAL FIBRILLATION AND TACHYCARDIOMYOPATHY:A CARDIO-RESPIRATORY NOCTURNAL SYNDROME? 105M. Matassini, F. Guerra, L. Cipolletta, S. Maffei, M. Brambatti, M. Marchesini, S. De Luca, G. Pupita, A. Capucci

23 TREATMENT FOR SLEEP APNEA SYNDROME DECREASE THE ABNORMAL POWER INCREASEIN FRACTAL ANALYSIS OF HEART RATE VARIABILITY 105M. Fujimoto, M. Kontani, M. Kiyama, K. Okeie, M. Yamamoto

24 COMPARISON BETWEEN MODIFIED-MOVING AVERAGE AND SPECTRAL TWA METHODS DURING EXERCISE-ECG 105A. Martino, F. Nuccio, A. Sette, C. Comisso, L. Sciarra, L. De Luca, L.M. Zuccaro, M. Rebecchi, E. De Ruvo, M. Minati, S. Matera,A. Ciccaglioni, G. Giunta, F. Guarracini, A. Fagagnini, G. Pendenza, M. Porfirio, E. Lioy, F. Fedele, L. Calo’

25 CHARACTERIZATION OF ENDOCARDIAL AND EPICARDIAL LATE POTENTIALS IN PATIENTSUNDERGOING VT ABLATION 105P. Vergara, N. Trevisi, F. Baratto, F. Petracca, A. Ricco, G. Maccabelli, P. Della Bella

26 REAL-TIME INTEGRATION OF INTRACARDIAC ECHOCARDIOGRAPHY AND ELECTROANATOMIC MAPPINGTO GUIDE ABLATION OF LEFT VENTRICULAR PREMATURE BEATS 106A. Avella, P. De Girolamo, F. Laurenzi, A. Pappalardo, C. Tondo

27 ACCURACY OF 3D RIGHT VENTRICLE RECONSTRUCTION PERFORMED WITH CARTOSOUND SYSTEMTM

IN ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY 106A. Avella, A. Pappalardo, F. Re, P. De Girolamo, F. Laurenzi, P. Baratta, G. d’Amati, E. Zachara, C. Tondo

28 TECHNIQUES IN APPROACH ABLATIVE: VENTRICULAR TACHYCARDIA 106C. Sardu, S.L. D’Ascia, V. Marino, V. Schiavone, V. Marullo, C. D’Ascia

29 VENTRICULAR TACHYCARDIA AND FLACCID PARALYSIS ATTACKS 107G. Gazzoni, C. Sussenbach, A. Ferrari, E. Lima, R. Etchapare, P. Soliz, R. Manhabosco Moraes, M.A Goldani, R. Piant, E. Bartholomay, C. Kalil

30 ACUTE INTOXICATION BY FLECAINIDE IN CHILDHOOD: REPORT OF CASE 107M. Cabrera Ortega, D. Castillo Meriño, J. Gell Aboy, E. Dìaz Berto, V. Monagas Docasal

31 THE ACUTE EFFECTS OF FELODIPINE PLUS RANOLAZINE ON LEFT VENTRICULAR DIASTOLIC FUNCTIONAND QT DISPERSION IN PATIENTS WITH ESSENTIAL HYPERTENSION 107N. Siniscalchi, T. Cerciello, F. Oliviero, L.I. Siniscalchi, L. Misso

32 ADDITIVE EFFECTS OF REMIFENTANIL AND SEVOFLURANE ON THE ELECTROPHYSIOLOGYOF THE SINUS AND AV NODE IN A PORCINE MODEL 107M. Anadon, J. Almendral, M. Zaballos, B. Del Blanco, F. Atienza, C. Gimeno

33 LONG QT SYNDROME LEADS TO TORSADES DE POINTES IN A PATIENT WITH HIV AND HEPATITIS C COINFECTION 108J. John, X. Amley, C. Gitelis, G. Bombino, B. Topi, G. Hollander, J. Ghosh

34 ECG ABNORMALITIES AND RISK OF DEVELOPMENT OF SEVERE CARDIAC INVOLVEMENT IN SARCOIDOSIS 108S. Nagao, H. Watanabe, M. Kodama, J. Tanaka, E. Suzuki, I. Narita, Y. Aizawa

35 PREVALENCE OF PATENT FORAMEN OVALE IN PATIENTS WITH CRYPTOGENETIC STROKE 108V. Giudici, A. Locatelli, B. Casiraghi, R. Grandi, G.B. Antongiovanni, P. Scopelliti

36 A NOVEL LOSS-OF-FUNCTION SCN5A MUTATION ASSOCIATED WITH BRUGADA SYNDROME,CONDUCTION DISEASE, AND MONOMORPHIC VENTRICULAR TACHYCARDIA 109N. Yagihara, H. Watanabe, A. Sato, Y. Hosaka, M. Chinushi, Y. Aizawa

37 VALUE AND SECURITY OF ORAL ADMINISTRATION OF FLECAINIDE STRESS TEST TO UNMASKTHE TYPE 1 BRUGADA ELECTROCARDIOGRAPHIC PATTERN 109S. Gallino, S. Dubner, A. Cerantonio, R. Bonato

38 PRKAG3 POLYMORPHISMS ASSOCIATED WITH SPORADIC WOLFF-PARKINSON-WHITE SYNDROMEIN TAIWANESE PEOPLE 109K. Weng, C. Chiou, C. Lin, L. Ger, K. Hsieh

39 CORRELATION BETWEEN PVS ELECTRICAL ISOLATION AND ENCIRCLING LESION CONTINUITY 109C. Lavalle, C. Pandozi. S. Ficili, M. Russo, M. Galeazzi, F. Giovannetti, A. Tranquilli, M. Santini

LIST OF AUTHORS 111CONTENTS

XX

1

FREE PAPERSTuesday, November 30

CARDIAC IMPLANTABLE DEVICES REMOTEMONITORING MANAGEMENT EVALUATION:EXPERIENCE FROM ELECTROPHYSIOLOGYUNIT-SAN MATTEO HOSPITAL-PAVIAM. LANDOLINA1, P. Lago2, P. Sacchi3, G. Beccagutti4, F. Borghetti4,S. Valsecchi5, R. Busca6, F. De Seta5

1Electrophysiology Unit, Cardiology Department, Policlinico S. Matteo IRCCS,Pavia, ITALY, 2Clinical Engineering Department, Policlinico San Matteo IRCCS,Pavia, ITALY, 3Centro Technology Assessment and Management, ConsorzioPavese per Studi Post Universitari nell’Area Economico Aziendale, Pavia, ITALY,4Medtronic Italia SPA, Milan, ITALY, 5Medtronic Italia SPA, Rome, ITALY,6Medtronic International Trading Sarl, Tolochenaz, SWITZERLAND

Purpose: In the last years, remote monitoring systems ofPacemaker (PM) and Implantable Cardiac Defibrillator (ICD) havebeen recommended by international guidelines and scientific asso-ciations and they help to manage the increasing number of follow-ups (FU) due to the growing implantation rate. The aim of this analysis was to evaluate the managerial impactconsidering the introduction of Medtronic Carelink NetworkService (remote monitoring system) in the Electrophysiology Unit-Cardiology Division-San Matteo Hospital.Materials and Methods: The follow-up management was ana-lyzed before and after the Carelink Service introduction. Thepatients’ satisfaction was evaluated with specific questionnaires. Results: The hospital staff includes 4 expert electrophysiologistsand 4 post-graduated physicians. Till now, about 1,500 patients arefollowed by the ambulatory staff, (50% coming from out ofRegion); 60 pts are currently in remote monitoring. Two physiciansand 1 nurse are in charge of in-office FU. For all implanted patients(with PM or ICD) the first FU visit takes place 1 month after theimplantation. Then, the FU visits (duration: 15-20 minutes) arescheduled every 8 months-1 year for PM patients, and every sixmonths for ICD patients. Carelink Network allows a remote FUevery 3 months (duration: 7-8 minutes) for each patient. Patients inremote monitoring declared an improvement in their quality of life(71% of pts) and decreased impact of the disease in their dailyactivity (86% of pts).Conclusion: Remote monitoring allows a continue patients’ check-up. A telemedicine ambulatory management will be very useful toface the increase of patients implanted with ICD or PM (and theFUs rise) with a more close fitted fulfillment to internationalguidelines about the minimum number of FU procedures.The analysis of this scenario will be the base for an optimizedremote monitoring model and it could be a key example for otherItalian hospitals.

IMPLANTABLE CARDIAC DEFIBRILLATOR PATIENTREMOTE MONITORING FOLLOW-UP ECONOMIC ANDMANAGERIAL EVALUATIONG. MOLON1, G. Vergara2, F. Zanon3, P. Delise4, C. Perrone5, A. Proclemer6,M. Bertaglia7, F. Borghetti8, J. Comisso8, G. Zanotto9

1General Hospital, Negrar, ITALY, 2General Hospital, Rovereto, ITALY, 3GeneralHospital, Rovigo, ITALY, 4General Hospital, Conegliano, ITALY, 5GeneralHospital, Arzignano, ITALY, 6General Hospital, Udine, ITALY, 7General Hospital,Mirano, ITALY, 8Medtronic, Rome, ITALY, 9General Hospital, Legnago, ITALY

Background: The prevalence of Implantable Cardiac Defibrillator(ICD) patients is constantly raising caused by the progressivelyageing trend populations, the associated increase in age-relatedhealth Conditions and an expansion in indications for implantabledevices. The technology evolution allows a follow-up of technicalissues of the devices and of the main clinical parameters. Aim: to evaluate the ICD patient management after the introduc-tion of remote monitoring Follow up (Carelink Network) com-pared with the traditional follow-up.

Methods: 976 patients in 13 Italian Centers were included, with amean follow up of 2.2 years. The ambulatory visits, the timepassed for the in-office follow-ups and for remote follow-ups wereobserved. For each ambulatory follow-up, the value of € 67,77 hasbeen assigned, according to the National ambulatory tariffs andadding the cost of the hospital staff for the visit. The same scenariohas been analyzed with the hypothesis of the remote monitoringintroduction. Results: Considering the traditional management, the averageambulatory visits number observed was of 4.5 visits-patient-years(a total of 7,300 follow-ups for all the patients, during 2.2 years).Computing a mean duration of 20 minutes for each visit, the totalengagement for the hospital staff was of 304 working days.The cost from the point of view of National Health Service was of€ 213 per patient. With the remote monitoring introduction,according to the recent European guidelines (mean time for a fol-low-up = 6 minutes), the hospital staff would spend 77 workingdays for the same n° of patients and follow-ups. Conclusions: The traditional patient management causes a hugeburden for the National Health Care. According to theInternational guidelines, the introduction of remote monitoringfollow-up allows to increase the clinical information and to opti-mize the time of patients, caregivers and hospital staff, improvingthe efficacy.

RATIONALE OF IMPLANTABLE CARDIAC DEFIBRILLATORSPATIENTS REMOTE MONITORINGA. PROCLEMER1, G. Zanotto2, L. Tomasi3, M. Brieda4, L. Leoni5,R. Mantovan6, R. Verlato7, J. Comisso8, F. Borghetti8, G. Vergara9

1Azienda Ospedaliero - Universitaria, Udine, ITALY, 2General Hospital,Legnago, ITALY, 3Hospital Borgo Trento, Verona, ITALY, 4General Hospital,Pordenone, ITALY, 5General Hospital, Padua, ITALY, 6General Hospital, Treviso,ITALY, 7General Hospital, Camposampiero, ITALY, 8Medtronic Italia, Rome,ITALY, 9General Hospital, Rovereto, ITALY

Background: One of the main clinical events during the life of apatient with an implantable cardioverter defibrillator (ICD) is ashock episode (appropriated or not appropriated shock). The closerelation between shocks, mortality and hospitalizations has beenrecently detected and showed. Anyway, no national or internatio-nal guidelines exist about which check-ups for patients and devi-ces are necessary after a shock episode. The remote monitoringcould be very useful for an improvement of the current scenario. Objective: to retrospectively evaluate the management aspect ofthe ICD patients, in particular after a shock episode, by analyzingthe different hospital scenarios in three regions of ITALY and todescribe the patient management changes after the introduction ofthe remote monitoring (Carelink Network).Methods: the project has been divided into two phases. Firstphase: retrospective evaluation of the ICD patient traditionalmanagement, including the number of ambulatory visits, the timeinterval between the arrhythmic episode and the next in-officevisit, the clinical consequences of the arrhythmic episodes. Secondphase: prospective evaluation of the management of ICD patientsafter the remote monitoring introduction. Results: During the first phase 976 patients in 13 Italian centerswere included (mean FU = 2.2 years); 503 shock episodes weredetected in 153 patients. The mean interval time passed between ashock episode and the next in-office/emergency department visitwas in a range of 0 - 4 days, with a median value of 1 day. Payingattention to the hospitalizations and the scheduled and not sche-duled visits, each ICD patient was visited 4.5 times a year (total of8,100 follow-ups). Conclusions: The data obtained by the observation of ICD patientambulatory management, mainly after an arrhythmic episode, willbe the solid base for a comparison with the ICD patients followedwith remote technology.

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FOLLOW UP OF PATIENTS WITH PACE-MAKER AND ICD:ROLE OF CARE-LINK REMOTE MONITORINGC. AMELLONE1, M. Giuggia1, G. Trapani1, B. Giordano1, G. Cirillo1,L. Tognazzolo1, B. Indino2, G. Senatore1

1Cardiologia, Cirie’, ITALY, 2Medtronic, ITALY

Patients with PM and AICD require careful follow up.Introduction of devices with possibility of remote control could beuseful in the management. We performed an evaluation of actabi-lity of remote control.Methods: 83 patients implanted with Medtronic devices (23 pts.with biv AICD Consulta CRT-D, 24 patients with AICD Secura DR,22 PM EnRhythm and 14 PM Adapta DR) obtained CareLinkdomestic monitoring system. Each AICD was programmed fortransmission every 3 m. and each PM every 6 m. New transmis-sions, programmed or for CareAlerts, was reviewed by a nurseand submitted to cardiologist attention. If datas were complete wesend to pt. copy of the transmission with clinician notes. In case ofunsatisfactory datas pt. was programmed for in office control.Results: Pts. with AICD are followed with a mean follow up of 10months (1- 15 m.) with 134 transmissions. Of those, 19 (in nine pts)were not programmed, 9 for atrial fibrillation or other arrhtmyasand 10 for Optivol CareAlert. In 4 pts. automatic threshold was notavailable and 2 more had unsatisfactory results. Those pts. had inoffice control. 32 pt. with regular remote follow up were not sub-mitted to in office visit. Pts with PM (36), have mean follow up of9.5 months (1-14) with total 84 routine transmissions. Pts. withAdapta DR (14), with automatic threshold, did not need in officecontrol. Pts. with Enrhythmy were submitted to annual ambulato-rial control for threshold measure; datas obtained with remotecontrol were useful for rhythm surveillance leading to changes intherapy.Conclusions: remote control is feasible and safe and allows a rapidand precise patient management. Arrhythmic episodes have beendiagnosed immediately, thus leading to accurate changes in thera-py when indicated. All pts. declared to be satisfied with this kindof control.

REMOTE MONITORING OF CARDIAC DEVICE PATIENTS:OUR EXPERIENCEV. SCHIRRIPA, A. Politano, M. Sgueglia, G. Panattoni, V. Romano,D.G. Della Rocca, A. Topa, L. Santini, G.B. Forleo, G. Magliano,L. Papavasileiou, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Purpose: Remote monitoring of implantable cardioverter defibril-lators (ICDs) allows continuous follow up of patients and earlydetection of adverse events. We describe our experience with theremote monitoring. Methods: From July 2008 to September 2010, 93 patients were pro-spectively enrolled in remote monitoring (38 Medtronic CareLink®

Network, 30 Merlin@home transmitter by St Jude Medical®, 14LATITUDE® Patient Management system by Boston Scientific, 11BIOTRONIK Home Monitoring®). Total number of transmissions,arrhythmic events (VT/VF, AT/AT) and fluid retention were eva-luated. All patients with events were recalled for an inclinic visitResults: Mean age of our population was 64,1±5; 86,8% of patientswere males. Wireless technology was available in 81 devices (87%).The network received 1060 transmissions (11,4/patient).We received 966 events-free transmissions and 94 transmissionswith events.

Events detected were: 23 shocks (VT/VF) and 105 anti-tachycardiapacing (ATP), all appropriate according to the recorded electro-grams. No inappropriate device intervention was detected.5 patients were recalled for possible lead malfunction, as reportedby networks: in all cases, leads during in clinic visits showed nor-mal thresholds and appropriate sensing. One patient had a SprintFidelis lead rupture that was not reported because the patient wasaway for the weekend without the remote monitoring system. In 2pts AF burden was greater than 20 hours/day, leading to recallpatients for in clinic visit. Fluid overload was detected in 10patients, in 5 of them adjustment of therapy was required. Conclusion: Remote monitoring is an effective and time-sparingtool. Nevertheless, patients’ collaboration is important, in order toreceive periodic transmissions and avoid adverse events due tolead failure.

NEW ONSET OF ATRIAL ARRHYTHMIAS DETECTEDTHROUGH REMOTE MONITORING IN PATIENTS TREATEDWITH CARDIAC RESYNCHRONIZATION THERAPYS. IACOPINO1, G. Colangelo1, V. Aspromonte1, I. Lo Cane1, G. Fabiano1,A. Talerico1, S. Pellicano2, D. Roccaro3, M. Davinelli3

1Electrophysiology Unit, S. Anna Hospital, Catanzaro, ITALY, 2University ofMessina, Messina, ITALY, 3Medtronic Italia, Milan, ITALY

Background: AF and AT are major causes of morbidity and morta-lity in heart failure (HF) patients treated with CRT. However, therisk of new AF/AT onset in implanted patients is not well known.New tools allow to continuously follow-up implanted patientsthrough a remote monitoring system, which alerts physicians incase of AF/AT.Objective: This study was aimed at assessing the incidence ofatrial fibrillation/atrial tachycardia (AF/AT) new onset in patientsimplanted with a cardiac resynchronization therapy (CRT) device,managed using the Medtronic CareLink® Network remote monito-ring system.Methods: CRT patients without previous documented atrialarrhythmias were enrolled. Medtronic Carelink® wireless remotemonitoring system was given to patients. This tool transmits devi-ce data to implanting physicians if a pre-defined burden of AF/ATis reached. AF/AT-related transmissions over a 12-month periodwere collected and reviewed.Results: 104 patients (78% males, 95% in III New York HeartAssociation Class, 50% with HF of ischemic etiology) were enrol-led. After 12 months, 121 automatic transmissions due to AF/ATwere reported in 33 (32%) patients. Average number of transmis-sions per patient was 8±6. In 8 (25%) patients reported atrial arrhy-thmias were asymptomatic. AF/AT was treated in 9 (9%) patientsand 7 inappropriate device interventions due to high-responseAF/AT were documented in 4 (4%) patients.Conclusions: New onset of AF/AT appears in about one third ofpatients treated with CRT.The wireless-based Medtronic Carelink® Network system allowsearly detection of AF/AT and timely intervention to ensure effec-tive resynchronization therapy and appropriate treatment of thearrhythmia.

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MORBIDITY IN LONG TERM FOLLOW UP OF ICDIMPLANTED FOR PRIMARY PREVENTION OFSUDDEN CARDIAC DEATHW. RAUHE, L. Bertagnolli, F. Clari, I. Endrizzi, M. Manfrin, F. Pescoller,E. Raytcheva, M. Tomaino, W. Pitscheider

Ospedale di Bolzano - Department of Cardiology, Bolzano, ITALY

Purpose: Aim of this single centre study was to evaluate morbidi-ty in long term follow up (FU) of patients with ICD implanted forprimary prevention of sudden cardiac death (SD). Materials and Methods: The study population included 133patients. Implanted devices were: single-chamber ICD in 66% ofpatients, dual-chamber ICD in 14% and an ICD with cardiac resyn-chronization therapy in 20% of cases. Results: No complication occurred during implantation. In thelong term FU of 35,7 months the following complications wereseen: inappropriate shock deliveries in 23 patients (17%), leadrelated complications in 14 patients (10,5%), pocket infections thatrequired removal of the whole system in 3 patients (2,25%).Inappropriate ICD interventions have been mainly caused by atri-al tachyarrhythmias (15 out of 23 patients = 65%). Other reasonsfor non-motivated discharges have been the following: sinustachycardias (2 patients), T-wave oversensing (2 cases), externalelectromagnetic interference (2 patients), lead dislodgment (2patients) and lead fracture (1 patient). Lead related complicationsconsisted mainly of lead dislocations (9 patients), lead fractures (3patients) and exit blocks (2 patients). All the cases of lead relatedcomplications required a surgical re-intervention. A significanthigher incidence of surgical revision has been observed in patientswith biventricular devices (19% of cases versus 7,5% of cases inpatients with single- and dual- chamber ICDs). Conclusions: ICD implantations remain associated with an impor-tant morbidity. The incidence of lead related complications is sig-nificantly higher in patients with biventricular resynchronizationdevices. Whereas inappropriate ICD interventions can be man-aged in most cases noninvasively, lead related complicationsrequire surgical re-interventions. Given the higher risk for deviceinfection of repeated surgical procedures these observations needto be taken in consideration when selecting patients for ICDimplantation in the setting of primary prevention of SD, particu-larly when more sophisticated devices are considered.

ELECTRICAL STORM IN BRUGADA SYNDROME:EFFICACY OF ORAL HYDROQUINIDINE TREATMENTL. SCIARRA1, G. Allocca2, M. Rebecchi1, E. Marras2, L. De Luca1, L. Zuccaro1,M. Marziali1, E. De Ruvo1, E. Lioy1, L. Corò2, P. Delise2, L. Calò1

1Department of Cardiology, Policlinico Casilino, Rome, ITALY, 2Departmentof Cardiology, Hospital of Conegliano, Conegliano, ITALY

Background: Electrical storm is a relatively rare phenomenon thatcan complicate the clinical course of pts with Brugada syndrome(BS). Pharmacological treatment of such a malignant event may bechallenging. Methods: Our study cohort consisted of 166 consecutive pts withBS (44 symptomatic and 122 asymptomatic). 87 (52%) of them hada spontaneous type 1 ecg pattern while 79 (48%) developed a type1 ecg pattern after flecainide administration. In pts 107 (64%) weperformed also EPS. In all patients the presence of the followingrisk factors was evaluated: familial history of sudden death (SD),syncope and positive EPS. Aim of our study was to investigate onthe potential role of oral hydroquinidine in the treatment of ptswith BS and ES.Results: Among a population of BS pts, 41 pts (mean age 45±13years; 130 males) were selected for implantable ICD implantation.In the follow-up of 30±24 months, 5 pts (mean age±years; 4 males)who were implanted with an ICD experienced an electrical storm.In four of those pts, diagnosis of BS was made on the basis of a

spontaneous type 1 ECG, while in one patient, a type 1 ECG wasevident after flecainide infusion. Three of those 4 pts had beensymptomatic for syncope before ICD implantation. All the ptsexperienced multiple appropriate shocks for sustained VF andwere admitted to coronary care unit. All the pts with BS and ESwere treated with oral hydroquinidine at a dosage of 250 mg b.i.d.No relapse of sustained VT/VF and no ICD shocks were recorded,both in an acute phase and in a 8±3 months.Conclusions: ES in our experience occurred in 12% of patientswith BS and ICD implantation; oral hydroquinidine seems to be asafe and effective treatment in patients with BS and ES.

SAFETY AND EFFICACY OF MAGNETIC RESONANCEIMAGING (MRI) IN PM/ICD PATIENTSP. LUPO1, G. De Ambroggi1, S. Foresti1, H. Ali1, M. Pittalis1, E. Bianco1,T. Infusino1, F. Secchi2, F. Sardanelli2, R. Cappato1

1Arrhythmias and Electrophysiology Center, IRCCS Policlinico San Donato,University of Milan, Milan, ITALY, 2Department of Radiology, IRCCS PoliclinicoSan Donato, University of Milan, Milan, ITALY

Purpose: Implanted pacemakers (PMs) and defibrillators(Implantable Cardioverter Defibrillators, ICDs) have been regar-ded as an absolute contraindication to MRI for a long time.Nevertheless, previous studies suggested the feasibility and safetyof MR imaging at 1.5 Tesla (T) in PM patients. Our aim was to inve-stigate safety and efficacy of MRI in pts with intracardiac devices(PM and ICD).Methods: After IRB approval and informed consent, 105 patientspreviously implanted with PM/ICD (45 PMs, 60 ICDs) and strongindication to MR examinations were included (20 brain, 20 spine,54 heart, 3 breast, 6 abdomen, 2 knee). We excluded PM-dependantpatients and those implanted before 2000. Before MR, we collectedbattery and lead parameters and disabled all the therapies (ATPand shocks). The MR examinations were performed at 1.5 T(Sonata, Siemens, Germany) with commonly used parameters.After MR all devices were checked again and late follow-up per-formed. Myocardial necrosis markers sampled immediately befo-re and 4 h after MR (in-patients, n=33).Results: During the MR examinations we did not observe any rele-vant clinical modification. After MR the PM/ICD interrogationshowed neither significant modifications nor alert warnings. In the33 in-patients, no significant increase of myocardial necrosis mar-kers was observed after MR. The MRI was fully diagnostic in themost patients. During the follow-up (1-12 months) the patientsresulted free of any symptom which could be related to a pacema-ker dysfunction and the PM/ICD parameters did not change. Conclusions: Our results show that, under carefully controlledconditions and with an appropriate selection of candidates,patients with implanted devices of last or next to last generationcan be safely and efficaciously studied with MR imaging.Moreover they can help to understand the technical tools (MR pro-tocols and PM/ICD programmation) to avoid clinical and devicecomplications.

THE POTENTIAL OF RISK OF MISDETECTION ORDELAYED DETECTION OF ADVERSE EVENTS WITHOUTA DAILY REMOTE CONTROL SYSTEM IN PATIENTSWITH CARDIAC RESYNCHRONIZATION THERAPY ICDE. DE RUVO1, E. Pisanò2, R. Quaglione3, L. Sciarra1, L. De Luca1, L. Iannucci3,L.M. Zuccaro1, M. Rebecchi1, A. Sette1, A. Fagagnini1, M. Minati1,S. Matera1, F. Guarracini1, F. Magliari2, E. Lioy1, A. Gargaro4, L. Calò1

1Policlinico Casilino, Rome, ITALY, 2Vito Fazzi Hospital, Lecce, ITALY, 3PoliclinicoUniversitario Umberto I, Rome, ITALY, 4Biotronik Italia S.p.A., Vimodrone, ITALY

Purpose: A high rate of clinical and device-related adverse events(AE) are reported in patients with cardiac resynchronization thera-IC

D OUTCOM

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py (CRT) ICD. A standard follow-up program based on 3-monthvisits may be associated to an increased risk of AE misdetection ordelayed detection, in absence of a remote control system.Methods: We analysed HM database and hospital files of 122 CRT-ICD patients: 94 male (77%), age 69±10, 59 ischemic, 63 non-ische-mic dilated cardiomyopathies, ejection fraction 26%±6%, NYHAclass range 2-4, primary prevention ICD indication in 122. All thepatients were visited in hospital quarterly; fifty six patients wereadditionally controlled remotely with the Biotronik HomeMonitoring (HM). Mean follow-up duration was 15±9 months(range 1-38). AEs were classified as clinical or device-related:Kaplan-Meier curves of AE free rates were obtained. Results: Clinical AEs were: ventricular and atrial arrhythmias in19 and 16 patients respectively, low CRT pacing in 6, heart failureor death in 20. Device-related AEs were: insufficient pacing/sen-sing performances in 17 patients, lead dislodgement in 9. As com-paring the HM-controlled group with the remaining patients,Kaplan-Meier curves of clinical AE free rates significantly diver-ged in the considered follow-up period: 21.4% (95%CI 2.1%-42.8%)in the HM group and 64.8% (51.3%-78,5%) in the remainingpatients (p=0.03), with an hazard ratio (no-HM vs. HM group) of0.41 (95%CI 0.23-0.75). On the other hand, a trend toward diver-gent Kaplan-Meier curves was observed for device-related AE freerates: 40.4% (12.4%-68.5%) for the HM group; 83.2% (73.5%-92.8%)for the remaining patients (p=0.19), with a non-significant hazardratio 0.48 (0.22-1.03).Conclusions: CRT-ICD patients not remotely controlled with adaily HM system had a 59% higher risk of misdetection or delayeddetection of clinical AEs within a mean follow-up period of 15months, despite a follow-up program of quarterly in-hospitalvisits. Also device-related AEs tended to be detected earlier.

HOMEGUIDE REGISTRY: MAY GAME THEORY BE AUSEFUL TOOL TO QUANTIFY CLINICAL EFFICACY OFREMOTE MONITORING PATIENT MANAGEMENTWITH THE EXPECTED UTILITY CONCEPT?G. ZANOTTO1, G. Buja2, L. Calò3, A. Campana4, R. Quaglione5, G. Gasparini6,V. Lettica7, C. D’Ascia8, L. Santini9, N. Rovai10, A. Gargaro10, R.P. Ricci11

1Mater Salutis Hospital, Legnago, ITALY, 2University Policlinic, Padua, ITALY,3Casilino Policlinic, Rome, ITALY, 4S. Giovanni di Dio e Ruggi D’AragonaHospital, Salerno, ITALY, 5Umberto I Policlinic, Rome, ITALY, 6Umberto IHospital, Mestre, ITALY, 7Guzzardi Hospital, Vittoria, ITALY, 8Federico II Hospital,Naples, ITALY, 9Policlinico Tor Vergata, Rome, ITALY, 10Biotronik Italia, ITALY11San Filippo Neri, Rome, Vimodrone, ITALY

Background: Sensitivity is a basic concept for diagnostic procedu-re assessment estimating the conditional probability of detectingan event when it really occurs. There are circumstances when sen-sitivity is not completely meaningful for reliability assessment.The HomeGuide Registry is an ongoing survey collecting datafrom relevant clinical events occurring in a cardiac-device patientpopulation controlled remotely with Biotronik Home Monitoring(HM) technology. To assess HM detection reliability we proposeda method based on the Game Theory derived concept of ExpectedUtility (GTEU).Rationale: The HomeGuide survey has collected 1053 true eventsso far from 1063 HM patients. After an independent review, HMsensitivity will be estimated. Due to the unpredictable nature ofthe collected events, the GTEU concept may be appropriate, lettingeach event present with k properties as a result of a lottery. GTEUis a function of lottery outcome payouts (ck) and the attached pro-babilities (pk): GTEU=,,∏kpkck. Although the payouts may bearbitrary set, GTEU is unique up to a positive linear transforma-tion whenever the von Neumann-Morgenstern conditions hold.We selected k=4 properties: whether or not (1) an event could bedocumented by HM, (2) the initial diagnosis was correct; (3) sym-ptoms were associated; (4) corrective actions were taken. Payouts(ck) were functions of a-priori binomial probability of these pro-

perties: 1/16 for no properties, 4/16 for 1 property, 6/16 for 2,12/16 for 3, 15/16 for 4; pk will be estimated by the frequenciesobserved in our event collection. For example, if 90% of HM-detec-ted events occur with 4 properties, and 10% have 3 but are associa-ted to symptoms, sensitivity will results in 100%, while GTEUmore realistically will give 77%, accounting for a minor utility ofremotely controlling symptomatic events.Conclusions: GTEU may be associated to sensitivity to betterassess event detection reliability of a remote monitoring system.

THE ITALIAN HOMEGUIDE REGISTRY IN THE REMOTEMONITORING PRACTICE: ENROLMENT RATE ANDPATIENT CHARACTERISTICSA. D’ONOFRIO1, L. Calò2, L. Morichelli3, G. Buja4, T. Toselli5, I. Caico6,L. Pavia7, F. Caravati8, V. Calzolari9, G. Lolli10, N. Rovai11, D. Vaccari12

1Monaldi Hospital, Naples, ITALY, 2Casilino Policlinic, Rome, ITALY, 3San FilippoNeri Hospital, Rome, ITALY, 4University Policlinic, Padua, ITALY, 5S. AnnaHospital, Ferrara, ITALY, 6Macchi Hospital, Varese, ITALY, 7Piemonte Hospital,Messina, ITALY, 8Di Circolo Hospital, Varese, ITALY, 9Civil Hospital, Treviso,ITALY, 10Santa Maria Nuova Hospital, Reggio Emilia, ITALY, 11Biotronik Italia,Vimodrone, ITALY, 12Civil Hospital, Montebelluna, Reggio Emilia, ITALY

Background: The HomeGuide Registry is an ongoing survey col-lecting data from 65 Italian centres implementing remote monito-ring (with the Biotronik Home Monitoring [HM] technology)during normal clinical management of patients with cardiacimplanted devices: pacemakers (PM), implantable defibrillators(ICD), with/-out cardiac resynchronization therapy (CRT). A spe-cific ambulatory organization model for HM implementation wasadopted with the aim of estimating the model manpower and itsclinical efficiency in terms of sensitivity, positive predictive valueand expected utility of clinical and device-related event detectionand management.Methods and Results: The HomeGuide survey started in March2008 and it is still ongoing with 1063 patients enrolled up to date(mean follow-up is 16.1,,b9.1 months): 278 PMs (26%, 19 withCRT), 267 single (25%) and 246 (23%) dual-chamber ICDs, 272(25%) ICD-CRT. The overall mean enrolment rate is 33.9 per month(40.2 in the last six months). The expected sample size within thenext six months is 1304 and the current estimation of enrolmentclosure is at the level of 1500 patients. There are 255 (24%) womenin the survey, overall mean age 70,,b11; in the PM group, 82% arein NYHA class I or II, in the ICD group, 80% in Class II to III, in theCRT group, 35% in Class II, 64% in Class III-IV. Dilatative andischemic cardiomyopathies are respectively present in 10% and20% of PM patients, 58% and 55% of ICD patients, 76% and 47% inCRT patients. For PM patients implant indication was Sick SinusSyndrome in 43% and atrio-ventricular blacks in 35%, for the ICDgroup indication for primary prevention was in 69%.Conclusions: The sampled population of the HomeGuide Registryresembles the “real-world®” characteristics of patients receivingcardiac devices and will provide reliable estimates of manpowerand clinical efficiency of HM patient management.

ICD OUTCOM

E AND REMOTE CONTROL

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ALERT MESSAGES MANAGEMENT IN THE REMOTEMONITORING OF ICD AND PACEMAKERA. FOLINO1, F. Chiusso2, E. Marras3, R. Mantovan4, D. Vaccari5, G. Boscolo6,A. Vaglio7, G. Gasparini8, G. Zanotto9, A. Megna10, S. Iliceto1, G. Buja1

1Department of Cardiologic, Thoracic and Vascular Sciences, University ofPadua, Padua, ITALY, 2Biotronik Italia, Milan, ITALY, 3Department ofCardiology, Civil Hospital, Conegliano, ITALY, 4Department of Cardiology, Ca’Foncello Hospital, Treviso, ITALY, 5Department of Cardiology, Civil Hospital,Montebelluna, ITALY, 6Department of Cardiology, Civil Hospital, Chioggia,ITALY, 7Department of Cardiology, SS. Giovanni e Paolo Hospital, Venice,ITALY, 8Department of Cardiology, Dell’Angelo Hospital, Mestre, ITALY,9Department of Cardiology, Civil Hospital, Legnago, ITALY, 10Department ofCardiology, S. Tommaso dei Battuti Hospital, Portogruaro, ITALY

Background: Remote monitoring of pacemakers and implantablecardioverter defibrillators (ICDs) allows an accurate supervisionof patient and device. Nevertheless, an accurate alerts settingseems to be a crucial item for an easy and effective use of these sys-tems. The purpose of our study was to evaluate the different con-ducts in alerts setting and alert messages management in patientswith pacemakers and ICDs.Methods: We prospectively evaluated 282 patients (mean age72±11yrs), referring to 9 electrophysiological centers of Venetoregion, ITALY, for pacemaker (76 pts) or ICD (206 pts) implant, andin which a remote monitoring was activated (Biotronik, HomeMonitoring®). The study cohort comprised 76 patients with dual-chamber pacemaker, 83 with single-chamber ICDs, 78 with dual-chamber ICDs, and 45 with ICD-CRT (Cardiac ResynchronizationTherapy). Results: During a mean follow-up of 382±261 days, 106,039 trans-missions were received. In pacemaker group, the alerts more fre-quently activated were those reporting battery exhaustion, survey-ing impedances, sensing and threshold, as well as missing trans-missions. The more frequent alerts arrived were those reportingmissing transmissions, a reduction of P wave amplitude, a pro-longed mode switch duration, and prolonged high ventricular rateepisodes. In ICD/ICD-CRT groups, the alerts almost always acti-vated were those indicating detection set off, battery exhaustion,critical values of impedance or ineffective maximum energy shock.The more frequent alert arrived were those notifying missingtransmissions, VF and VT1 episodes, and a low percentage of CRTpacing. In both groups, alerts concerning heart rate monitoringand supraventricular arrhythmia, were activate in a lower numberof cases. Conclusions: Our study showed that particular attention wasaddressed to the alert surveying critical technical data, whereasless attention has been paid to the alarms on patients’ clinical pro-file. An accurate setting of alerts, personalized on patients clinicalfeatures, seems to be an essential task for an easier and more effec-tive management of patients followed remotely.

TOTAL REMOTE FOLLOW-UP PACEMAKER CLINICM. LORD, M. Allain, M. Badra, J-F Roux, F. Ayala-Paredes

CHUS, Sherbrooke, CANADA

Background: The use of devices’ remote follow-up reduces thenumber of face to face visits. We decided to implement a comple-te remote follow-up schedule for pacemaker patients (pts)Materials and Methods: All pts receiving a Biotronik HomeMonitoring (HM) pacemaker since April 2009 were offered to befollowed only by the HM system; we then prospectively registeredthe number of messages received and we classified them in orderto ascertain if complete remote follow-up reduces the work’s loadto a pacemaker clinic.Results: 514 pacemakers were implanted from April 2009 toAugust 2010. 159 had the HM available, 45 patients refused orwere judged ineligible to be followed remotely; 4 patients wereexcluded (death or no transmissions, pts lost to f-up).

A total of 110 pts composed the cohort analyzed. Mean age of ptswas 73 y.o. and 66.5% were males. The clinical indication forimplant was: SSS in 54%; AV bloc in 34% and syncope/others in12%. Pts were followed between 1 to 47 months (mean 7.45 +/-6,72 mo). Compared to standard f-up (one visit post implant andthen twice a year) HM reduced a mean of -0.53 the number of face-to-face visits (-7 to +3 visits). HM generated 615 messages: 80%administrative, 14.3% clinically relevant without in clinic visit, and5.7% triggering a clinic visit; other 102 visits were done eitherbecause pts were symptomatic or because scheduling mistakes.Conclusion: This first experience of total remote follow up allo-wed a reduction in the number of visits to the pacemaker clinic,thus reducing the workforce load. 20% of messages generated byHM were clinically relevant and in 5.7% of cases they triggered avisit advancing diagnose and treatment of otherwise concealedconditions. The longer the follow up the greater the number ofvisits reduced.

CAN WE PREDICT AND PREVENT ADVERSE EVENTSRELATED TO HIGH-VOLTAGE IMPLANTABLECARDIOVERTER-DEFIBRILLATOR LEAD FAILURE?R.P. RICCI, C. Pignalberi, B. Magris, S. Aquilani, V. Altamura, L. Morichelli,A. Porfili, L. Quarta, F. Saputo, M. Santini

Ospedale San Filippo Neri - Dipartimento Malattie Cardiache, Rome, ITALY

Background: In 2007 a great concern raised up about long term fai-lure rates of Implantable Cardioverter Defibrillator (ICD) leadsfrom several manufacturers. In that year Medtronic Inc. recalledthe Sprint Fidelis® lead family.Objective of this analysis was to evaluate the incidence and predic-tors of Sprint Fidelis lead failure in order to find the best clinicalstrategy to prevent lead-related adverse events.Methods: Four hundred fourteen ICD patients equipped withright ventricular Sprint Fidelis lead (357 male, 67±12 years) werefollowed in our institution.Results: In a median follow-up of 35 months (25th-75th percenti-le=27-47 months) and a total follow-up of 1231 patient-years, leadsfailure occurred in 40/414 (9.7%) patients. Annual rate was 3.2% perpatient-year. Thirty-five (87.5%) failures were associated with thepace-sense connector fracture. The risk of lead fracture was higher inpatients younger than 70 years (odds ratio=2.31 (95% confidenceinterval=1.14-4.68, p=0.02). Among 30 patients with pace-sense con-ductor failure and available device diagnostics for failure alerting,the diagnostics which first responded to lead failure was pace-senseimpedance in 8/30 (26.7%) and sensing integrity counter in 19/30(63.3%). The median time (25th-75th percentile) between diagnosticsalert and lead failure adverse events or acknowledgment was 2.1(0.3-13.5) days. Continuous monitoring could have detected impen-ding failures, associated with shocks, in 47% of cases.Conclusions: Sprint Fidelis leads need careful monitoring to pre-vent failure-related adverse events. Algorithms to early detectimpending failure may be effective in near 50% of cases.Automatic remote monitoring may be of help in managing thesepatients.

INCIDENCE RATE AND PREDICTORS OF PERMANENTPACEMAKER IMPLANTATION AFTER TRANSCATHETERAORTIC VALVE IMPLANTATIONS. CONTI, E. Puzzangara, Gp. Pruiti, A. Di Grazia, C. Liotta, Gp. Ussia,C. Tamburino, V. Calvi

Cardiology Department, Ferrarotto Hospital, Catania, ITALY

Purpose: Aim of this study was to identify the incidence rate ofconduction disorders (CDs) and the predictors of early postopera-tive PPM requirement in a large series of patients undergoing tran-scatheter aortic valve implantation (TAVI). TAVI is an alternativePR

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therapy for high-risk surgery with severe symptomatic aorticvalve stenosis. CDs and permanent pacemaker (PPM) implanta-tion are common complications in patients undergoing TAVI.Materials and Methods: Data were analyzed from 129 consecuti-ve patients at high-risk surgery who underwent TAVI at our insti-tute between July 2007 and February 2010. All patients underwentimplantation of the third-generation percutaneous self-expandingCoreValve® prosthesis (CoreValve, Inc., Irvine, CA, USA). In allpatients a 12-lead electrocardiogram and a 24-hours holter moni-toring was recorded before and after the procedure in order toassess the presence of CDs. Clinical data, preoperative CDs, echo-cardiographic patterns and procedural data were tested as predic-tors of complete atrioventricular block (AVB) following TAVI.Results: Overall mortality at discharge was 4.3% (5/115). Left bun-dle branch block (LBBB) was the most common CD, with an inci-dence of 45.4% at discharge. Thirty-four (35%) patients developeda persistent complete AVB and a PPM was implanted in 33 cases.The indication of PPM implantation was strongly correlated withthe presence of preoperative right bundle branch block (RBBB)which was found to be the only independent predictor of PPMimplantation (HR 6.15, CI 2.789-13.567, p < 0.001).Conclusions: LBBB and PPM implantation requirement after TAVIare common occurrences. In this large series of consecutivepatients only RBBB was found to be a strong predictor of PPMrequirement.

WENCKEBACH POINT PREDICTS VENTRICULAR PACINGPERCENTAGE SO STABLE AV CONDUCTION INPATIENTS WITH SICK SINUS SYNDROME AND DUALCHAMBER PACEMAKERSF. ROCOMA, M. Badra, J-F Roux, F. Ayala-Paredes

CHUS, Sherbrooke, CANADA

Background: In patients (pts) with sick sinus syndrome (SSS),atrial pacing (AAI) provides physiological and less costly pacingthan dual chamber systems (DDD). The incidence of high gradeAV block varies between 0.6 and 3%.Methods and Results: Retrospective study, with Wenckebachpoint (WP) measured once or twice yearly;% V-Pace was recordedfrom devices, in pts with SSS and a DDD pacemaker installed bet-ween 2003 and 2007. Each pts had at least 3 WP measurements,including if available the one at implant.Each pts was optimized to prevent unnecessary V-pace with meanmanual PAV-SAV of 230 30 msec (to have AS or AP and VS atEGMs at rest) and with AV hysteresis activated when available.261 pts were included; mean age of 75.3 years (11.3 years), 60%were males. Maximum f-up was 84 months (mean f-up 40months). Pts with WP >120bpm, had a mean% V-Pace of 9%, whilepts with WP <120bpm had a mean% V-Pace of 48% (p<0,001).Mean age for pts with WP < 120 bpm was 79,7 years versus 73,5years in pts with WP > 120bpm (p<0,001). The mean WP and themean% V-Pace of this pts did not change significatevely during f-up. A mean decrease in WP of 27bpm was associated with a meanincrease of the% V-Pace of only 2%. There were no significant dif-ferences in WP measured at implant (mild sedation) and f-up WPmeasurements.Conclusion: The Wenckebach point is a good predictor of% V-Pacedelivered in SSS pts; it could determine the type of pacemaker toinstall (AAI vs DDD) at implant, as a value > 120 bpm measuredat implant could be safe enough to chose a single atrial chamberdevice as VP is seldom nedeed.

STRAIGHT SCREW-IN ATRIAL LEADS “J POST-SHAPED”IN RIGHT APPENDAGE VS. J-SHAPED SYSTEMS FORPERMANENT ATRIAL PACING: A SAFETY COMPARISONF. ZOPPO, G. Brandolino, F. Zerbo, E. Bacchiega, A. Lupo, E. Bertaglia

Dipartimento di Cardiologia Mirano, Mirano,Venice, ITALY

Background and objectives: The reliability of active-fixation atrialleads have been compared with passive-fixation and betweenstraight and J-shaped screw-in lead systems. Few data are availa-ble on procedural and short-term safety. This retrospective studycompared the procedural safety of non-pre-shaped screw-in leadswith those of passive and active fixation J-shaped leads.Patients and Methods: From January 2004 to January 2010, 1464patients underwent to a new PM/ICD implantation. Of these, 915(study population) received a passive or active fixation pre-J-sha-ped or a straight screw-in atrial lead; the remaining 549 patients,receiving only a ventricular lead, were excluded. The 3 studygroups were: Group S-FIX (165 patients, 18%) receiving a straightscrew-in atrial lead (post-shaped in right appendage); Group J-PASS (690 patients, 75.4%) receiving a passive-fixation J-shapedatrial lead and Group J-FIX (60 patients, 6.6%), receiving an activefixation screw-in J-shaped atrial lead.Procedural and short-term complication rates were analyzed up to3 months post-implantation. Results: One complication occurred in each group (S-FIX 0.6% vsJ-PASS 0.1% vs J-FIX 1.6%, p=0.3, 0.1 and 0.4 respectively for eachrates comparison). The rate of atrial lead dislodgement was higherin Group J-PASS patients compared with S-FIX but not with J-FIX(group S-FIX 0 vs group J-PASS 16 vs group J-FIX 1 dislodgements;p=0.04 and 0.7 respectively).Conclusion: Straight screw-in atrial leads, “J post-shaped” in theright appendage, offer a better stability compared with the passi-ve J shaped fixation and displayed a similar acceptable safety pro-file compared with both the J-shaped systems.

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RISK STRATIFICATION IN ISCHEMIC CARDIOMYOPATHYAND MILD DEPRESSED VENTRICULAR FUNCTION.PREVALENCE OF FQRS AND NON-NEGATIVE MTWAC. COMMISSO1, G. Pendenza2, M. Porfirio2, F. Guarracini2, L. Sciarra1,L. De Luca1, E. E. de Ruvo1, F. Nuccio1, A. Sette1, L.M. Zuccaro1,M. Rebecchi1, M. Minati1, A. Fagagnini1, S. Matera1, E. Lioy1, L. Calo’1

1Policlinico Casilino, ASL RMB, Division of Cardiology, Rome, ITALY,2University of L’Aquila, Cardiology, L’Aquila, ITALY

Purpose: Risk stratification of sudden cardiac death (SCD) inpatients with ischemic cardiomyopathy with ejection fraction (EF)>35% is difficult. Microvolt T-wave alternans (MTWA) and frag-mented QRS (FQRS) measure different elements of the arrythmo-genic substrate and, therefore, it has been suggested their potentialrole as predictor of SCD. Materials and Methods: We enrolled form January to July 2010, 50consecutive patients (86% men) 90 days after myocardial infarc-tion, with left ventricular eject fraction (LVEF) >35%. All patientsunderwent an electrocardiogram (ECG) with 40 Hz and 100 Hz fil-ter to assess FQRS, MTWA, ECG Holter (with HRT, TW variabili-ty and HRV study) and cardiac MRI. In case of positive findings(i.e. positive TWA, presence of FQRS, etc.) the patients underwentEP study.Results: Eighteen patients (35%) showed FQRS. MTWA was nega-tive in 23 patients (46%), positive in 7 patients (14%) and indeter-minate in 20 patients (40%). Therefore, non-negative MTWA wasfound in 27 patients (54%). Three patients had non-sustained ven-tricular tachycardia (NSVT) at ECG-Holter. These three patientshad MTWA non-negative and two FQRS. Of the 18 patients withthe presence of FQRS 9 patients (50%) had non-negative TWA.Conclusion: This study found in about 1/3 of patients the pres-ence of FQRS and in about half of patients non-negative MTWA.Nine (18%) of 50 patients showed both FQRS and non-negativeTWA. Long term follow-up is necessary to validate the role of thisnon invasive tests to predict the presence of the arrythmogenicsubstrate and the risk of sudden death.

B-TYPE NATRIURETIC PEPTIDE AS AN INDIPENDENTFACTOR OF SUDDEN CARDIAC DEATH ANDAPPROPRIATE ICD THERAPY IN ICD RECIPIENTSL. DURO, R. Cioè, L. Santini, G.B. Forleo, G. Magliano, L. Papavasileiou,M. Sgueglia, V. Romano, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Background: Ventricular arrhythmia is the main cause of suddencardiac death (SCD) in patient with cardiac disease. Myocardialstrain and its remodeling are involved in malignant arrhythmiapathogenesis and secretion of B-type natriuretic peptide (BNP)from myocardiocities. Aim of this study is to identify the value ofplasmatic BNP as a predictive factor of death and appropriate ICDtherapies.Methods and Results: 42 consecutive patients, receiving ICD forprimary or secondary prevention of SCD, were enrolled. Using themedian plasmatic BNP value of 383 pg/ml, obtained by pre-implanting plasmatic BNP dosages, patients were divided in 2groups, that had same baseline and clinical parameters. The medi-um follow up has been 12.2 3,4 months. In the group with plasmat-ic BNP levels under 383 pg/ml (22/42 patients, 52%; age: 64.811;EF: 24.88%), 2 patients (9%) received appropriate ICD therapy (1fast VT treated by appropriate shock; 1 VT treated by ATP). In thisgroup mortality was 0%. In the group with plasmatic BNP levelsover 383 pg/ml, (20/42 patients, 48%; age: 67.311;EF: 230,5%), 2patients (10%) received appropriate ICD therapy (1 fast VT and 1VF treated by shocks). In this group mortality was 20% (5patients).The combinate endpoint (death plus ICD therapy) wasrecorded in 7 patients (35%). Kaplan Maier curve analysis showsthat the group with plasmatic BNP levels over 383 pg/ml is char-

acterized by a significantly higher mortality (p=0,003). Two groupsdid not show significant difference in terms of malignant ventric-ular arrhythmias (FVT and VF) requiring appropriate ICD therapy(p = 0,89). Conclusion: The study shows a significant correlation betweenelevated plasmatic BNP levels and higher risk for appropriate ICDtherapy and SCD. So, a single dosage of plasmatic BNP before ICDimplantation could be a useful parameter to stratify the risk ofSCD and appropriate ICD therapy.

DIABETES MELLITUS AND RISK OF ARRHYTHMIAIN PATIENTS WITH IMPLANTABLE CARDIOVERTERDEFIBRILLATORSD.G. DELLA ROCCA, L.P. Papavasileiou, G. Panattoni, G.B. Forleo, L.Santini, G. Magliano, A. Giomi, A. Topa, C. Ticchi, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Introduction: Diabetes mellitus is one of the most important riskfactor for cardiovascular diseases, but we have few data about theinfluence of high glycemic levels on the development of arrhy-thmia events. The aim of the study was to evaluate the importan-ce of diabetes on outcomes of patients implanted with implantablecardioverter defibrillators (ICDs).Materials and Methods: We investigated 356 consecutive patients(84.3% males, mean age 66.9±11.3 years) who underwent ICDimplantation in secondary and primary prevention at our Istitution.Patients were divided into two groups based on the presence (DMgroup, n=103) or absence (no DM group, n=253) of diabetes in themedical history. Patients were followed at 1, 3 and 6 months postimplantation and successively every 6 months. We considered theincidence of appropriate therapy and overall mortality. Results: No statistically significant differences were found at thebaseline. During a mean follow-up of 20.8±17.4 months, in DMgroup 17 patients (16,5%) experienced an appropriate discharge(time to 11.0±8.6 months, range 1.4 - 30.8 months) vs 54 patients(21,3%) in no-DM group (p=0.4) (time to 15.6±15.2 months, range0.0 - 60.9 months, p=0.3). In DM group 19 patients (18,4%) died vs33 patients (13,04%) in no DM group (p=0.26).Conclusion: Diabete mellitus does not identify patients with ahigher risk of arrhythmia, even if it is importance to have in thesepatients a metabolic control to avoid a worsening of their clinicalstatus.

TREATMENT OF LEFT VENTRICULAR DYSFUNCTIONWITH PROLONGED QT IN OBESE PATIENTSWITH DIABETES TYPE IIN. SINISCALCHI1, T. Cerciello1, F. Oliviero1, L.I. Siniscalchi1, L. Misso1

1Dipartimento di Gerontologia, Geriatria e Malattie del Metabolismo IIUniversità di Napoli., NAPOLI, ITALY, 2Ospedale Civile di Sarno, SARNO (SA),ITALY

Obese patients (Ps) with diabetes II frequently exhibit asymptoma-tic left ventricular dysfunction (LVD) and impaired exercise tole-rance, even when not suffering from hypertension. In those Ps aprolonged QT interval may be considered as indicator of risk andpossible target for prevention of arrhythmic death. Intracellularcalcium overload is thought to play a central role in heart failure.Therefore, the aim of this study was to identify high risk obese dia-betic Ps and show whether Valsartan plus Ranolazine reduce thelength of QT intervals and improve LVD.18 obese diabetic women,mean age 59±5 years, with Doppler- Echocardiographic evidenceof diastolic LVD and prolonged QT intervals were studied by anopen study with parallel randomized group design. After twoweek single-blind run-in period of placebo treatment, Ps were ran-domly allocated to either Valsartan 20 mg/die plus Ranolazine1000 mg/die or placebo, and followed up for 12 weeks. All Ps wereSU

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investigated at the beginning of the study and at 4, 8 and 12 weeksof randomization with blood samples for hematology, urea, elec-trolytes, creatinine and with a 12-lead E.C.G. QT intervals werecorrected with Bazett’s formula and QT dispersion was calculated.Chest X-ray and Doppler - 2Dimensional Echocardiography wereperformed at the start and at the end of the study. Exercise capaci-ty was assessed using bicycle ergometer during the run-in periodand after 6 and after 12 weeks of treatment. 16 Ps completed thestudy. Valsartan plus Ranolazine improved significantly (p<0,05)diastolic ventricular function parameters, increased significantly(p<0,05) exercise duration after 6 and 12 weeks of treatment ; final-ly, Valsartan plus Ranolazine was able to correct QT dispersion.Our results indicate that Valsartan plus Ranolazine can improvecardiopulmonary reserve in obese Ps with diabetes II, increasedthe myocardial electrophysiological stability and can delay theonset of the overt heart failure.

MORTALITY IN RECIPIENTS OF ICD IMPLANTED FORPRIMARY PREVENTION OF SUDDEN CARDIAC DEATHW. RAUHE, L. Bertagnolli, F. Clari, I. Endrizzi, M. Manfrin, F. Pescoller,W. Pitscheider

Ospedale di Bolzano - Department of Cardiology, Bolzano, ITALY

Purpose: Aim of this single centre study was to evaluate mortalityin long term follow up (FU) of patients with ICD implanted forprimary prevention of sudden death (SD). Materials and Methods: We followed up 133 patients. Baselinedata: mean age 64,1±8 years; mean EF 24%±6,4; NYHA I 36%,NYHA II 33%, NYHA III 29% and NYHA 4 2%.Results: Over a mean FU of 35,7 months 33 patients (24,8%) died.A progressive increase in mortality rate (MR) was observed in rela-tion to worsening of functional capacity (MR 12,5% in NYHA I,25% in NYHA II, 34% in NYHA 3 and 100% in NYHA 4) and to ageat implantation (12% among patients < 55 years; 24% between 56-65 years and 66-75 years, 54% among patients > 75 years). Themain cause of death has been advanced heart failure (63,6% ofpatients). Appropriate ICD therapies have been more frequentamong patients who died than in the whole population (48 versus32,3%). MR has been higher among patients with appropriate thanwithout appropriate ICD interventions (32,5 versus 20%). Meantime from implantation to first appropriate discharge: 20,4months. Mean time from implantation to death 26,2 months.Conclusions: Despite ICD implantation and high incidence ofappropriate ICD discharges total mortality in patients with ICDimplanted as primary prophylaxis of SD is high, particularly inolder patients: one fourth of our whole population and half ofpatients > 75 years died within 3 years of FU. Nearly 2/3 of deathswere due to refractory heart failure. Appropriate ICD dischargesmay sometimes be a marker of poor prognosis. These data need tobe taken in consideration when selecting patients for ICD implan-tation in the setting of primary prevention of SD, particularly inpatients with advanced age and heart failure.

REMOTE MONITORING OF PACEMAKER IN THEMANAGEMENT OF DEBILITATED ELDERLY PATIENTSA. FOLINO1, R. Breda2, J. Comisso3, P. Calzavara2, F. Borghetti3,S. Iliceto1, G. Buja1

1Department of Cardiologic, Thoracic and Vascular Sciences, University ofPadua, Padua, ITALY, 2Local Social Sanitary Unit, Padua, ITALY, 3MedtronicItalia, Rome, ITALY

Purpose: Most of patients with pacemaker are elderly and suffe-ring from different serious illnesses. Often they are unable to walk,or do so with extreme difficulty. The aim of our study was to assesapplicability, efficacy and cost of remote controls of pacemakers,devoted to debilitated elderly patients. Method: Among elderly debilitated patients with pacemakers, weselected 37 subjects (8 males, 29 females; mean age 86±8yrs; range53-98) implanted with Medtronic devices, compatible with theCarelink® remote monitoring. The transmitter was delivered athome by a trained nurse, and in this occasion the patient, familymembers and other caregivers, were instructed on the operationalprocedures. Results: During 7 months of follow-up, a total of 75 transmissionswere received (mean transmissions per month 10.7, mean perpatient 2.0, range 1-5). A complete set of information were collectedby remote monitoring, as usually obtained by programmer, as wellas 2 ECG strips: during spontaneous rhythm and magnet. In thisperiod, 4 pacemakers were replaced due to battery exhaustion,after a mean of 6.8 years from implant (range 6.4-7.0yrs).Ventricular high rate episodes were detected in 18 patients, atrialhigh rate episodes in 6. Two patients died (annual mortality 9.3%).No patients refused remote controls. Only in one case the presenceof the nurse at home was requested for transmissions. In 2 patientstransmissions failed due to problems related to telephone line.Considering the costs sustained by hospital and patients for con-ventional ambulatory controls, either for medical personnel, care-givers and transportation, the estimated saving was of 151.31 €per year per patient. Conclusions: Our study evidenced as remote control of pacema-kers represents a reliable, effective and cost saving procedure inelderly, debilitated patients. Besides these aspects, the benefitsassociated with the avoidance of patient moving from home tohospital, are also to be considered.

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CLINICAL PRESENTATION AND LONG-TERM OUTCOMEOF NON IMMUNE AND ISOLATED ATRIOVENTRICULARBLOCK WHEN CONGENITAL OR DIAGNOSED DURINGCHILDHOOD: A FRENCH MULTICENTRIC STUDYA. BARUTEAU1, J.J. Schott2, E. Villain3, J.B. Thambo4, F. Marcon4,V. Gournay4, F. Rouault4, A. Chantepie4, S. Guillaumont4, F. Godart4,C. Bonnet4, A. Fraisse4, J.M. Schleich4, J.R. Lusson4, Y. Dulac4, J.C. Daubert1,H. Le Marec2, P. Mabo1, V. Probst2

1CHU Rennes, Rennes, FRANCE, 2lnstitut du Thorax, Nantes, FRANCE, 3NeckerEnfants Malades Hospital - APHP, Paris, FRANCE, 4French Society ofCardiology, Paris, Paris, FRANCE

Introduction: When isolated and non immune, prevalence of con-genital and childhood atrioventricular blocks (AVB) is extremelylow and little is known about their natural history.Methods: a multicentric study retrospective from 1980 to 2009allowed inclusion of 141 children from 13 French referral centers.Included children presented an AVB diagnosed in utero, at birth orduring childhood before the age of 15 years, without structuralheart abnormalities and without maternal antibodies.Results: 26 congenital and 114 childhood AVB were included.Symptoms lead to diagnosis in 15,6% whereas AVB was asympto-matic in 84,4%. Most AVB (73%) were complete and 26,2% AVBwere incomplete at first presentation. Progression to permanentcomplete AVB occurred in 21 of the incomplete blocks (56,7%).Narrow QRS complexes were found in 69,2% congenital and 91,2%childhood AVB. In the 112 (79,4%) implanted children, mean dura-tion between AVB diagnosis and pacemaker implantation was 35months. Pacemaker primo-implantation occurred during the firstyear of life for 18 children and 90 children (63.8%) were pacedbefore 10 years old. Pacing was required for symptomatic brady-cardia in 37,5% whereas prophylactic cardiac pacing accounted for61,6%. The median follow-up was 96 months (from 6 to 384months). The majority (85,1%) experienced no complication andneither dilated cardiomyopathy nor death had occurred at last fol-low-up. Pacemaker-related complications appeared in 11,6%.Conclusion: We describe the largest reported experience with iso-lated and non immune congenital and childhood AVB. Such ablock is a nodal damage from unknown origin that may postnatal-ly progress in incomplete forms. Outcome is not influenced by ageat diagnosis. Prognosis is very good with no late-onset dilated car-diomyopathy, a few pacemaker-related complications in the mod-ern technological era and no death at last follow-up.

ALTERED 2-D STRAIN MEASURES OF RIGHT BUT NOTOF LEFT VENTRICULAR FUNCTION IN PATIENTS WITHBRUGADA SYNDROMEA. PUZZOVIVO, I. Nalin, F. Monitillo, V.E. Santobuono, M. Iacoviello,C. Forleo, V. Marangelli, S. Sorrentino, S. Favale

Cardiology Unit - University of Bari, Bari, ITALY

Purpose: To evaluate the presence of abnormalities in right (RV)and/or left ventricular (LV) myocardial function in patients (pts)affected by Brugada syndrome by using Two-Dimensional (2D)strain analysis.Materials and Methods: We enrolled 22 patients with Brugadasyndrome (males 86%, aged 43±7 years) and 20 age and sex mat-ched controls (males: 85%, aged 41±10 years), who were free fromany cardiovascular disease. Brugada syndrome was diagnosedaccording with second Consensus Conference criteria of HeartRhythm Society and European Heart Rhythm Society. In allBrugada syndrome pts cardiac magnetic resonance was previouslyperformed to exclude structural disease. Standard apical two- andfour-chamber and long axis views and a RV focused apical 4-chamber view were recorded at a frame rate of 50-70/sec. 2D spec-kle tracking analysis (EchoPAC, GE) of basal, mid and apical seg-ments of lateral RV wall and of all segments of LV was performed.

For each segment systolic strain (sS) and strain rate (sSR) and earlydiastolic strain rate (eSR) were calculated as the mean of threecycles. Results: Patients with Brugada syndrome in comparison with con-trols showed significantly lower sS values of basal RV (-29.7±3.1%vs. -33.0±3%, p:<0.001) and of mid RV (-30.5±2.9% vs. -33.9±3.4%,p:<0.001). Moreover, lower values of mid RV sSR (-1.73±0.26 s-1 vs.-1.90±0.27 s-1, p:0.036) and of mid RV eSR (1.75±0.47 s-1 vs.2.12±0.45 s-1, p:0.013) were observed. No differences betweengroups were found when the remaining 2D strain measures of RVand those obtained by LV segments analysis were compared.Conclusions: In patients with Brugada syndrome lateral segmentsof RV show reduced systolic strain and systolic-diastolic strainrate, thus suggesting the presence of subclinical abnormalities inRV myocardial function that could be useful to better characterizephenotype expression of the syndrome.

PREVALENCE OF CARDIAC ABNORMALITIESEVALUATED WITH COMPLETE ECHOCARDIOGRAPHICEXAM IN TRAINED YOUNG ATHLETESF. QUARANTA1, F. Sperandii3, F. Guarracini2, E. De Ruvo2, A. Parisi1,L. Sciarra2, A. Spataro1, L. De Luca2, E. De Marchis1, M. Rebecchi2,Z. Lazarevic1, L.M. Zuccaro2, A. Martino2, E. Ciminelli1, A. Fagagnini2,C. Lanzillo2, E. Lioy2, L. Calò2, F. Pigozzi1

1University of Rome, Foro Italico, Rome, ITALY, 2Department of Cardiology,Policlinico Casilino, Rome, ITALY, 3Istituto di Medicina dello Sport di Roma,Villa Stuart, Rome, ITALY

Background: Prevalence of cardiac abnormalities in young trainedathletes are not available actually. The incidence of sudden cardiacdeath is expected at one case for each 200,000 young athletes peryear and in the large part was caused by congenital abnormalities.Young athletes echocardiographic evaluation can assess situationsthat may put the subject life in risk of acute and chronic cardiova-scular diseases. Two dimensional echocardiography is an accuratemethod to shows cardiac pathological alteration that could lead toconclamated cardiac disease or long term consequences. Methods: Screening two-dimensional and color-doppler echocar-diogram protocol (Siemens Acuson X300 with probes P5.1 andP8.4 MHz) was performed into the routine athletic medical asses-sment in 1000 trained young athletes (average age 12 years). Results: Echocardiography and Color-Doppler studies identified25 (2.5%) previously unknown cardiac abnormalities: hypertro-phic cardiomyopathy (1), bicuspid aortic valve (5), foramen ovalepervious (9), interatrial defect (5), interatrial septal aneurysm (3)and mitral valve prolapse (2). Conclusion: This study demonstrates that screening echocardio-gram should be incorporated into the pre-competition routineathletic medical examination for young subjects and should beconsidered very important to show asymptomatic but significantcardiac alteration.

THROMBOLITIC TREATMENT OF LEFT ATRIALTHROMBUS GUIDED BY INTRACARDIACECHOCARDIOGRAPHY DURING CATHETER ABLATIONFOR ATRIAL FIBRILLATIONA. PLACCI, C. Tomasi, F. Giannotti, M. Margheri

Department of Cardiology - Ravenna Hospital, Ravenna, ITALY

A 74-year-old man with hypertension and a previous ablation oftypical atrial flutter, had a several admission for heart failure dueto high frequency atrial fibrillation while was taking antiarrhy-thmic drugs (Amiodaron). He was admitted for catheter ablationof atrial fibrillation. Ablation procedure was guided by CARTOSOUND. Intracardiac echocardiography imaging (ICE) was per-formed using a Sequoia diagnostic ultrasound catheter (5.5 to 10EC

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MHz, 10 F). He was admitted for catheter ablation of atrial fibril-lation. A intraatrial thrombus was excluded by preprocedural tran-sesophageal echocardiogram. Dual transseptal catheterization guided by intracardiac echocar-diography imaging was performed to place two 8F Mullins she-aths, continuously flushed with heparinized saline at a rate of 30mL/h. After the 2 transseptal sheaths were placed, a left atrial ser-piginous thrombus (4 mm) was detected by ICE. We started the bolus of intravenous heparin, 5000 U in to the she-ath, but waiting 5 minutes the thrombus became bigger. So weinjected a single bolus of 30 mg (0.5 mg/kg) of actylise in the leftatrium. 10 minute later the thrombus disappeared completely andwe started the 4 complete pulmonary vein isolation without com-plications. Some authors suggest in this rare cases to make an aspi-ration trough the sheats of thrombus, but we think that is better tohave a completely dissolution of thrombus using a thrombolyticdrug. The Carto Sound has the advantage of allowing early detec-tion of intracardiac thrombus and thus an early intervention fortreatment of this complication.

PREVALENCE OF VENTRICULAR REPOLARIZATIONABNORMALITIES IN TRAINED YOUNG ATHLETESF. GUARRACINI1, F. Sperandii3, E. De Ruvo1, F. Quaranta2, L. Sciarra1,A. Spataro2, L. De Luca1, E. De Marchis2, M. Rebecchi1, Z. Lazarevic2,L.M. Zuccaro1, A. Martino1, A. Fagagnini1, M. Minati1, M. Porfirio1,C. Commisso1, G. Pendenza1, E. Lioy1, F. Pigozzi2, L. Calò1

1Department of Cardiology, Policlinico Casilino, Rome, ITALY, 2University ofRome, Foro Italico, Rome, ITALY, 3Istituto di Medicina dello Sport di Roma,Villa Stuart, Rome, ITALY

Background: Recent data showed a high prevalence of ventricularrepolarization changes in inferior and lateral ECG leads in thegeneral population and even more frequent in trained youngathletes. Recent studies on healthy subjects surviving a cardiacarrest or with primary ventricular fibrillation (VF) suggested thatthese abnormalities couldn’t be an innocent finding. An associa-tion between early repolarization, T wave abnormalities and QRSslurring or notching in the inferior and lateral ECG leads and therisk of VF was demonstrated by several authors. Methods: We retrospectively analysed a database of 418 youngmales trained athletes (average age 12 years). We defined earlyrepolarization as an elevation of QRS-ST junction of at least 0.1 mVfrom baseline in at least two inferior or lateral leads and we evi-denced the presence of slurring or notching in the terminal portionof the R-wave. Results: Early repolarization alone was condition present in 59(14%) athletes. The association with the presence of QRS slurringor notching recur in 60 (14%) subjects. Inferior, lateral, and infe-rior-lateral QRS notching was associate to J-point elevation in 17(4%), 15 (3%) and 28 (7%) young athletes respectively. In our data-base we identified 1 prolonged QTc interval, 2 Brugada sign (type3 pattern) and 12 subjects with ecochardiographic pathologicalalteration with marked ECG abnormalities in a case (hypertrophiccardiomyopathy). Conclusion: The evidence of J point elevation and QRS slurring ornotching was frequent in trained young. If these “abnormalities”are the sign of sub-clinical disease will be evaluated during the fol-low-up.

NEW FINDINGS IN LEFT INTRAVENTRICULARDYSSYNCHRONY AT PATIENT WITH LEFT BUNDLEBRANCH BLOCKM. ZEMLYANOVA, E. Suslina, I. Philippova, A. Semagin, J. Tracht,S. Khokhlunov

Samara Health Care Clinic, Samara, RUSSIA

Objectives: evaluate the developmental character of dyssynchro-ny in left ventricular with live three-dimensional ECHO (3D-ECHO) at patients with left bundle branch block (LBBB).Methods: 45 patients, middle age 55,2±5,3 (48-60) with LBBB wereexamined. They were divided into two groups: with EF > 50% - 27patients and EF < 49% - 18 patients. In addition to standard exami-nations (ECG, 2D - ECHO, angiography and ect.) 3D - ECHO wasperformed. The time to minimum systolic volume (Tmsv) and thedispersion (Diff.) in these values for each segmental were analyzed.Results: Left intraventricular dyssynhrony did not have any corre-lations between QRS-complex duration (ratio= 0, 75, p=0, 46 infirst group; ratio= 0, 6, p=0, 15 in second group) and LBBB presen-ce.The first group had the following characteristics of intraventri-cular dyssynchrony by 2D ECHO: intraventricular delay was57,0±17 ms, delay in contraction posterior wall to intraventricularseptum - 85,5±40,7 ms. Characteristics of intraventricular dyssyn-chrony in the second group had nothing significant changes(55,6±13,5 ms and 87,5±17,0 ms; p = 0,78 and 0,46 correspondin-gly).Nevertheless intraventricular dyssynchrony were emergedfrom 3D ECHO data. While intraventricular dyssynchrony wasnot observed in the first group (Sel-SD Tmsv 24,63±8,2 ms, Sel-Diff. 22,0±15,6 ms, Sel-SD Tmsv 2,9±1,2ms) it was being found sta-ble in the second group (Sel-SD Tmsv 124,3±86,2 ms, Sel-Diff.242,4±185,6 ms, Sel-SD Tmsv 15,6±10,2 ms). All of the differenceswere significant (p = 0,0002, 0,0003, 0,0003 correspondingly). EFdid not depend on intraventricular delay and have low pure cor-relation witht (r=0,06, ð=0,76 è r=0,04, ð=0,61 correspondently).However 3D-ECHO parameters had strong dependence betweenEF and left intraventricular dyssynchrony.Conclusion: LBBB does not have any influence on lent intraventri-curlar dyssynchrony. The greatest imbalance in left ventricularcontraction is observed when EF is below 50% and even in thiscase EF does not depends on QRS-complex duration.

ECHO

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NONINVASIVE MAPPING AND CATHETER ABLATIONOF ATRIAL TACHYCARDIASG. Simonyan, T. DZHORDZHIKIYA, O. Sopov, V. Kalinin, A. Revishvili

Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, RUSSIA

Purpose: A novel 3D surface ECG based mapping technology wasprospectively evaluated in patients with different atrial tachycardias.Methods: Noninvasive mapping using 240-lead ECG combinedwith CT scan based anatomy (Amycard, RUS) was prospectivelyperformed in 10 patients (7 male/3 female, mean age 46,7±17,07)with ectopic atrial tachycardias refractory to antiarrhythmic thera-py. We compared results of noninvasive mapping with invasivemapping (Carto XP) and successful radiofrequency ablation (RFA).Results: In 10 cases (100%) clinical target was accurately identifiedand successfully terminated by RFA. Ectopic activity in 4 patientswas localized in coronary sinus ostium, in 2 cases - in the basis ofright atrial appendage, in 2 patients - in the basis of left atrialappendage, one was in crista terminalis and one in right superiorpulmonary vein. The distance between noninvasive target andeffective point of ablation was 3±1,34 mm. Time of fluoroscopy ingroup of patients that underwent noninvasive mapping was sig-nificantly lower 8,67±1,5 min in comparison with average16,25±2,9 min (p<0,05).Conclusion: Initial experience with noninvasive mapping provedits clinical utility, feasibility of accurately locating the target in var-ious atrial tachycardias and significant reduction of fluoroscopyand procedure time.

RADIOFREQUENCY CATHETER ABLATIONS FORIDIOPATHIC ATRIAL TACHYCARDIAS - MORE THANTWO YEARS EXPERIENCEA. BULAVA, J. Hanis, D. Sitek, K. Rehouskova

Cardiac Center of Ceske Budejovice Hospital, Ceske Budejovice, CZECH REPUBLIC

Introduction: Idiopathic atrial tachycardias (IAT) represent a rela-tively rare group of supraventricular arrhythmias (SVA).Arrhythmogenic mechanisms include abnormal depolarization,triggered activity and micro- or macro-reentrant circuits.Goals: Goal of this study is to describe our experience with radio-frequency catheter ablation (RFA) of IAT during the short existen-ce of our department of arrhythmology.Results: 1261 RFA procedures for SVA was performed at ourdepartment between January 2008 and June 2010. RFA for IAT wasperformed in 20 patients (9 men, 11 women, mean age 61±18 years)of the whole cohort (1,6%). 3D mapping using CARTO system wasperformed in 7 patients, the rest were mapped conventionally. Theprocedure was considered acutely successful in 19 out of 20patients (95%). Mean procedural and fluoroscopy times were121±63 min and 14±8 min, respectivelly. Overview of the spots ofarrhythmia termination during RFA is following: superior aspectof the tricuspid annulus, superior vena cava, distal crista termina-lis, interatrial septum (both from the right and the left side), leftatrial roof, left upper pulmonary vein, ostium of the coronarysinus (CS) and distal coronary sinus. During the mean follow-upof 237±212 days the arrhythmia recurrence was documented in 1patient. Another patient complained about palpitations, but onlyventricular premature beats were recorded on Holter ECG. In therest of patients stable sinus rhythm was documented on the 7dayHolter (90% long term success rate). 2 patients were on the beta-blocker therapy, another patient was still using propafenone. Wedocumented one pseudoaneurysm of the femoral artery, no othercomplications were recorded.Conclusions: IATs represent a rare group of SVTs. Patients with thesearrhythmias should be referred for the causal treatment by radiofre-quency catheter ablation with excellent long-term success rate.

SLOW PATHWAY POTENTIALS IN KOCH TRIANGLET. COPPI, C. Lavalle, S. Ficili, M. Galeazzi, M. Russo, F. Venditti,A. Pandozi, G. Chiarelli, C. Pandozi, M. Santini

Department of Cardiology San Filippo Neri, Rome, ITALY

Background: The origin of the multicomponet potentials insideKoch's triangle (KT) area is controversial. We investigated the cha-racteristics of multicomponent potentials recorded in that area, inpatients with and without atrio-ventricular nodal tachycardia(AVNRT).Methods and Results: 32 patients (16 AVNRT; 16 NO-AVNRT)underwent a sinus-rhythm electroanatomic mapping of the rightatrium (RA). Conduction velocities (CV) in the RA and in the KTwere evaluated quantitatively on activation maps and qualitative-ly on isochronal/propagation maps. The presence, location andtiming of different types of multicomponent potentials were eva-luated. A mean of 149±44 points were sampled in the RA while amean of 79±21 points were collected inside the KT. Slow conduc-tion inside the KT was found in all (mean CV: 126.5 [89.1-170]cm/soutside KT versus 60.0 [40.9-90] cm/s inside KT, p<0.001).Jackman potentials were identified inside KT in almost all thepatients and were invariably found on the collision line betweenthe wavefronts activating the KT in opposite directions.Conclusions: Conduction slowing was demonstrated during pro-pagation of the sinus impulse inside the KT. The genesis of theJackman potential may be related to the collision of the wavefrontsactivating KT in opposite directions. No difference was found bet-ween patients with and without AVNRT.

PALPITATIONS OCCUR MAINLY AT NIGHT INELDERLY PATIENTS WITH ATRIOVENTRICULARNODAL REENTRANT TACHYCARDIAK. Blaszyk, W. SENIUK, M. Wasniewski, A. Gwizdala, A. Baszko,M. Popiel, S. Grajek

University of Medical Sciences, Poznan, POLAND

Palpitations (PALP) are the most common symptom in patients(pts) with atrioventricular nodal reentrant tachycardia (AVNRT). The aim of the study was to present the circadian occurrence ofpalpitations with respect to the age of the patients with AVNRT. Data were collected from 200 consecutive pts (mean age 43,3 yrs;SD±14,7; F-145/M-55) with AVNRT admitted for radiofrequency(RF) ablation. Palpitations were the most often symptom, occur-ring in all pts (n=200, 100%). According to pts, PALP were provo-ked by: an emotion (n=134; 68%), without clear cause (n=106;53%), a rapid change of the body position (n=97; 48,7%), during adaily rest (n=87; 43,7%) and physical effort (n=79; 39,7%). Themost important trigger factor for PALP was emotion (p<0,05).Significant difference (Kruskal-Wallis test; p<0,05) was noticed inthe circadian occurrence of PALP according to patient’s age. PALP,during the day only, were present among the younger group. But,in a group older by 2 decades PALP occurred only during the nighthours. It applies to the age of pts at the first noticed symptoms(24,7 vs. 48,8 yrs, p = 0,02), as well as, to the age of pts during EPstudy and RF ablation (40,9 vs. 60,5 yrs; p= 0,049). Conclusion: 1. Among the pts with AVNRT, palpitations occurringduring the day appear only in younger group of pts, but thosenoticed during the night occur mainly in older patients. Mean agedifference between those two groups is approximately 20 years.2.Changing of the electrophysiological features of the AV node inelderly pts is probably important for occurrence of palpitationsduring the night hours.

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SIMULTANEOUS ENDOCARDIAL AND EPICARDIALMAPPING OF CARDIAC VENTRICLES BASED ON THEINVERSE ELECTROCARDIOGRAPHY PROBLEMSOLUTION FOR PATIENTS WITH WPW SYNDROMEV.V. KALININ, F.SH. Revishvili, O.S. Lyadzhina, G.YU. Simonyan, O.V. Sopov,E.A. Fetisova

Bakoulev Center of Cardiovascular Surgery, Moscow, RUSSIA

The inverse problem of electrocardiography is known in two sta-tements: in the form of endocardial potentials and in the form ofepicardial potentials. In the first instance, endocardial electro-grams need to be restored based on ECG findings - measurementsat the surface of a bag catheter introduced into the cardiac cham-ber. In the second instance, epicardial electrograms need to bereconstructed based on surface ECG mapping data (BSM).However, for cardiac cycle moments, when electrical activity ofventricles and atria does not synchronize, BSM findings may ena-ble reconstruction of both epicardial and endocardial electro-grams. Research objective Topical diagnostics of accessory AVpathways (AAVP) in patients with WPW syndrome using thenoninvasive endo-epicardial mapping.Materials and Methods: 16 patients with WPW syndrome andwith history of repeated AV tachycardia paroxysms were obser-ved. All patients underwent BSM using a 240-lead system and car-diac and thoracic computer tomography. Based on these data,computational electrogram reconstruction was carried out for achosen ventricular cardiac cycle and isochronal maps were genera-ted on the endocardial and epicardial surfaces of the ventricles andinterventricular septum.Results: On results of endo-epicardial mapping 6 patients hadrear-lower AAVA, 7 had right-side lower paraseptal AAVP, 1 hadleft-side lower paraseptal AAVP, and 1 had left-side rear AAVP.Based on a time difference between endocardial and epicardialactivation, it was possible to locate AAVP in relation to endocar-dium and epicardium. Conclusion: The possibility of noninvasive endo-epicardial map-ping was demonstrated in patients with ventricular pre-excitation.The endo-epicardial mapping allows to significantly reduceintraoperative mapping time during catheter ablation.

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ANATOMICAL ATRIOVENTRICULAR REMODELINGBY INTERATRIAL SEPTAL PACINGS. PORCELLINI1, G. Macca1, P. Brioschi1, A. Rimini1, G. Tortora1, S. Gilardi2,T. De Santo2, S. Biasi1

1Clinica San Carlo, Paderno Dugnano, ITALY, 2Medtronic Italy, Sesto SanGiovanni, ITALY

Purpose: Several clinical studies reported that interatrial septum(IAS) pacing is more successful than conventional right atrialappendage pacing for Atrial Fibrillation (AF) prevention.The aimof this analysis is to assess the anatomical atrial and ventricularremodeling due to IAS and to confirm the feasibility and reliabili-ty of this kind of lead implant. Methods: Consecutive patients (Pts) with Parossistic AF (PAF) andeligible for a pacemaker (PM) or defibrillator (ICD) procedureunderwent implantation with atrial lead screwed in IAS.Featuresfor prevention and treatment of AF were enabled in all pts.Atrial,ventricular dimensions and performances were assessed by thesame cardiologist via echocardiography at implantation, 6 monthsFU and 1 year FU.Results: 10 pts (40% male, 70±6 years) affected by PAF wereimplanted with dual chamber PM (70%) or ICD (30%).Basal Echoparameters were: Ejection Fraction (EF) 51±14%, Left VentricularEnd-Diastolic Diameter (LVEDD) 138±55ml, Left Ventricular End-Systolic Diameter (LVESV) 74±51ml, Left Atrium (LA) Area23±5cmq and Volume 70±27ml, Right Atrium (RA) Area 15±5cmqand Volume 38±19ml.Mean follow-up was 12.7± 3.6 months. RAthresholds and sensing remained stable at 12 months FU(implant:sensing 2.0±0.9mV, threshold 0.9±0.5V@ 0.4msec; 12months FU:1.7±0.5mV and 1.0±0.4V@0.4msec). At 12 months theLA transverse diameter was significantly reduced (median valuefrom 45 to 40mm,p=0.044). In addition a significant improvementwas found regarding LVEDD, LVESD and EF (p=0.028,p=0.040and p=0.011 respectively). Other atrial anatomical parametersshowed a positive trend, even if not significant. The percentage ofRA pacing was>70% in all pts but does not seem to be correlatedwith the variation in any studied parameter. Conclusion: Our results, even if related to a limited number of pts,confirmed that IAS pacing is safe and effective and suggest thatthis kind of pacing can lead to an atrial remodeling and animprovement in ventricular performances.This kind of implanta-tion procedure is preferable when pt has PAF history.

NEW METHOD OF MYOCARDIAL CONTRACTILITYOPTIMIZATION DURING IMPLANT DUAL-CHAMBERPACEMAKERA. TSYGANOV, M. Didenko, A. Bobrov, A. Fedyainova, G. Khubulava

Military Medical Academy, Saint-Peterburg, RUSSIA

Aim: It was to evaluate the optimal position of right ventricular(RV) lead in patients with DDD(R) pacemakers. Methods: We enrolled 9 patients with total and subtotal atrioven-tricular block who had underwent DDD(R) pacemaker implanta-tion. Two RV pacing sites were studied in the random order: theRV apex and RV septum near the His bundle (RVS). The locationof the electrode was confirmed by X-ray in 3 projections. In everyposition we measured cardiac output (CO) by two methods: thefirst was echocardiographic time velocity integral in the ascendingaorta, the second was invasive pulse contour CO calculationmethod. CO was calculated at the rest and at the increased heartrates (HR): 70, 80…150 bpm. The first point of CO curve on thechart was equal to the initial CO predetermined as 100%. All thenext points on the curve of CO were calculated as percentage ofthe initial value. The best position is characterized by the maximalincrease in CO at the maximal HR. Decreasing of CO while HRincreasing identifies the decompensation of the heart work.Critical HR is determined as point on the chart when CO starts

going down. Value of the index in this point is characterized asreserve of myocardial contractility. Results: The correlation between values of CO calculating by twomethods was moderate, r=0.51 (p<0,05). Dual chambers pacing(atrial and RV apex) resulted in a mean 34% increase in CO at 140bpm. DDD pacing in atrial and RVS position leads to a mean 42%increasing in CO at 150 bpm.Conclusion: This new method of hemodynamic monitoringduring pacemaker implantation allows to determinate of optimalRV pacing lead placement to achieve maximal myocardial recruit-ment.

HEMODYNAMIC MODIFICATIONS ASSESSEDBY TRANSVALVULAR IMPEDANCE RECORDINGE. MORO1, G. Allocca2, E. Zorzi1, A. Cera1, E. Marras2, N. Sitta2, P. Delise2

1Department of Cardiology, Arzignano (VI), ITALY, 2Department of Cardiology,Conegliano (TV), ITALY

Introduction: Permanent hemodynamic monitoring by implantedsensors would improve the medical care of patients at risk ofhemodynamic deterioration, including heart failure. There isincreasing evidence that relevant hemodynamic information canbe provided by the Trans-Valvular Impedance sensor (TVI), whichdetects electric impedance fluctuation between right atrium andventricle along the cardiac cycle. Aim: The present study was aimed at checking whether acutechanges in TVI parameters are correlated with conventional echo-cardiographic markers of left-ventricular hemodynamics.Methods: In 10 patients implanted with a Sophòs pacemaker(Medico), a reduction in diastolic filling was induced by tempora-rily increasing the pacing rate stepwise from 60 to 110 bpm. Theassociated hemodynamic modifications were assessed by Dopplermeasurement of mitral and aortic flow velocity, and by determina-tion of left-ventricular EDV-ESV by 2D or M-mode echocardiogra-phy. The pacemaker simultaneously derived and sampled the TVIwaveform, which was transmitted by telemetry and stored by theprogrammer.Results: By increasing the pacing rate in DDD from 60 to 100 bpm,the LV total diastolic filling-time decreased from 454±81 to 260±51ms and EDV decreased from 102±19 to 83±13 ml, while ESV wasvirtually unchanged. The SV decreased from 69±10 to 52±3 ml andthe velocity-time integral of the aortic flow (AoVTI) was reducedby 15±10%. The peak-peak amplitude of TVI signal (pk-pkTVI)was similarly affected (-15±14%). Both hemodynamic and TVIparameters gradually changed as a function of the pacing rate. Asa result, a good correlation was demonstrated between AoVTI andpk-pkTVI (R-squared ranging from 0.49 to 0.92), and between EDVand end-diastolic TVI (R-squared from 0.76 to 0.97). Conclusion: Changes in TVI parameters induced by high-ratepacing are correlated with echocardiographic markers of LV fun-ction. The sensitivity to acute hemodynamic changes supports TVIapplication in permanent hemodynamic monitoring of pacemakerpatients.

DUAL-CHAMBER PACING MODES TO MINIMIZERIGHT VENTRICULAR PACING: MEDIUM ANDLONG-TERM CLINICAL OUTCOMESN. CABANELAS, V.P. Martins, D. Durão, F. Valente, M. Alves, A. Francisco,P. Branco, G.F. Silva

Cardiology Department, Santarem, PORTUGAL

Introduction: Dual-chamber pacing algorithms to minimize rightventricular pacing (RVP) were built few years ago, and their long-term clinical impact on reducing heart failure(HF), atrial fibrilla-tion (AF) and mortality are now being evaluated. Objective: Compare specific algorithms conceived to reduce RVPPH

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(MVP-Medtronic and AAIsafeR2-ELA Medical) versus simpleDDD programming with AV interval optimization.Methods: Patients admitted to a Pacing Unit for permanent dual-chamber pacemaker implantation, from February/2006 toAugust/2007 (n=253), followed for 3 years, were retrospectivelyevaluated. Two groups were established: Group A-patients whosedevices have specific algorithms to reduce RVP (n=94), and GroupB-patients with devices without these algorithms (n=161). Age,proportions of patients with <50% of time on RVP, arrhythmic bur-den <10% of time, hospital admission for HF (HAHF), time to firstHAHF, persistent AF, total and cardiovascular mortality werecompared.Results: The age of patients of both groups was 68.6±7.4vs70.3±8.1years,p=ns. After one year follow-up, there was a significant differenceregarding RVP<50% (77.1%vs41.0%,p<0.01), prevalence of arrhythmicburden <10%(80.95%vs60.0%, p<0.01), HAHF(6.7%vs18.1%,p=0.05),and persistent AF(3.8%vs11.0%,p=0.02). There was a tendency in B, forhigher total and cardiovascular mortality. After three years, 70% of patients in A vs 23.9% in B had <50% ofRVP(p<0.001). In A, there was a tendency for arrhythmic burden <10%to be more prevalent (66.6%vs58.5%,p=ns), as was incidence of HAHF(17.2%vs22.2%,p=ns), persistent AF (14.0%vs17.5%,p=ns), total morta-lity (6.4%vs9.3%,p=ns) and cardiovascular mortality (0%vs3.1%,p=ns).Time to first HAHF was higher in A (24.43±3.53vs15.82±9.52months,p=0.04).Conclusions: Pacing algorithms designed to minimize RVP weremore effective in maintaining intrinsic conduction. They were cle-arly associated with less persistent AF, HAHF, and mortality, thansimple AV optimization, after one year. At three years follow-up,although the efficacy in preservation of RVP remains evident withspecific algorithms and clinical outcomes tend to be slightly better,the huge difference seen at medium term tends to decrease withlonger follow-up.

PATIENTS WITH SURGICALLY CORRECTEDCONGENITAL HEART DISEASE AND PACEMAKER:TWENTY YEARS FOLLOW-UPA. GROßE, S. Raffa, M. Brunelli, K. Wauters, J.C. Geller

Zentralklinik Bad Berka, Departement of Rhythmolgy, Bad Berka, GERMANY

The need for pacemaker-implantation after surgery of CDH iscommon due to either the operation or the CHD. Aim of the studywas to evaluate: frequency of battery-replacement, long term leadperformance and influence of frequent ventricular stimulation onfunctional status and arrhythmia occurrence. Patients operated for CHD who underwent PM implantation havebeen regularly followed up in our hospital and included in theanalysis. 23 pts (11 male, 30±11 yrs) were included. The surgical correctionof the CHD was performed a mean of 22± 8 yrs ago for the follo-wing indications: AV-channel (n=6), TGA (n=4), Ebstein (n=3),TOF (n=2), VSD (n=5), ASD (n=1), ASD+VSD (n=1), VSD + coar-ctation of aorta (n=1). The first PM-implantation was performed amean of 19±6 yrs ago for: complete AV-block (n=18), AV- andsinus-node-disease (n=1), sick-sinus-syndrome (n=3), AF withslow ventricular rate (n=1). The initial device was VVI in 20 pts,VDD in 2 and DDD in 1. Battery exchange was needed a mean of3 times per pt. After a mean of 12± 5 yrs 12 pts underwent anupgrade to dual-chamber PM, none got a biventricular PM or defi-brillator. 17/23 pts received lead revision after a mean of 9± 6 yrs,because of body-growth or capture-defect (lead fracture in 11 pts).At last follow-up 21 pts were in sinus-rhythm and 2 in AF. Highdegree AV-block was still present in 16 pts. In 18 pts the percenta-ge of VP was > 70% (overall mean of VP 76± 41%). No ventricular-arrhythmias were detected. Battery and lead exchanges are common in thus pts, because ofbattery depletion, system upgrade and lead dysfunction. In the

majority of pts the need for right VP persists over the long-term.Overall incidence of AF and ventricular arrhythmias is low.

LEFT VENTRICULAR SYSTOLIC AND DIASTOLICFUNCTION IN PEDIATRIC PATIENTS WITH DEFINITIVEPACEMAKERM. Cabrera Ortega1, A.E Gonzales Morejon2, F. DORTICOS1Cardiocentro Pediatrico William Soler, Department of Arrhytmia and CardiacPacing, Ciudad de la Habana, CUBA, 2Cardiocentro Pediatrico Willam Soler,Department of Echocardiography, Ciudad de la Habana, CUBA

Background: Chronic right ventricular pacing is associated withdeleterious effects in left ventricular form and function.Alternative sites of stimulation could avoid the cardiac remode-ling and ventricular dysfunction.Objective: Compare the effects of chronic right ventricular and leftventricular pacing in children with structurally normal hearts.Methods: Echocardiographic data were retrospectively and pro-spectively obtained from patients with structurally normal heartsthat required the implantation of definitive pacemakers at rightventricle epicardium (n=7), at right ventricle endocardium (n=30)and at left ventricle epicardium (n=18), between January 1, 2000,and December 31, 2009. Fractional shortening and fractional ejec-tion were calculated as a measure of left ventricular systolic fun-ction, doppler mitral inflow, pulmonary vein flow and tissue dop-pler were estimated to diastolic function analysis; left ventricularend-diastolic diameter and left ventricular end-systolic diameterwere also determined. Echocardiographic evaluations were madebefore pacemaker implantation, immediately after and regularlyduring a medium term follow-up.Results: Left ventricular diastolic function did not change in anysite pacing during the follow up; left ventricular fractional shorte-ning and fractional ejection were higher in left ventricular epicar-dium pacing (42±8, 73±6) than in right ventricular endocardiumpaced group (36±4, 66±5) and right ventricular epicardium pacedpatients (34±6, 64±5). Left ventricular end-diastolic and end-systo-lic diameters were increased as a result of depressed systolic fun-ction in both right ventricular pacing.Conclusion: Left ventricular form and function are better in pedia-tric patients with structurally normal hearts and chronic left ven-tricular pacing as compared to children with chronic right ventri-cular pacing.

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DIFFERENT IMAGE INTEGRATION MODALITIES TOGUIDE AF ABLATION: IMPACT ON PROCEDURALAND FLUOROSCOPY TIMESC. PRATOLA1, E. Baldo2, P. Artale1, M. Bertini1, L. Pirani1, C. Cavazza1,T. Toselli1, R. Revelchion1, R. Ferrari1

1Cardiology Institute Ferrara University Hospital, Ferrara, ITALY, 2Cardiology,Lagosanto (FE) Hospital, Lagosanto, ITALY

Introduction: The aim of this study was to evaluate the impact ofdifferent image integration modalities on procedural and fluo-roscopy times during AF ablation. Methods: 60 patients (mean age 52.2±12.0 years, 48.3% males, 75%paroxysmal AF) undergoing pulmonary vein (PV) encircling withPV disconnection for symptomatic drug-refractory AF were ran-domized to ablation with CARTO electroanatomical mapping inte-grated with: a) preprocedural magnetic resonance imaging (MRI;Group1); b) intracardiac echocardiography (ICE; Group2); c) pre-procedural MRI and ICE (Group3). Results: PV disconnection was achieved in all patients. Total pro-cedural time (Group1: 124.7±47.0; Group2: 112.5±30.4; Group3:108.6±34.7 minutes) and total ablation time (from the first point ofablation to the end of the procedure) were similar between groups(p=ns). MRI integration alone required a higher fluoroscopy time(23.8±6.9 in Group1 vs. 11.0±2.3 and 13.9±4.2 minutes in Groups 2and 3, respectively; p<0.005) and a longer time spent in the leftatrium (109.0±43.5 in Group1 vs. 78.2±29.7 and 74.8±34.3 minutesin Groups 2 and 3, respectively; p=0.03) in comparison to ICE inte-gration. Addition of MRI to ICE integration showed a tendency fora higher fluoroscopy time in comparison to ICE integration alone(p=0.06). At a mean FU of 9.1±2.2 months there were no significantdifferences in AF recurrences among the groups (p=ns).Conclusion: ICE image integration significantly reduces the fluo-roscopy time and the time spent in the left atrium in comparisonto MRI integration alone. Addition of MRI to ICE integration doesnot reduce total procedural time and seems to lead a higher fluo-roscopy time in comparison to ICE integration alone.

TRANSCATHETER ABLATION OF ATRIAL FIBRILLATION:THE UTILITY OF THE NEW CARTO 3 MAPPING SYSTEML. SCIARRA1, S. Dottori2, L. De Luca1, E. De Ruvo1, P. Pitrone2, C. Lanzillo1,M. Minati1, M. Rebecchi1, L. Zuccaro1, A. Fagagnini1, E. Lioy1, L. Calò1

1Policlinico Casilino, Rome, ITALY, 2Biosense Webster, Milan, ITALY

Introduction: Mapping systems are widely used to guide radiofre-quency catheter ablation (RFCA) of atrial fibrillation (AF). Thenew Carto3 mapping system allows catheter visualization and anew 3D reconstruction of the cardiac chambers: the fast anatomi-cal mapping (FAM).Aim of the study: to test the utility of the Carto3 system to guideRFCA of AF and to compare the accuracy of left atrial FAM withthe cardiac magnetic resonance imaging (MRI).Methods: 32 patients (mean age 55±11 years, 30 males; 12 paroxy-smal, 20 persistent AF) underwent left atrial ablation with encir-cling/de-connection of pulmonary veins (PVs). PVs isolation wascompleted and validated by a circular mapping catheter visuali-zed on CARTO3 system. In patients with persistent AF, complexfractionated atrial electrograms maps were built upon the FAMreconstruction of the left atrium and ablation was performed. Apost-procedural comparison between the FAM and the MRI of theleft atrium was performed in a subgroup of 10 patients. The quali-tative comparison included number/position of PVs. The quanti-tative analysis was performed by integration of the FAM surfaceand MRI image and by evaluation of maximal PV ostial diametersfor both FAM and MRI.Results: Acute successful isolation of PVs was 96%. Mean proce-dural time for Paroxysmal and Persistent AF ablation procedurewas 170±54 and 197±38 minutes, respectively. Mean fluoroscopy

time for Paroxysmal and Persistent AF ablation procedure was32±19 and 41±15 minutes, respectively. No complication occurred.A 100% match with MRI was found in terms of number and posi-tion of PVs. Correlation data demonstrated close agreements bet-ween MRI and FAM for the assessment of maximal PV ostial dia-meter (LSPV r2=0.93 P=NS, LIPV r2=0.85 P=NS, RSPV r2=0.87P=NS, RIPV r2=0.86 P=NS)Conclusions: The new Carto3 mapping system revealed to be auseful tool to guide RFCA of AF, allowing an accurate MRI-likereconstruction of the left atrium.

EVALUATION OF ELECTRICAL ISOLATION OF PVOBTAINED BY CRYOBALLOON-ABLATION FORATRIAL FIBRILLATION, USING ELECTROANATOMICALVOLTAGE MAPPINGD. CATANZARITI1, M. Maines1, C. Angheben1, M. Centonze2, G. Broso1,G. Vergara1

1Cardiology Division - Ospedale S. Maria del Carmine, Rovereto (TN), ITALY,2Radiology Department, Ospedale S. Chiara, Trento, ITALY

Background: Balloon-based technology and cryoenergy wererecently introduced to increase the safety of procedure and toreduce discontinuity of circular lesions around pulmonary veins(PVs), by avoiding a major role in the outcome of the operatorydexterity. However relatively unknown remains the exact level ofPVs isolation induced by cryoballon-ablation (CBA).Methods: In 22 consecutive patients undergoing CBA for paroxy-smal or short standing persistent atrial fibrillation after prior MRIdata acquisition, 3D reconstruction of the LA could be generatedusing the EnSite Verismo Software incorporating the 3D recon-struction of the LA created by MRI. This software was also usedfor measuring distances and the diameter of various anatomicalstructures and for reconstructing the complete “true” anatomy ofPVs antra. Using preselected amplitude voltage limits of 0.05-0.5mV and differential pacing techniques, the topographic extensionof PVs isolation was assessed after CBA. Results: All 80 PVs ofpatients study were isolated by CBA (including 9 left commontrunk and 2 right middle accessory veins). An antral level of isola-tion was observed in the vast majority of PVs with severe reduc-tion of voltage outside the tubular portion of PV and at variousextent proximal to the PV ostium. Indirect approaches to CBAwere preferred in 42% of cryofreezes to enlarge the perivenousatrial lesions, while the coaxial approach was reserved in theremaining cases.Conclusion: CBA exerts its effects on electrical isolation at theantral level of PV ostia largely resorting to indirect approaches forachieving mechanical occlusion during cryoenergy delivery.

LATE ATRIAL TACHYCARDIA FOLLOWING PULMONARYVEINS ISOLATION: ANALYSIS OF SITES OF SUCCESSFULDISCRETE ABLATIONF. ZOPPO, G. Brandolino, F. Zerbo, E. Bertaglia

Dipartimento di Cardiologia, Mirano (Venice), ITALY

Introduction: The role of left atrial linear lesions added duringpulmonary isolation (PVI) to prevent atrial tachycardias (AT) isnot yet clear. Objective: To analyse successful ablation sites of late onset postPVI-AT and to understand whether lines at mitral isthmus and leftatrium (LA) roof could have been useful in preventing them.Methods: From March 2002 to August 2008, 366 patients under-went PVI alone for drug refractory atrial fibrillation (AF). Duringfollow-up, 26 of these patients (7.6%) developed late AT and werereferred for ablation. Successful ablation discrete sites were analy-sed. In no patient the index AT was terminated by means of a line-ar lesion on mitral isthmus or LA roof.NE

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Results: Twenty-seven ATs were mapped; mean CL was 261±71.6msec). In 3/26 patients, (11,5%), the mapping was unsuccessful,while 23/26 patients (88.5%) underwent a successful procedure(24 AT morphologies in 23 patients: 3/24 mapped as mitralisthmus and 1/24 as LA roof dependant AT). Among the 24 successfully mapped AT, 17/24 (70.8%) displayed amacroreentrant activation and focal in the remaining 7/24 (29.1%). Finally, in 22/26 (84.6%) of patients no ATs were still inducible. At22.4±12.2 months mean f/u, 23/26 patients (88.4%) remained ATfree (AAD prescribed in 5/26, 19.2% for AF prevention). Conclusions: Less than one/fifth of post-PVI ATs were found asmitral isthmus or LA roof-dependent. Late ATs may be successful-ly ablated once they appear instead of adopting a preventive abla-tion strategy by means of linear lesions.

PERIODIC TRANSTELEPHONIC ECG MONITORING ANDASYMPTOMATIC RECURRENCES AFTER ABLATION OFLONGSTANDING PERSISTENT ATRIAL FIBRILLATIONM. FIALA1, V. Bulkova2, J. Chovancik1, J. Pindor1, J Gorzolka1, H. Tolaszova2,S. Krawiec1, D Vavrik1, S. Kralovec3, J. Brada3, J. Januska1

1Department of Cardiology, Hospital Podlesi, Trinec, CZECH REPUBLIC,2Department of Cardiology and Angiology II, General University Hospital andCharles University School of Medicine, Prague, CZECH REPUBLIC, 3CzechTechnical University in Prague, Faculty of Biomedical Engineering, Prague,CZECH REPUBLIC

The study aimed at proving stable sinus rhythm (SR), and expo-sing asymptomatic atrial fibrillation/tachycardia (AF/AT) recur-rences after ablation of longstanding persistent atrial fibrillation(LSPAF) by means of periodic transtelephonic monitoring.Methods: Of 135 consecutive patients (pts), all finished >6 month,and 115 pts >12 month follow-up after LSPAF ablation. They weremonitored following a lapse of 6 and 12 months with episodicECG recorder for 3 weeks and asked to send several random ECGrecordings a day or during the sense of arrhythmia. The ECGswere correlated with patients’ symptom diary. Repeat ablationwas performed in 41 pts. Results: First and second round of monitoring after 7+2, resp.15+7 months was completed in 132, resp. 110 pts, while 3, resp. 5patients with persistent AF/AT recurrence declined to participate.N. of monitoring days/pt was 23+8, resp. 24+7, and N. of trulymonitored days/pt, was 21+8, resp. 23+7 (94+15%, resp. 94+18%of the total monitoring days). Pts sent 77+28, resp. 76+31 recor-dings, i.e. 3.5+1, resp. 3.5+2.5 recordings/pt/day. SR was presenton 77+39%, resp. 89+29% of the recordings. Only SR was found in89 (66%), resp. 85 (74%) pts. Only persistent AF/AT in 21 (10%)and 9 (8%) pts, and additional 8(5%) or 5 (4%) pts had singleAF/AT terminated by cardioversion during monitoring, 2 episo-des in 2 pts were asymptomatic. Self-terminating paroxysmal/per-sistent AF/AT (1-13 episodes/pt) were found in 14 (10%), 11(10%), of whom 3, 4 pts did not perceived some of the episodes. Conclusion: Pts displayed good adherence to longer-term transte-lephonic monitoring after ablation of LSPAF. Recurrences werepredominantly represented by persistent symptomatic AF/AT;however, scarce unforeseen asymptomatic episodes cannot beexcluded. Rare patients with asymptomatic self-terminating paro-xysmal AF/AT are usually known to have the recurrences fromstandard means of follow-up. The work was supported by grantsIGAMZNR9143-3/2007, IGAMZNS/9684-4/2008,and IGAMZNS10261-3/2009.

BENEFICIAL EFFECT OF ATORVASTATIN FORPREVENTION ATRIAL FIBRILATION IN PACED PATIENTSE. HATZINIKOLAOU-KOTSAKOU, T.H. Beleveslis, G. Moschos, E. Reppas,M. Kotsakou, P. Latsios, K. Tsakiridis, S. Olalere

Saint Lukes Hospital -Thessaloniki -Electrophysiology Department, Thessaloniki,GREECE

Introduction: New generation pacemakers have diagnostic data sto-rage that allow for Atrial fibrillation (AF) monitoring over time. We studied the time to first AF recurrence and burden of AF followingDDDR pacemaker insertion in 85 consecutive patients (pts) with sym-ptomatic bradycardia and paroxysmal AF. AF burden (hr/d) wasretrieved at each follow-up visit by interrogation of the pacemaker. There were 62 males, mean age 72± 11 years, 42 with hypertension,22 with a history of CAD and 60 with normal left ventricular fun-ction (LVF).. Group A included 47 pts who were on atorvastatin tre-atment and group B was consisted by 38 no atorvastatin therapypts. AF recurrence following pacemaker implantation in 72 pts. Univariate predictors of no AF recurrences following pacemakerimplantation were normal LVF and the use of atorvastatin therapy.Age, sex, the antiarrhythmic drug therapy (Class I/IIIdrugs) andthe pacemaker programmation, were not predictive of AF recur-rence or burden over time. The time to first recurrence of AF wassignificantly earlier in not atorvastatin therapy pts (p<0.002),During follow-up, AF burden was significantly lower in the groupA, (median 0,12 hr./d) compared to the group B, (median 0.72hr/d, p=0.003). Atorvastatin therapy was an independent factorpredictive AF elimination. Conclusion:Atorvastatin is associated with a reduction in AFrecurrence and overall AF burden. Our results suggested the needfor a prospective randomized trial to assess the efficacy of atorva-statin for AF prevention.

QUALITY OF LIFE IN PTS WITH SUSTAINED AF ANDADVANCED CHF SUBMITTED TO BIVENTRICULAR PACE-MAKER UPGRADE OR BIFOCAL RIGHT VENTRICULARPACING OVER THE 12 MONTHS OF FOLLOW-UPB. MALECKA, A. Zabek, J. Lelakowski

Department of Electrocardiology, Institute of Cardiology, Jagiellonian University,John Paul II Hospital, Krakow, POLAND

Aim: Study of the quality of life (QOL) over the 12 months of fol-low-up (12FU) after upgrading from right ventricular apicalpacing (RVAP) to cardiac resynchronization therapy systems in theelderly.Methods: The QOL was evaluated using the SF-36 questionnairein 27 patients with a mean age of 71.2 years (20 males) with chro-nic heart failure (NYHA class III - 24, class IV - 3 patients) and AF,with a RVAP (for a mean of 92.5 months) submitted to upgradingto bifocal right ventricular pacing (BFRVP - 9 patients) or biventri-cular pacing (BVP - 18 patients). The patients were on ventricularpacing over 95% of the time.We analyzed self-assessment parameters at baseline and 12FUafter pacemaker upgrade: 1. Improvement in general QOL expressed as quality of life index(SF index). 2. Physical quality of life (PCS) and its correlation with NYHAclass in patients with BFRVP and BVP using Spearman’s rank cor-relation (RS). 3. Relationship between changes in the QOL with three diseases(hypertension, diabetes mellitus and renal failure). 4. Quality of completion of self-administered questionnaire in rela-tion with age.Results: Over 12FU 48% patients experienced improvement inQOL whereas 52% detected deterioration. The patients withimprovement less frequently had hypertension and diabetes mel-litus, but more often had renal failure.NE

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Error rates for completion of self-administered questionnaire was1.85% at baseline and 1.95% at 12FU, with difference being insigni-ficant. Errors in completion were not significantly related withpatient’s age.At 12FU RS between PCS and NYHA class was as follows: RS=-0.25 (p=0.33) in the BVP group, RS=-0.81 (p=0.0066) in the BFRVPgroup and RS=-0.43 (p=0.025) in the whole population.Conclusion: The study demonstrated a significant relationshipbetween improvement in physical quality of life and improvementin NYHA class at 12 months after pacemaker upgrading in thestudy population, especially in patients with BFRVP.

TREATMENT OF ATRIAL FIBRILLATION WITH RADIOFRE-QUENCY ENERGY DURING OPEN HEART SURGERYF. IEZZI, R. Cini, P. Sordini, V. Loiaconi, M. Santini

San Filippo Neri Hospital - Department of Cardiac Surgery, Rome, ITALY

Objectives: We present mid-term results of epicardial radiofre-quency ablation of atrial fibrillation, during concomitant cardiacsurgery.Methods: A selected group of 76 patients (mean age 67±6, 42 weremale) underwent the epicardial ablation of pulmonary veins byradiofrequency energy, with exclusion of the left atrial appendage,with a purse-string suture, and section of Marshall ligament, byelectrocautery at low power, during open heart surgery.The pulmonary veins were carefully dissected and isolated usinga blunt technique. Pulmonary vein ablation was achieved using abipolar radiofrequency device, at 25-40 W and local temperature of70°C, to guarantee the transmurality setting lines. Isolation of pulmonary veins was performed with a semicircularablation line close to the inferior, and another one around thesuperior pulmonary veins. These were connected by a transverselesion across the posterior left atrium wall.After the operation, all patients were monitored continuously forarrhythmias. Amiodarone administration was started with anintravenous 300 mg bolus, followed by an infusion of 900mg/day.After that, oral administration of 400 mg/day followed for 1 year.The anticoagulant drugs was stopped in patients with sinusrhythm and left atrial contraction, well documented by echocar-diography.There were no severe early postoperative complications. No com-plication related to the ablation procedure occurred.Results: Follow-up was complete at 1 year postoperatively.During postoperative days, some of the patients lose the sinusrhythm and they was treated with electrical cardiovertion. At thetime of discharge from hospital 76% of the patients were in sinusrhythm. The definitive rhythm stabilizes during the first year in89% of the patients. Conclusions: The primary end point was restoration of the sinusrhythm and re-establish the atrial mechanical function. Midtermresults in our patients show satisfactory results. We emphasizeevaluation of factibility and safety in procedure of atrial fibrilla-tion ablation.

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FREE PAPERSWednesday, December 1

CIRCULATING PROGENITOR CELLS IN PATIENTSWITH PERSISTENT ATRIAL FIBRILLATIONL. PERROTTA, E. Sticchi, F. Cesari, P. Pieragnoli, G. Ricciardi, C. Fatini,S. Sacchi, L. Padeletti, G.F. Gensini, R. Abbate, A. Michelucci

University of Florence, Florence, ITALY

Background: Altough electrical cardioversion (CV) is effective inrestoring sinus rhythm in patients with atrial fibrillation (AF), AF fre-quently recurs in spite of antiarrhythmic medications. This study wasaccomplished to better establish in patients with persistent AF whounderwent CV, the role of circulating progenitor cells (CPC) in rela-tion to recurrence rate of AF in the first 2 weeks after CV. Moreoverthe influence of NT-proBNP and homocysteine was evaluated. Methods: We studied 34 patients (26M, mean age: 66± 11.64 years)with persistent AF (duration <2 months) and mean LVEF 53±8%,who underwent CV. Blood samples for homocysteine, NT-pro-BNP and CPC (CD34, CD133, CD34133, CD34KDR, CD133KDR)were obtained before CV. Immediately after CV, a 12-lead ECGwas recorded. Thereafter, cardiac rhythm was monitored by along-term continous ECG recording (7-days) in order to excludeasymptomatic AF episodes and a standard 12-lead ECG was per-fomed at 7- and 15-days after CV. Results: AF recurrence (within 15 days) was observed in 15 pts(44%). No differences for age and CPC were observed betweenpatients with and without AF recurrences [mean age: 67.73±13 vs63.71±11 years; median CD34: 280 (range 80-1227) vs 248 (177-693)cells x 106 events; CD133: 280 (80-1227) vs 243 (107-687); CD34133:260 (80-1227) vs 237 (107-689); CD34KDR 17 (0-33) vs 15 (0-43);CD133KDR 17 (0-30) vs 11.50 (0-37); all p N.S.) There was a directcorrelation between: age and NT-pro-BNP (R=0.79; p<0.0001);homocysteine and CPC (CD133KDR: R=0.569, p<0.01; CD34KDR:R=0.516, p<0.03). Instead there was an inverse correlation betweenage and CPC (CD133: R= -0.51, p<0.006; CD34133: R=-0.376,p<0.045); NT-pro-BNP and CPC (CD34: R=-0.345, p<0.049; CD133:R=-0.346, p<0.048).Conclusion: CPC did not differ between patients with and with-out AF recurrences after CV. Age, NT-pro-BNP and homocysteineare able to condition CPC number even if in a different manner.

IS THE PERSONALITY TYPE ASSOCIATED WITH LONEATRIAL FIBRILLATION RECURRENCES RATE?: NEGATIVEAFFECTIVITY OF TYPE D PERSONALITY PREDICTS THEINCREASED RISKE. HATZINIKOLAOU-KOTSAKOU, E. Reppas, T.H. Beleveslis, G. Moschos,M. Kotsakou, P. Latsios, K. Tsakiridis

Saint Lukes Hospital -Thessaloniki -Electrophysiology Department, Thessaloniki,GREECE

Background: Type D (distressed) personality-a joint tendencytowards negative affectivity (NA) and social inhibition (SI) hasbeen observed that might affect the atrial fibrillation recurrencesrate (AFRR) in patients with lone atrial fibrillation (LAF). Hypothesis: We hypothesized that both Type D personality and itsindividual traits (NA and SI) predict AFRR in a population with LAF. Methods: Over a follow-up period of 4.8±0.8 years we recordedthe incidence of atrial fibrillation recurrences in a cohort of 185consecutive patients (mean age 48±11 years), who were knownwith LAF. At baseline, these patients completed the Type DPersonality Scale (DS-14, German Version), a validated self-descri-bing standard questionnaire.Results: NA and SI was diagnosed in 31.8% and 34.5% of thepatients respectively. From the total cohort, 22.3% had both NAand SI and therefore were classified as having a Type D personali-ty. In Cox regression analysis, Type D personality proved signifi-cantly and independently predictive for AFRR, with an adjustedHR of 2.19 (95% CI 1.07-4.48, P=0.031). When The dimensions ofType D were entered as individual variables into regression

models adjusting for age, gender, and arrhythmia duration, onlyNA significantly predicted AFRR (HR 2.27 (95%CI 1.15-4.78,p=0.029), whereas SI was not associated with AFRR. (HR 1.1095%CI 0.57-2.28, p=0.745) Conclusions: Our results confirm Type D personality is as a poten-tial risk for lone atrial fibrillation recurrences rate. Importantly,however, we found that the increased risk of AFRR with type Dpersonality is solely driven by NA (representing experience ofincreased negative distress), whereas SI (representing inhibition ofnegative emotions) is not associated with AFRR

LATE DETECTION OF ATRIAL FIBRILLATION IN APATIENT WITH CRYPTOGENIC STROKE THROUGHAN IMPLANTABLE CARDIAC MONITORD. CERVELLATI1, C. Brignola2, C. Camanini1, P. Vassallo1, A. Cervellati3

1Ospedale S.Maria della Scaletta - U.O. Cardiologia, Imola, ITALY, 2OspedaleS.Maria della Scaletta - U.O. Medicina, Imola, ITALY, 3Università di Bologna,Bologna, ITALY

We present a case of a man who sustained definite cerebrovascularinfarction. A 66 years old man, with diabetes mellitus type II andhypertension, was admitted to the hospital because of acute lefthemiparesis. Extensive work-up did not reveal any underlying etio-logy: EF=60%, normal left atrial diameter, no carotid lesions to ultra-sonography. The ECG at admission and during hospital stay wassinus rhythm. The patient was discharged with the diagnosis ofcryptogenic stroke and treatment with antiplatelets was started inaccordance with guidelines. Since both comorbidities (diabetes andhypertension) are also risk factors for developing atrial fibrillation(AF), we decided to implant a loop recorder Reveal XT (Medtronic).At the first follow-up 3 months after Reveal XT implantation therewere no arrhythmias stored by the device. At the next follow-up, 8months after implantation, 5 episodes of atrial arrhythmias (atrialflutter and AF) were stored during 2 consecutive days: one of themshowed an AF burden of 4 hours, but the patient did not feel anysymptom suggestive of AF. He was immediately switched from anti-platelet therapy to oral anticoagulation therapy.Conclusion: Detecting AF after stroke is not a proof that this wasthe cause of the cerebral ischemia, but any patient with AF and aCHADS2 score of at least 2 should be anticoagulated in accordan-ce with guidelines. This patient had a score = 4: oral anticoagula-tion is expected to dramatically decrease the risk of a stroke recur-rence in this high risk patient.

TEMPORAL DISTRIBUTION OF ATRIAL ARRHYTHMICEPISODES: IMPLICATIONS FOR ATRIALARRHYTHMIAS MONITORINGA. CAPUCCI1, F. Censi2, R. Quaglione3, A. Castro4, E. Capponi5, P. Paoloni6,G. Gasparini7, G. Calcagnini2, E. Mattei2, P. Bartolini2, G. Biancalana8,A. Gargaro8

1Lancisi Hospital, Ancona, ITALY, 2Istituto Superiore di Sanità, Rome, ITALY,3Policlinico Universitario Umberto I, Rome, ITALY, 4Sandro Pertini Hospital, Rome,ITALY, 5Ospedale Civile di Gubbio, Gubbio, ITALY, 6A. Murri Hospital, Fermo, ITALY,7Umberto I Hospital, Mestre, ITALY, 8Biotronik Italia, Vimodrone (MI), ITALY

Background: Standard monitoring/follow up methods forpatients with paroxysmal Atrial Tachycardia/Fibrillation (AT/AF)have low sensitivity and specificity. An efficient monitoring of AFpatients should allow daily ECG monitoring at home with timingcorrectly set to increase the probability AF detection. Methods and Results: The aim of this study is to investigate thedaily distribution of AT/AF episodes, analyzing data from theBurden II Study which involved patients implanted with pacemakerfor Brady-Tachy Syndrome. The analysis was performed on themode switch list including date, time and duration of episodes. Atotal of 11747 AT/AF episodes were analyzed in terms of onset timeAT

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and duration, from 119 patients. Most episodes (8654, 73.7%) wereshorter than 30 s, while 1426 (12.1%) lasted >5 minutes. About 59%of episode onset occurred during the day, 41% during night-time.Shorter episodes started mainly during day respect to longer episo-des. Long-lasting episodes are equally distributed between day andnight. The overall onset pattern was non-uniformly distributed overthe 24 h (p<0.0001, Chi-square test). Most episodes occurred betwe-en 9.00 AM and 10.00 AM. For episodes >30s, onset distribution sho-wed peaks during night, early in the morning, at 7.30 AM, at lunchti-me, and in mid afternoon. Qualitatively speaking, occurrences of epi-sodes longer than 30 s are more frequent during night and early mor-ning (from 12.00 PM to 10.00 AM) than during day and late evening.AT/AF episodes were more common on Monday and substantiallyless common on the end of the week.Conclusion: From our results it appears that the 24h periods whenAF episodes could be most likely detected are the early morning,lunchtime, and the first sleep hours. The clinical usefulness of ouranalysis relies on the indication of the moments of the day morefavorable to arrhythmic events, regardless of symptoms.

DOES ONE SIZE FIT ALL? EFFECTIVENESS OFA WARFARIN DOSING REGIMEN IN THE OBESE ANDMORBIDLY OBESEA. SALACATA, S. Keavey

Great Lakes Heart Center of Alpena, Alpena, USA

Although anticoagulation with warfarin is the most effectivemethod of stroke prevention in atrial fibrillation (AF), use of thedrug is difficult, given it¡¦s mechanism of action and its interac-tion with food and other medications. A number of algorithms formanaging warfarin anticoagulation have been developed and arein use. The effect of obesity on the performance of these algo-rithms, however, has not been described. METHODS We had pre-viously developed a web based program for dosing warfarinbased on ACCP recommendations, and validated it in the elderly.From our anticoagulation practice we then identified 167 patients(102 male, age = 75.1 +/- 10.2 yrs.) with chronic atrial fibrillationwhose medical regimen was otherwise stable. Their INR and clini-cal histories were then abstracted. They were then stratified accor-ding to BMI into normal (N), overweight (OW), obese (OB) andmorbidly obese (MOB). The times in therapeutic (TTR), as well astime in sub therapeutic (SUB) and supra therapeutic (SUP) rangesfor each group were then calculated and compared using ANOVA.Results: There were significantly more men than women(p=0.0002) in our cohort. There was however no difference in agebetween men and women (74.21 „b 9.90 yrs. vs. 76.60 „b 10.89,p=0.14). The patients in the MOB group were significantly youn-ger compared to those in the other groups (MOB = 68.3¡Ó12.8 yrs;N = 76.7¡Ó12.9; OW = 78.2¡Ó8.9; OB = 73.7¡Ó9.4). Otherwise obesi-ty did not seem to affect the TTR or the SUB or SUP.

N (40) OW(58) OB(57) MOB(12)pTTR 0.60 0.66 0.65 0.63nsSUB 0.26 0.20 0.20 0.26nsSUP 0.13 0.12 0.14 0.10nsConclusion: A warfarin dosing regimen based on current ACCPguidelines is robust and effective regardless of body weight.

AV NODE ELECTRIC BYPASS IN PATIENTS WITHREFRACTORY SYMPTOMATIC PERMANENT ATRIALFIBRILLATION: SINGLE CENTRE PROSPECTIVE STUDYP. FERRERO, P. Defilippo, P. Ferrari, R. Brambilla, F. Cantù

Ospedali Riuniti Bergamo, Dipartimento Cardiovascolare, Unità Elettrofisiologiaed Elettrostimolazione, Bergamo, ITALY

Background: Ablate and pace provide optimal rate control inpatient with refractory symtpomatic atrial fibrillation. Main draw-

back of this strategy is life-long nonphysiologic ventricular activa-tion. An appealing solution is to set up an AV node electric bypass(AVNEB) combining pure His bundle stimulation with compactnode ablation. We sought to investigate the feasibility and the longterm clinical and technical outcome of this strategyMethods: This intention-to-treat study enrolled patients with longlasting symptomatic atrial fibrillation refractory or not further amena-ble of rhythm control with heart rate not controlled. Preliminary wor-kup included: echo, six minute walking test, quality of life assessment(SF 36). All patients underwent an attempt of AVNEB; if it failed, con-ventional ablate and pace procedure was delivered. In patients under-going AVNEB a back up lead was implanted. Pre procedural asses-sment and device control were repeated at 3, 6 and 12 months. Results: 12 patients (67±6 years) were enrolled: in 10/12 AVNEB wasachieved, in 2/12 a conventional ablate and pace procedure was per-formed. Out of the 10 patients with AVNEB, we observed a transientloss of capture during RF application in 5/10, a late loss of His cap-ture in 2/10 and recovery of AV conduction in 2 patients that requi-red a redo ablation. His threshold increased over time (4,1±0,9 vs1,49±0,85 V@0,5: 2,5 fold at 1 year vs baseline). All 12 patients, signi-ficantly improved quality of life scores (51,25±8,9 vs 41,6±8,7) and 6minute Walking Disatance (631±128 vs 400±76 m) p=0,01; while EFincrease (57% vs 51%) was not significant. Conclusions: Although AVNEB is an attractive strategy, we obser-ved important drawbacks that may limit its routine applicability. Themain challenge appears to be the capability of delivering a stablepure His pacing togheter with an efficacious ablation of the AV node.

HYBRID TREATMENT OF LONE PERSISTENT AF: A SAFEAND EFFECTIVE THERAPEUTICAL OPTIONG. BISLERI1, A. Curnis2, L. Bontempi 2, C. Muneretto1

1Division of Cardiac Surgery, University of Brescia Medical School, Brescia, ITALY,2Division of Cardiology, University of Brescia Medical School, Brescia, ITALY

Background: Ablation strategies (either percutaneous or surgical)for the treatment of lone atrial fibrillation(AF) have been rapidlyevolving during the past decade with improved results and outco-mes. We therefore investigated the results of a novel, hybridapproach combining a surgical and electrophysiological(EP) abla-tion in patients with lone AF. METHODS: Twenty-one(21) consecutive patients with either per-sistent (2 pts, 9.5%) or long-standing persistent (19 pts, 90.5%) iso-lated AF were enrolled in the study: mean age was 63.3±10.1 yrs.,mean AF duration was 92.2 months(range: 20-240), mean left atrialdimension was 50.2 mm (range: 32-60). The surgical procedureconsisted of a monolateral, thoracoscopic approach in order to per-form a "box" lesion set with an irrigated radiofrequency monopo-lar device(Cobra Adhere XL, Estech). RESULTS: The procedure was successfully completed in all caseswith a mean ablation time and procedural time of 25±7 and 78±18minutes respectively. Exit block was confirmed intraoperatively inall cases, while entry block was achieved in 85.7% (18/21 pts.). Acontinuous monitoring rhythm device (REVEAL XT, Medtronic)was implanted at the time of surgery. No ICU stay was requirednor any complications occurred; hospital mortality was 0%. At amean interval of 32±2 days following surgery, an EP study wascarried out: entry-exit block was confirmed in 76.1%(16/21) whilegaps at the level of the box lesion were observed in 23% (5/21) ofpts. Respectively. Additional right- and left-sided lesions were per-formed in 62% of cases (13/21 pts.). At a mean follow-up of 18±4months, 90% (19/21) of pts are in sinus rhythm and no cases of leftatrial flutter were recorded.CONCLUSIONS: Combined endoscopic and trans-catheter hybridapproach in persistent AF provided superior clinical outcomeswhen compared to isolated surgical/EP approaches.

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CATHETER ABLATION OF ATRIAL AUTOMATICTACHYCARDIA MISTAKEN FOR INAPPROPRIATESINUS TACHYCARDIAC. SARDU1, S.L. D’ Ascia1, V. Marino1, V. Liguori1, V. Marullo2,V. Schiavone2, C. D’ Ascia1

1AOU Federico II, Naples, ITALY, 2Casa di Cura Pineta Grande, Caserta, ITALY

A 39 year old woman drug refractory with persistent atrial tachy-cardia in the last year,mistaken for inappropriate sinus tachycar-dia. Automatic atrial tachycardia is a supraventricular arrhythmia,frequently associated with progressive cardiac dilatation but it ispotentially reversible with control of the arrhythmia (1-2). Becausemedical treatment is of limited efficacy (3-6) radiofrequency abla-tion is a higly effective technique A quadripolar Josephson diagno-stic catheter was inserted into the coronary sinus via left subcla-vian vein as a reference. A twenty pole catheter HALO was inser-ted in right atrium perimeter, a quadripolar catheter in right ven-tricular apex and a quadripolar catheter in his region, via rightfemoral vein. An 8 mm tip catheter was used for ablation.The electrophysiological findings showed a stable atrial tachycar-dia of 520 msc cycle length showing cranio-caudal activation (figu-re 1), regular atrio-ventricular conduction, and an AP intervalduring atrial tachycardia > 30 msc near HRA 9-10. Once earlyatrial activation site was located, we have done pace mapping. We performed a reconstruction of the right atrium using EnsiteNavX system. (Endocardial Solutions Inc., St Paul, Minnesota) (7).An activation-voltage map, obtained moving the ablation catheterpoint by point inside the right atrium while patient was still in sta-ble tachycardia, showed a large no-signal area on a surface betwe-en right auricola and superior cava vein. RF application in conti-nuos way (70 Watts 50 ºC) was attempted along this site drawingback the ablation catheter from the scar area to the superior cavavein,without using fluoroscopy during the procedure (figure 2).After ten RF applications atrial tachycardia was interrupted withrestoration of sinus rhythm (figure 3). EnSite NavX system is anexcellent electroanatomic and activation map of any cardiac cham-ber and reliable monitoring of the ablation catheter (8), reducesfluoroscopy time during ablation precedures and allows to per-form difficult procedures with complex substrates.

RESULTS OF THE SURVEY ITHAQUE: MONITORINGAND THERAPIES FOR SYSTOLIC HEART FAILURECH. Leclercq, M. HERO,

CIC_IT, Inserm U 642, University of Rennes I and CHU, Rennes, FRANCE

Electrical therapies by defibrillators (ICD) and resynchronizationdevices (CRT-D - CRT-P), have demonstrated their benefits onsymptoms, morbidity and mortality in selected heart failurepatients (HF). The ITHAQUE survey aims to describe the differentsupports of patients in HF patients with impaired left ventricular(LV) function (LV ejection fraction < 45%)Methods: 927 patients treated for HF were seen in outpatient visitwith a general cardiologist (75%) or in a tertiary center (25%). Asurvey of treatments and follow-ups was completed by the physi-cian. 3 groups under optimal treatment, defined by the FrenchSociety of Cardiology (SFC) guidelines, have been analyzed:Gr1 - Class 1B (patients with ischemic cardiomyopathy and coro-

nary revascularization, NYHA II and III, LVEF <30%) - Class 2aB(30% <LVEF <35% + VT_VF triggered) and class 2bC.Gr2 - Class 2aB (dilated cardiomyopathy, NYHA II and III, LVEF<30%) and class 2bC (30% <LVEF <35%).Gr3 - Class 1B (HF Patients, NYHA III and IV, LVEF <35% andQRS> 120 ms) Results: Of the total patients, 79 received an ICD (8.5%), 22 a CRT-D (2.4%) and 76 a CRT-P (8.2%). On the other side, 279 patients eli-gible according to the recommendations of the SFC did not receiveadditional treatment with ICD or CRT (30%). Pharmacological

treatment associated is mainly composed of IEC (76.5%), Beta-blockers (76.6%), Diuretics (90%), anticoagulants (80%) and Anti-arrhythmic (31%). Rules lifestyle modifications (77.8%) and practice of physical activ-ity (31.2%) are also prescribed, associated or not. Conclusion: Although the specific conditions of therapeuticpatient must be taken into account, the ITHAQUE survey didshow that the electrical therapies recommended by the SFC forheart failure patients with systolic dysfunction are underused.

PREDICTORS OF ALL-CAUSE MORTALITY, VENTRICULARARRYTHMIAS AND CARDIAC HOSPITALIZATIONS INPATIENTS IMPLANTED WITH CRT: DATA FROM THEACTION-HF REGISTRYL. OTTAVIANO1, C.D. Dicandia2, M. Mantica3, L. Santangelo4, G.Q. Villani5,P. Pantaleo6, P. Rossi7, A. Perucca8, E. Marangoni9, G.L. Botto10

1Clinica Multimedica, Milan, ITALY, 2Care and Research GVM, Bari-Lecce, ITALY,3S.Ambrogio, Milan, ITALY, 4A.O. Monaldi, Naples, ITALY, 5Osp. S.G. Da Saliceto,Piacenza, ITALY, 6CdC Villa Azzurra, Rapallo, ITALY, 7Ospedale S. Martino,Genoa, ITALY, 8P.O. SS. Trinità, Borgomanero, ITALY, 9Ospedale Maggiore, Milan,ITALY, 10Ospedale S. Anna, Como, ITALY

Aim: In patients implanted with cardiac resynchronization thera-py with defibrillation backup (CRT-D) according to current clinicalpractice, identify which characteristics may predict major eventsamong all-cause mortality, cardiac cause hospitalizations or ventri-cular arrhythmias.Methods and Results: Data from 406 patients enrolled in theACTION-HF registry were considered: male gender 81%; ischemicaetiology 48%; age 68±9 years; QRS duration 157±32 ms; ejectionfraction (EF) 26±6%; NYHA class>II 73%; Atrial Fibrillation(AF)history: 28.2%. Within 2 years 47 Patients died, 48 were hospitali-zed for cardiac reasons and in 123 at least one adjudicated ventri-cular arrhythmia episode occurred. Among the analyzed parame-ters (diabetes, chronic obstructive pulmonary disease (COPD),renal disease, NYHA class, QRS duration, EF, history of AF), AFwas associated with increased all-cause mortality (HR:2.05 p<0.05)and ventricular arrhythmias (HR:1.81 p<0.01); additionally COPDwas associated with increased cardiac cause hospitalization(HR:2.00 p<0.05)Conclusions: In this data set of CRT patients, AF patients are expo-sed to higher risk for mortality and ventricular arrhythmias atmid-term follow up. Pulmonary co-morbidity is also associatedwith cardiac cause hospitalization. Data on longer follow up areneeded to confirm these results.

THE EFFECTS OF CARDIAC RESYNCHRONIZATION THE-RAPY ON PATIENTS WITH MEDICALLY REFRACTORYHEART FAILUREG. PANATTONI, L.P. Papavasileiou, D.G. Della Rocca, F. Vecchio, V. Minni,C. Tota, M. Cesario, F. Paparoni, A. Di Molfetta, G.B. Forleo, L. Santini,F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Introduction: Cardiac resynchronisation therapy (CRT) is effectivein the treatment of patients with heart failure (HF) and in theimprovement of their functional capacity. In these patients qualityof life (QoL) is severely compromised. Special attention must begiven not only to objective parameters, but also to the patient’shealth self-perception. The aim of this study was to determine the benefits of resynchro-nization in patients with medically refractory HF.Materials and Methods: We investigated 49 consecutive patients(67,3% men, mean age 68,52±10,02 years) who underwent a CRTimplantation at our Institution between September 2005 and July2010. Objective parameters of HF were evaluated with the six-CA

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minute walk test (6MWT) and echocardiography while health self-perception was measured with the Minnesota Living with HeartFailure Questionnaire (Minnesota LihFE).Results: The functional benefits of resynchronization were valida-ted by an increase in the walking distance measured by the sixminute walk test from 236±97 to 257±67 meters (p=n.s.) and by animprovement in the left ventricular ejection fraction (EF) from24,53±7,05 to 33,36±9,51 (p=n.s.). Health self-perception evaluatedby Minnesota LihFE showed that the mean total score decreasedfrom 37,10± 21,80 to 28,27± 20,03 after CRT (p=0.06); particularly,physical and emotional dimensions improved from 16,3± 9,4 to12,44± 8,87 (p=0.05) and from 7,5± 6,0 to 5,6± 5,1 (p=0.13) respecti-vely. Conclusion: Cardiac resynchronisation therapy is effective anduseful in patients with HF. Even if objective parameters of HF,such as EF and 6MWT, do not present a statistically significantamelioration, patients’ self-perception of health status increases. Amore careful evaluation and eventually treatment of their psycho-logical status may help them to improve their quality of life.

CARDIAC RESYNCHRONIZATION THERAPY IN ISCHEMICPATIENTS WITH NARROW QRS: THE NARROW-CRTSTUDYC. Muto1, R. CALVANESE1, M. Nastasi2, P. Gallo3, F. Solimene4, R. Sangiuolo5,L. Ascione1, G. Carreras1, L. Ottaviano5, C. La Rosa6, N. Marrazzo4,M. Canciello1, P. Guarini3, R. Iengo1, B. Tuccillo1

1Ospedale S. Maria di Loreto Mare, Naples, ITALY, 2Casa di Cura Villa Bianca,Bari, ITALY, 3Casa di Cura Villa dei fiori, Acerra (NA), ITALY, 4Casa di CuraMontevergine, Mercogliano (AV), ITALY, 5Ospedale Buon ConsiglioFatebenefratelli, Naples, ITALY, 6Casa di Cura Villa Verde, Taranto, ITALY

Aim: Benefits of CRT in narrow QRS patients has been analyzedonly in small, not randomized trials. Purpose of this randomizedprospective study is to demonstrate the efficacy of CRT in patientswith ischemic cardiomyopathy and narrow QRS with intraventri-cular mechanical dyssynchrony.Methods: From February 2007 to June 2009, 234 patients wereenrolled in accordance with the following inclusion criteria: ische-mic heart disease, sinus rhythm, QRS < 130 ms, NYHA III and II,left ventricular (LV) ejection fraction < 35%.LV dyssynchrony (LVD) was determined by TDI methodology cal-culating the delay between septal to lateral wall, LVD was consi-dered positive if bigger than 60 ms.Patients with positive LVD received the CRT-D device and wererandomly assigned to the CRT-ON group or CRT-OFF group in 1:1ratio.Patients without mechanical dyssynchrony (LVD<60ms) wereawarded in the control group and implanted with bicameral ICDas current implant guidelines.The primary endpoint was the death from any cause or ventricu-lar/atrial arrhythmias or HF hospitalization whichever came first.Results: We enrolled 234 patients and randomized 103 patients (52CRT-ON, 51 CRT-OFF) with the following characteristics: age 67±10years; male 89%; QRS 104±17 ms; EF 28±5%; MDI 79±20 ms; the dif-ference between the two groups were not statistical significant.On 72 patients with a 6 month follow-up, the primary endpointswere achieved by 25% (34% CRT-OFF; 17.5% CRT-ON). The biggest difference between the two groups has been related toHF hospitalizations (12.5% CRT-OFF; 5% CRT-ON) and ventricu-lar arrhythmias (15.5% CRT-OFF; 7,5% CRT-ON).Conclusions: Partial results of our work show that the differencesbetween two groups (CRT-OFF, CRT-ON) are strong but withoutsignificant differences. One year follow-up, as scheduled, could confirm that in ischemicpatients with narrow QRS and evidence of mechanical dyssyn-chrony, the CRT is effective in slowing the progression disease.

CORRELATION BETWEEN INTRA-THORACIC IMPEDANCEAND IMPEDANCE CARDIOGRAPHY FOR THE DETEC-TION OF HEART FAILURE DETERIORATION:A LONGTERM STUDYE. MORO1, E. Zorzi1, C. Marcon2, G. Allocca2, E. Marras2, N. Sitta2, P. Dovigo1,P. Delise2, A. Varbaro3, S. Valsecchi3

1Department of Cardiology-Arzignano General Hospital, Arzignano, ITALY,2Department of Cardiology-Conegliano General Hospital, Conegliano, ITALY,3Medtronic, Rome, ITALY

Background: Some implantable defibrillators (ICD) are able toautomatically measure the intra-thoracic impedance between theICD case and the right ventricular lead to detect pulmonary fluidoverload and to alert patients of impending heart failure deterio-ration. Similarly, it was demonstrated that ambulatory noninvasi-ve impedance cardiography (ICG) can identify patients at increa-sed near-term risk of recurrent decompensation, when performedat regular intervals. Aims: to assess the relationship between ICD and ICG-detectedimpedance changes during long-term follow-up, concerning theheart failure status of patients with a CRT-ICD device.Methods: We studied 22 patients (66 ±11y, NYHAclass 2.5±0.7,ejection fraction 25±5%, QRS duration 158±32ms) implanted witha CRT-ICD device capable of intra-thoracic impedance measure-ment. CRT-ICD telemetry interrogation, intra-thoracic and ICGnon invasive impendence were regularly assessed every fourmonths of follow-up. We also evaluated the clinical status of ptswhich was quantified through a Heart Failure Score (HFS) basedon heart failure symptoms and signs (score range from 0 to 10)Results: During 14±5months of follow-up, 57 assessments of bothICD impedance and ICG were performed. The regression analysisdemonstrated a significant correlation between paired changes ofimpedance (r=0.606, p<0.001). With respect to stable clinical status,the median ICD-estimated fluid index (i.e. the cumulative diffe-rence between the daily impedance and the reference) resultedhigher when heart failure worsened with an increase of HFS(21ohm*days vs. 6ohm*days: p<0.05).Conclusions: These data demonstrate a correlation between impe-dance changes automatically measured by the ICD and those esti-mated with a validated method of noninvasive ICG during long-term follow-up. Confirming previous findings obtained with ICG,a worsened heart failure status was found to be associated withincreased values of thoracic fluid content as assessed by the ICD.

INTRAOPERATIVE SCREENING OF RIGHT VENTRICULARPACING SITES IN HEART FAILURE PATIENTS UNDER-GOING THE CARDIAC RESYNCHRONIZATION THERAPYA. TSYGANOV, M. Didenko, A. Bobrov, A. Fedyainova, G. Khubulava

Military Medical Academy, Saint-Petersburg, RUSSIA

Aim: We have evaluated the impact of the right ventricular (RV)pacing site on the hemodynamic parameters during the cardiacresynchronization therapy (CRT) procedure. Methods: We observed 7 patients (4 women and 3 men, 58 to 70years) with ischemic and dilated cardiomyopathy who had beenundergone CRT device implantation. Two RV pacing sites werestudied in the random order: RV apex and RV septum near the Hisbundle (RVS). The location of the electrode was confirmed by X-ray in 3 projections. At each site we have measured the cardiac out-put (CO) by two methods: the first was echocardiographic timevelocity integral in the ascending aorta, the second was invasivepulse contour CO calculation method. CO was calculated at therest and at increased heart rates (HR): 70, 80…140 bpm. The firstpoint of CO curve on the chart was equal to the initial CO prede-termined as 100%. All the next points on the curve of CO were cal-culated as percentage of the initial value. The best position is cha-racterized by the maximal increase in CO at the maximal HR.CA

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Critical HR is determined as point on the chart when CO startsgoing down. Value of critical HR is characterized contractilityreserve. Results: The correlation between values of CO calculating by twomethods was moderate, r=0.51 (p<0,05). Atrial pacing demonstra-ted an increase in CO up to a mean 18% at 110 bpm. Biventricularpacing with RV apex site turned out to be the better comparedwith RVS site pacing. The RV apex pacing has increased CO up to29% at 140 bpm, unlike IVS pacing - up to 25% at 120 bpm.Conclusion: The new method of CO monitoring during the CRTdevice implantation is able show the best position of RV lead withthe maximal myocardial reserve.

LONG-TERM PACING AND SENSING FUNCTION OFCATHETER DELIVERED PACING LEADS TO THE RIGHTVENTRICULAR POSTERIOR OUTFLOW TRACT IN CAR-DIAC RESYNCHRONIZATION THERAPYH. KRISTIANSEN, T. Hovstad, G. Vollan, S. Faerestrand

Haukeland University Hospital, Department of Heart Disease, Bergen, NORWAY

Purpose: The conventional right ventricular (RV) lead position incardiac resynchronization pacemakers (CRT-P) is the RV apex.There are few data on pacing and sensing function and associatedcomplications of RV leads located in high posterior septal position(RV-HS) in CRT-P.Materials and Methods: One hundred and eight consecutivepatients with standard CRT-P indications were included from2005-2008. The RV-HS lead position was obtained by using theSelect Secure systemTM (Medtronic Inc, Minneapolis, Minnesota,USA). A lumenless 4,1French RV lead (Medtronic 3830; screw-in;bipolar) was advanced through a deflectable guide catheter to RV-HS and the position was verified by fluoroscopic anterior-poste-rior and left anterior oblique view. Pacing thresholds at 0,5ms and2,5V, sensing electrograms and lead impedances were measured atimplant and repeated at 1,3,6,12,18 and 24 months. Results: From 6-24 months the pacing thresholds were stable andmeasured 0,83V±0,35V (p=0,1) at 0,5ms and 0,09ms±0,05ms(p=0,09) at 2,5V. From 6-24 months the sensing amplitudes werestable at 11,8mV±5,5mV (p=0,7) and the lead impedances were sta-ble at 673Ohm±216Ohm (p=0,3). There was one RV-HS leadimplant failure (0,9%). Intraoperatively there were 2 lead dislodge-ments, 5 high RV pacing thresholds and 2 low R-waves that requi-red RV-HS lead reposition. During two-year follow-up 3 late RVlead revisions (2,8%) occurred. Conclusion: The RV-HS lead position with catheter deliveredpacing lead in CRT-P is safe and demonstrates acceptable and sta-ble pacing and sensing function.

SINUS RHYTHM RECOVERY IN PATIENTS WITH CHRONICATRIAL FIBRILLATION AND DILATED CARDIOMYOPATYWHO UNDERWENT CRT IMPLANT (SIBILLA STUDY)P. TURCO1, A. D’Onofrio2, G. Stabile3, F. Solimene4, V. La Rocca5,C. Cavallaro2, A. Iuliano3, N. Marrazzo4, F. Vecchione2, S. De Vivo2,C. Ciardiello6, A. De Simone5

1Hesperia Hospital, Modena, ITALY, 2A.O. Monaldi, Naples, ITALY, 3ClinicaMediterranea, Naples, ITALY, 4Casa di Cura Montevergine, Mercogliano (AV),ITALY, 5Casa di Cura S. Michele, Maddaloni (CE), ITALY, 6Boston Scientific, Milan,ITALY

Aim: The study aim was to evaluate the feasibility of performingelectrical cardioversion (EC) to restore sinus rhythm (SR) and theEC efficacy in preserving SR at follow-up, in patients implantedwith CRT-D with chronic atrial fibrillation (AF) and dilated cardio-myopathy.Methods: We screened 55 consecutive CRT-D patients with sym-ptomatic HF of any origin and chronic AF and enrolled 41 patients

with left bundle branch block (QRS duration>120 ms) and left ven-tricular ejection fraction (LVEF)<35%. In all patients, an atrial leadwith either passive or active fixation was used. We scheduled oneor more internal, by means of device, or external EC in all eligiblepatients.Results: Major population characteristics are: male gender 75%,age 71±9 years, ischemic heart disease 54%, III NYHA functionalclass 93%, QRS width 138±16 ms, LVEF 23.6±5.7% and left atrialdiameter (LAD) 51.3±7.8 mm.At a mean follow-up of 2.7±1.8 months 19/41 (46%) patientsunderwent at least one EC. Left atrial appendage thrombosis,blood coagulation status and poor clinical status were the majorreasons that jeopardize the EC procedures in the remainingpatients. No complications occurred during the EC procedures. ECwas effective in restoring SR in 13 patients (68% of treatedpatients); an intention to treat analysis shows a success rate of ECprocedure in restoring SR in 31% (13/41) of overall population.Eleven among thirteen patients (85%) with effective EC remainedin SR at a mean follow-up of 9.2±7.6 months. Moreover, spontane-ous conversion in SR was observed in two patients, one of thesewith an ineffective EC. Conclusion: In this study, EC was feasible in less than 50% ofpatients with chronic AF and CRT-D devices, however SR was per-sistent at six months in more than 30% of population, thus sugge-sting that an atrial lead may be considered at implant.

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SPECTRAL ANALYSIS OF SPONTANEOUS AND INDUCEDVENTRICULAR FIBRILLATION IN PATIENTS WITHIMPLANTABLE DEFIBRILLATORM. BERNASCONI1, V.D.A Corino2, S. Mantovano2, M. Marzegalli1, M. Santini3,M. Lunati4, P. Defaye5, J. Mermi6, A. Proclemer7, S. del Castillo-Arroys8,A. Kloppe9, L. Manotta10, E. Santi10, A. Marseglia10, S. Cerutti2

1San Carlo Hospital, Milan, ITALY, 2Politecnico di Milano, Milan, ITALY, 3OspedaleSan Filippo Neri, Rome, ITALY, 4Ospedale Niguarda Ca Granda, Milan, ITALY,5Hopital Albert Michalon, Grenoble, FRANCE, 6Klinikum Dortmund, Dortmund,GERMANY, 7Ospedale Santa Maria della Misericordia, Udine, ITALY, 8HospitalGermans Trias i Pujol, Badalona, SPAIN, 9Klinikum Ludenscheid, Ludenscheid, GER-MANY, 10Medtronic Italia, Sesto San Giovanni, ITALY

Purpose: It is well known that induced ventricular fibrillation (VF)is a sort of synchronized rhythm. Purpose of this study is to com-pare spontaneous and induced VF in patients with implantabledefibrillator (ICD).Materials and Methods: Sixteen patients with ICD were included inthe study. Power spectral analysis was performed on intracardiac elec-trograms of VF episodes using Welch periodogram (256-sampleHamming window, 50% overlapping) and the following parameterswere extracted: i) the dominant frequency (fD), i.e., the frequency atwhich the absolute spectral maximum occurs, ii) the spectral concen-tration (C), i.e., the area under the dominant frequency peak, and iii)the median frequency (fM), i.e., the frequency for which the integratedsignal amplitude is one-half of the total integrated power. Unpaired t-test was used to evaluate the differences between parameters.Results: Comparing spontaneous and induced episodes, the latterseem to be more organized. In particular, the fD and C are higher ininduced episodes, whereas fM is lower, being fD: 4.8±0.6 Hz vs.5.2±0.7 Hz, C: 0.35±0.21 vs. 0.43±0.23, fM: 13.3±3.3 Hz vs. 12.2±3.5 Hz.This trend remains the same when comparing patients with ejectionfraction > or < 30%. Comparing spontaneous episodes, only patientswith clinical HF seem to present more disorganized VF. In fact, thefD and C are higher in non-HF episodes, whereas fM is lower, beingfD: 4.6±0.5 Hz vs. 5.2±0.6 Hz, p=0.02, C: 0.26±0.12 vs. 0.48±0.25,p=0.02, fM: 14.5±2.9 Hz vs. 11.6±3.2 Hz, p=0.05.Conclusion: Induced episodes of VF seem to be more organizedthan the spontaneous ones. In addition, HF seems to increase thedisorganization of the arrhythmia.

INAPPROPRIATE THERAPIES’ RATE IN A ICD’S RECIPIENTSPOPULATIONV. ROMANO, G. Panattoni, L. Duro, V. Schirripa, M. Sgueglia, G.B. Forleo,L. Santini, G. Magliano, L. Papavasileiou, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Introduction: The implantable cardioverter defibrillator can treateffectively life-threatening ventricular arrhythmias. One of themajor complications is the inappropriate therapies delivery.Although complex and multiple options for tachycardia detectionand therapy have been developed, inappropriate shocks are stilldelivered in up to 5-10% of patients with dual chamber discrimi-nation algorithms enabled. Methods: We evaluated 389 consecutive patients implanted withICD from 2003 to 2010, 325 males (83.5%), mean age 66.7±11.4 years.All patients underwent a mean follow up of 21.9±15.3 months. Results: Twenty two of 389 patients evaluated underwent inap-propriate therapies. In 12 patients (54.5%) the inappropriatedischarges were caused by atrial fibrillation; two shocks and oneATP were caused by sinus tachycardia (13.6%), 2 shocks and oneATP (13.6%) by supraventricular tachycardia. We also reportedtwo cases of shock on electromagnetic interference, one T waveoversensing and one lead fracture (Medtronic Sprint Fidelis).Conclusions: In our population the incidence of delivery of inap-propriate therapies is 5.7% and the most common cause is highventricular rate atrial fibrillation. Moreover most inappropriatedischarges occurs within one year after implantation.

PREDICTIVE VALUE OF FRAGMENTED QRS IN ICD PATIENTSWITH LEFT VENTRICULAR DYSFUNCTION IMPLANTED INPRIMARY PREVENTION OF SUDDEN DEATHD.G. DELLA ROCCA, G.B. Forleo, L. Santini, L.P. Papavasileiou, G. Magliano,G. Panattoni, V. Romano, A. Viele, A. Politano, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Introduction: In primary prevention implantable cardioverterdefibrillator (ICD) patients, the incidence of appropriate ICD the-rapy is relatively low, prompting for better risk stratification.Fragmented QRS (fQRS) on a 12-lead ECG has been associatedwith adverse outcomes. Aim of this study was to evaluate the pro-gnostic value of fQRS in ICD recipients.Methods: 271 consecutive ICD patients implanted at our institutionfor primary prevention of sudden cardiac death (SCD), were retro-spectively evaluated. Patients were divided in two groups based onthe presence or the absence of fragmented QRS on the ECG obtainedbefore ICD implantation. The end-point of the study was all causemortality or the occurrence of any appropriate ICD delivered thera-py, whether shock or antitachycardia pacing.Results: Among 271 ICD recipients (232 males, age 66.4±11.0),fQRS was observed in 64 patients (23.6%). There were 135 patients(49.8%) with wide QRS at the time of implantation. Among thesepatients, fQRS was found in 15 subjects (11.1%). Patients infQRS(+) group were more likely to have coronary artery diseaseand a lower QRS duration, than those without fQRS.During amean follow-up of 23.2±18.5 months, mortality or ICD therapywere 12.5% and 17.2%, respectively, for fQRS(+) patients and12.7% and 19.0% for fQRS(-) patients (P =NS). By Kaplan-Meieranalysis, event-free survival was similar in the two groups.Conclusion: In ICD recipients for primary prevention of SCD,fQRS is not helpful in selecting a subgroup of patients who bene-fit from prophylactic ICD implantation.

CUMULATIVE RIGHT VENTRICULAR PACING AND OCCUR-RENCE OF VENTRICULAR TACHYARRHYTHMIAS IN UNSE-LECTED ICD PATIENTS: RESULTS FROM THE FIRST REGISTRYA. D’ONOFRIO1, A. Bartoletti2, E.M. Greco3, M. Mezzetti4, C. Tondo5,M. Elia6, A. Fazi7, L. Dore8, O. Piot9, L. Padeletti10

1Ospedale Monaldi, Naples, ITALY, 2Ospedale S. Giovanni di Dio, Florence,ITALY, 3Ospedale Civile di Cernusco, Cernusco, ITALY, 4Ospedale degli Infermi,Rimini, ITALY, 5Ospedale S. Camillo, Rome, ITALY, 6Ospedale S. Giovanni di Dio,Crotone, ITALY, 7Ospedale S. Maria Annunziata, Florence, ITALY, 8Ospedale SS.Annunziata, Sassari, ITALY, 9CCN St. Denis, St. Denis, FRANCE, 10OspedaleCareggi, Florence, ITALY

Aims: The FIRST Registry focuses on the incidence of ventriculararrhythmias according to cumulative ventricular (V) pacing in unse-lected Implantable Cardioverter defibrillator (ICD) patients (pts).This subanalysis aims to assess the impact of V pacing (Vp) on Varrhythmias occurrence over a 6-months (6M) Follow Up (FU). Methods: data were gathered from 239 single- (VR) and dual-chamber (DR) ICD pts from 42 European centres. V sustained andtreated arrhythmias episodes were retrieved from device memo-ries at 3M (72.9±22 days) and 6M (246±49 days) FU. Pts were clas-sified in two groups (Arr-Pos and Arr-Neg) whether or not theypresented >= 1 V Tachycardia (VT) or V Fibrillation (VF) episodeduring the FU period. Vp distribution (median and standarddeviation SD) was analysed in the two groups.Results: the included pts (63.8±12.7 yrs, 84% male, LVEF 33.1±12.5,16%/67%/16%/1% NYHA I/II/III/IV respectively,49%VR/51%DR) were implanted for primary (48%) and seconda-ry (52%) indications. Among 111 and 90 pts followed-up to 3M and6M respectively, 10 pts (9%) at 3M and 16 pts (17%) at 6M wereclassified in Arr-Pos group.%Vp (median, SD) distribution at 3Mwas significantly different at M6 between Arr-Pos and Arr-Neg(0.007, 23.4 in Arr-Neg and 0.32, 26.9 in Arr-Pos) (p=0.03) and atIC

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M6 (0.010047, 23.4 in Arr-Neg and 0.1194, 2.7 in Arr-Pos)(p=0.43).No relevant changes were observed at 6M.Conclusion: in this unselected ICD population, a significant impact ofVp on VT/VF occurrence was observed at 3M, but it was not obser-ved at 6M, probably due to limited population and too short FU

CORRELATIONS AMONG ARRHYTHMIAS, CLIMATIC VARIA-BLES AND AIR POLLUTION IN PATIENTS WITH PACEMAKERAND ICD FOLLOWED BY REMOTE MONITORINGA. FOLINO1, G. Zanotto2, G. Neri2, R. Mantovan2, E. Marras2, G. Gasparini3,F. Di Pede3, E. Bertaglia3, A. Vaglio3, G. Boscolo3, G. Morani4, R. Ometto4,B. Martini4, G. Scattolin4, F. Zanon4, S. Iliceto1, G. Buja1

1Department of Cardiologic, Thoracic and Vascular Sciences, University ofPadua, Padua, ITALY, 2Department of Cardiology, Legnago, Montebelluna,Treviso, Conegliano., ITALY, 3Department of Cardiology, Mestre, Portogruaro,Mirano, Venezia, Chioggia, ITALY, 4Department of Cardiology, Verona, Vicenza,Thiene, Este, Rovigo, ITALY

Background: Exposure to urban air pollution and short-term car-diovascular mortality and morbidity have been associated in seve-ral epidemiological studies, as well as the effects of specific gasand coarse particulate on electrical instability. However, results arevery composite and sometime contrasting. The purpose of ourstudy will be to evaluate the correlations among climatic variables,air pollution and arrhythmias occurrence, in patients with pace-maker and ICD followed by remote monitoring.Methods and design: In our prospective study, we plan to recruit atotal of 500 male and female subjects implanted with dual-chamberpacemaker, ICD or ICD-CRT, in 15 study centers of the Venetoregion, Italy. The primary objective of this study will be to determinewhether air pollutant and climatic variables affect myocardial elec-tric stability. Secondary objectives will be to determine whetherchanges of air pollution, or changes in temperature, air pressure orhumidity, are associated with significant variations of mean heartrate, heart rate variability and with an increase of mortality or hospi-talization for myocardial infarction or heart failure. The arrhythmiasconsidered will be either atrial and ventricular arrhythmias: atrialfibrillation or flutter, supraventricular tachycardia, ventricular tachy-cardia, ventricular fibrillation, premature ventricular complexes.Among physiological variables, mean heart rate and heart rate varia-bility, will be considered. Information on clinical and arrhythmicevents will be obtained by remote monitoring of devices, and byambulatory controls, during a 12 months follow-up. The pollutionparameters analyzed, obtained by fixed monitoring stations, will be:PM10, PM2.5, O3, CO, SO2, NO2. Conclusions: This study will provide comprehensive informationon the effects of air pollution and climatic variables on atrial andventricular electrical stability, in patients with heart diseases. Theuse of remote monitoring will provide a daily report of arrhythmicevents and physiological parameters, particularly important inassessing short-term effects of air pollution.

EVENT-FREE SURVIVAL WITH IMPLANTABLECARDIOVERTER-DEFIBRILLATORS (ICD) AND LATE OCCUR-RENCE OF FIRST APPROPRIATE ICD THERAPY (RX)F. HORLBECK1, N. Liliegren, G. Nickenig, J.O. Schwab

University Hospital Bonn, Bonn, GERMANY

Background: ICD-therapy is an established standard for the pre-vention of sudden cardiac death(SCD). The indication therefore isbased on the identification of an elevated risk for SCD withoutprecognition about the exact timing of its occurrence. Somepatients(pat.) will never experience arrhythmia, others will onlyexperience complications like lead failure or inappropriate ICD-Rx. This study analyzes the long term propability of the occurren-ce of ICD-Rx and their properties.

Methods: We investigated data of a single center during a periodof >20 years. Actually, we analyzed 912 pat. (61±13 years, EF38±14%) with 1487 ICD and all of their medical examinations until09/2009. We analyzed ICD-Rx and complications. We definedappropiate ICD-Rx as the occurrence of ATP or shock therapy inreaction to ventricular arrhythmia. Inappropriate Rx was definedas shock delivery for any other reason regardless wether becauseof SVT, lead defect, oversensing etc.Results: A total of 912 pat. with 1487 ICD were included (FU 57±50months, maximum 242 months). Most of the pat. were male andthe main cardiac morbidities were CAD and DCM. 471 pat. (52%) experienced ICD-Rx during FU, 392(43%) appro-priate and 147(16%) inappropriate with an overlap of 68 pat. whounderwent both. Interestingly, 68 pat. had their first Rx (57 appro-priate) only after ICD-replacement. This represents 15% of all firstappropriate ICD-Rx. Kaplan-Meyer-analysis showed an eventfreesurvival rate of only 21%(13%) after 10(15) years. A total of 123 pat.did only experience complications (78 with inappropriate shocks),but no appropriate Rx. Out of 142 pat. (16%) who died during FU,85 died without prior occurrence of adequate ICD-Rx.Conclusion: ICD therapy ist beneficial but it is associated with arelevant percentage of pat. who undergo complication withouthaving profited from appropriate ICD-intervention. On the otherhand, a relevant number of pat. undergo their first appropriateICD intervention only after first ICD replacement.

CLINICAL EVALUATION OF A FULLY SUBCUTANEOUSIMPLANTABLE DEFIBRILLATOR (S-ICD) SYSTEMP. Lupo1, H. ALI1, S. Foresti1, M. Pittalis1, G. De Ambroggi1, E. Bianco1,T. Infusino1, E. Renzullo1, E. Daleffe1, S. O’Connor2, R. Cappato1

1I.R.C.C.S. Policlinico San Donato - Dept. of Clinical Arrhythmia andElectrophysiology, San Donato Milanese, ITALY, 2Cameron Health, Inc, SanClemente, CA, USA

Background: Sudden cardiac death (SCD) is one of the major cau-ses of death in the industrial world. Implantable cardioverter defi-brillators (ICDs) have been established as effective live saving the-rapy, but are associated with complications, most related to tran-svenous leads. The S-ICD has been designed to provide the effica-cy of a standard ICD without the short and long term risks of thetransvenous leads or the need of fluoroscopy at implantation. Thisreport documents the clinical experience in 225 patients (pts)implanted worldwide with S-ICD in 2009 and 2010.Methods: Eligible subjects were pts with a Class I or II ICD indica-tions for primary/secondary prevention (ACC/AHA/HRS guide-lines). All pts were implanted and tested with the S-ICD systemfollowing informed consent. The device was implanted subcutane-ously at the level of the 5-6th intercostal space in the anterior axil-lary line, with a tunneled parasternal lead, 1-2 cm left of the midli-ne between the xiphoid and the sternal-manubrium junction,without the use of fluoroscopy. In all pts were evaluated detectionand conversion efficacy of the S-ICD system for induced VF.Results: A total of 225 pts (72% males, 28% females; mean age40±21 years) were implanted with S-ICD. All episodes of inducedVF were detected and conversion efficacy was 98%. Mean time totherapy was 14±2.5 seconds. During follow-up (81 yrs cumulativeF/U) no lead failures or device migrations were reported. 2.4%infection rate was reported (no infections from most recent 100+pts). All clinical VF episodes were sensed and converted to SR. In4.4% of pts inappropriate shocks were reported.Conclusions: The S-ICD system represents a viable alternative toexisting ICD systems which avoids the need and risks of transve-nous leads.

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ST MONITORING ALGORITHM: A NEW DIAGNOSTICOPTION IN FUTURE ICD GENERATIONSL. SANTINI, D.G. Della Rocca, G.B. Forleo, G. Panattoni, L.P. Papavasileiou,G Magliano, L. Duro, R. Cioè, M. Sgueglia, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Introduction: Implantable cardioverter-defibrillators (ICDs) havebeen proven effective in patients who are at high risk of suddencardiac death. The majority of ICD-treated patients has coronaryartery disease. New generation ICDs with ST monitoring algor-hythm might provide a new diagnostic option. Materials and Methods: We investigated 57 consecutive patients(50 males, mean age 65.8±9.1 years) who underwent ICD implan-tation between December 2008 and July 2010 at our institution.Patients were followed at 1, 3 and 6 months post implantation andsuccessively every 6 months.Device alerts were evaluated by two clinicians, experts on thealgorhythm and were defined as false positive ST alerts in theabsence of ischemic ST segment changes at EGMs. Results: Follow-up was completed in 55 patients. During a meanfollow up of 7.5±4.1 months, ST Monitoring diagnostics were pos-sible in 51 patients: one patient had advanced AV block that requi-red continuous pacing, one patient had atrial fibrillation, onepatient underwent a CRT implantation due to worsening of clini-cal symptoms and one patient underwent lead extraction due toinfection. ST monitoring algorhythm reported 5 device alerts.After EGM evaluation ST alerts resulted to be false positive. Weadjusted negative and positive threshold to avoid more alerts. Notrue positive events occurred. One patient experienced acute myocardial infarction before initialthresholds set up.Conclusion: ST monitoring might be a useful tool in follow-up ofpatients with ischemic heart diseases. Continuous evaluation andadjustments are required in order to avoid false positive alerts.

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THE AUTOMATIC ATRIAL CAPTURE MANAGEMENT:RESULTS OF THE CASA STUDYJ.L. Rey, M. HERO

CHU Amiens, Hopital Sud, Amiens, FRANCE

The CASA study has included 297 patients in France implantedwith an EnPulse® dual chamber pacemaker (Medtronic,Minneapolis, USA). Purpose of this study is to compare manualatrial threshold (MAT) and threshold assessed by the automaticatrial capture management function (ACM).Methods: Patients are 76±10 years old; indications were atrio-ven-tricular block (AVB) 70% and sinus dysfunction (SD) 30%; 31% hadparoxystic atrial arrhythmias before implantation. Measurementof P wave, manual atrial threshold and atrial lead impedance havebeen performed at implantation, before discharge, 6 to 12 weeksafter and at 6 months follow-up. At each follow-up automatic atri-al thresholds are collected by interrogation of the device viatelemetry and compared with the manual values by R coefficientcorrelation test.Results: P-wave amplitude and atrial lead impedance are stableduring follow-up without significant difference. Concerning atrialthresholds, there is no difference between manual and automaticthresholds at each follow-up. R coefficients are very high showingan excellent correlation between the two methods. At Implant (297 patients), the P-wave is 2.8±1.6mV, impedance is614±225 Ohm and the manual threshold is 0.8±0.5V. Durnig pre-discharge follow-up (269 patients), the P-wave is2.3±1.2mV, impedance is 537±153 Ohm and the manual thresholdis 0.7±0.4V. There is a good correlation (r= 0.844) with ACM0.7±0.4V. During the 6-12 Weeks follow-up (238 patients), the P-wave is 2.3±1.05mV, impedance is 518±146 Ohm and the manualthreshold is 0.6±0.4 V. There is a good correlation (r= 0.849) withACM 0.7±0.4 V. During 6 months follow-up (186 patients) the P-wave is 2.4±1.2mV, impedance is 498±142 Ohm and the manualthreshold is 0.7±0.4V. There is a good correlation (r= 0.891) withACM 0.7±0.5V.Conclusion: We are observed a very good correlation betweenatrial threshold assessed by automatic atrial capture managementfunction and manual atrial threshold test.

VENTRICULAR PACING RATE AND ATRIALARRHYTHMIAS ACCORDING TO INDICATION OFPACING AND PROGRAMMING MVP™ FUNCTIONAT 9 MONTHS FOLLOW-UPJ.L. Rey, M. HERO

CHU Amiens - Hopital Sud, Amiens, FRANCE

Methods: The multicenter observational Generation MVP™ studyincluded 224 patients aged 77 + / - 10 years (men: 53%) implantedfor sinus dysfunction (SD) or brady-tachy syndrome (SBT) (n =116) or atrio-ventricular block (AVB) (n = 108). Programming fun-ction MVP™ has been left to the discretion of the physician.Percentage of ventricular pacing and percentage of patients withparoxystic or persistent atrial arrhythmias was assessed at 9months on average according to the indication of pacing and thestate of programming function MVP™. Results: Percentage of ventricular pacing at 9 months is significan-tly lower for the 2 groups of indication for patients with MVP™function activated [On] compared with patients without functionMVP™ [Off]. Comparisons groups were made by the Mood’smedian test.For SD - BTS Indication the% VP median is significantly different(p<0.001) between MVP Off (79%) and MVP On (1%). ForAVBIndication the% VP median is significantly different (p<0.001)between MVP Off (99%) and MVP On (15%). Percentage of patients with atrial arrhythmias at 9 months was

significantly lower when the MVP™ function is programmed to[On] only in the AVB group.For SD - BTS Indication the% pts in AA median is non significan-tly different between MVP Off (26%) and MVP On (19%). For AVBIndication the% pts in AA median is significantly different(p<0.05) between MVP Off (23%) and MVP On (6%). Conclusion: In this study in current practice, at 9 months follow-up programming function MVP™ is associated with a significantdecrease of ventricular pacing for indications of SD-BTS and AVblock. Moreover programming function MVP™ is associated witha significant decrease of percentage for patients with atrial arrhy-thmias for AVB indications.

EVOLUTION OF THE GAIN IN SPONTANEOUSCONDUCTION BETWEEN ATRIO-VENTRICULAR DELAYHYSTERESIS ALGORITHMS AND A NEW PACING MODEP. LE FRANC, M. Hero

Clinique St Hilaire, Rouen, FRANCE

Most of studies show the interest to decrease ventricular pacing inpatients implanted with a dual chamber pacemaker. Algorithmsdeveloped to search spontaneous ventricular activity consistedfirst in increasing AV delay (AV delay hysteresis: AVDH). Morerecently, new modes of pacing were proposed: MVP™ mode(Managed Ventricular Pacing) Medtronic-USA or Safe-R™, (Sorin-Italia). The aim of this study was to evaluate the gain of spontane-ous conduction between different generations of AVDH and theMVP™ mode.Methods: We studied two populations of patients implanted forconduction disorder (CD) or sinus dysfunction (SD) distributed inthree groups. Group I: 115 patients implanted with Kappa® seriespacemaker (Medtronic-USA) and first generation AVDH (AVDH,CD: 56%, SD: 44%). Group II: 168 patients implanted withEnpulse® series pacemaker (Medtronic-USA) and second genera-tion AVDH (AVDH+, CD: 52%, SD: 48%). Group III: 156 patientsimplanted with Adapta® series pacemaker (Medtronic-USA) andthe MVP™ mode (CD: 40%, SD: 60%). Populations were not diffe-rent in sex, age and pacing indications. Patients who presented lessthan 1% of spontaneous ventricular activity were excluded fromanalysis. We compared first the gain in ventricular detection indu-ced by AVDH vs. AVDH+ and secondly the percentage of ventri-cular pacing between AVDH+ and MVP.Results: For patients with conduction disorder the median %VPAVDH (99.7%) and AVDH+(99.7%) is no significative but thep<0.001 with the%VP MVP (15.0%).For patients without conduction disorder the median%VP aresignificantly different (p<0.001) between AVDH (78.5%), AVDH+(25.8%) and MVP (1.8%).Conclusion: AVDH+ results in a decrease in VP in patientswithout conduction disorder but not in patients with conductiondisorder. The use of MVP™ results in a significant decrease of ven-tricular pacing compared to first and second generation of AVDHalgorithms in both patients with or without conduction disorderwith a high gain in spontaneous AV conduction.

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AMOUNT OF RIGHT VENTRICULAR PACING IN THE FIRSTTHREE MONTHS AFTER DEVICE IMPLANTATION:A PREDICTOR OF OUTCOMES AFTER THREE YEARSN. CABANELAS, V.P. Martins, D. Durão, F. Valente, M. Alves, A. Francisco,R. Silva, G.F. Silva

Cardiology Department - HDS, Santarem, PORTUGAL

Introduction: Higher amount of right ventricular pacing(RVP)predisposes to higher arrythmic burden, higher incidence of atrialfibrillation(AF) and worsening of systolic function. Careful analy-sis of some indicators in earlier follow-up visits can be importantin predicting and preventing harmful long term outcomes.Objective: To evaluate the amount of RVP during the first threemonths after device implantation as a predicting factor of longterm clinical and arrhythmic outcomes.Methods: Patients admitted to a Pacing Unit for permanent dual-chamber pacemaker implantation, from February/2006 toAugust/2007 (n=253) followed for three years, were retrospective-ly evaluated. Two groups were established: A (n=94)-patients withRVP less than 50% of time in the first three months, and B (n=161)-patients with more than 50% of RVP in that period. Age, propor-tions of patients with <50% of time on RVP, arrhythmic burden<10%, hospital admission for heart failure(HAHF), persistent AFand mortality were compared.Results: The patient’s age was similar(68.6±7.4vs70.3±8.1years,p=ns). After three years, 70.6% of patients of A remainedwith RVP<50% of time, as 13.8% in B achieved that end-point(p<0.001). Prevalence of arrhythmic burden <10% was86.6%vs69.1%,p=0.019. There was a tendency to lower incidence ofHAHF (16.5%vs18.2%,p=ns) and persistent AF in A(15.19%vs16.20%,p=ns). Total mortality was lower in A(3.8%vs13.3%,p=0.03).Using logistic regression, <50% of RVP in the first three monthswas a predictor of less than 50% of RVP after threeyears(p<0.001,OR0.07,IC 95%:0.035-0.165), arrhythmic burden<10%(p=0.048,OR2.9, IC95%:1.30-6.43) and all-cause mortality(p=0.038,OR3.89, IC95%:1.07-14.07).Conclusions: RVP in first three months after device implantationwas shown to be an early interesting parameter of some futureoutcomes in patients with dual-chamber devices. It predicts theneed of RVP, arrhythmic burden and mortality after three years. Itwas also related with a tendency to lower incidence of persistentAF and HAHF. A close follow-up and efforts to minimize RVP areessential to avoid that negative consequences.

EARLY DETECTION OF SILENT ISCHAEMIA THROUGHINTRATHORACIC FAR-FIELD ELECTROCARDIOGRAMSA. FAGAGNINI1, L.M. Zuccaro1, L. Sciarra1, E. de Ruvo1, L. De Luca1,M. Rebecchi1, M. Minati1, S. Matera1, F. Guarracini1, M. Porfirio1,G. Pendenza1, L. Sangiovanni1, M. Sforza1, F. Stirpe1, A. Masia2, R. Pavese2,A. Pollastrelli2, A. Sciahbasi1, E. Lioy1, L. Calò1

1Policlinico Casilino, Rome, ITALY, 2St. Jude Medica, ITALY

Background: Early identification of coronary syndromes with ST-segment elevation/depression could profoundly accelerate thetiming of revascularization and improve clinical outcomes. Silentmyocardial ischemia occurs more frequently than anginal episo-des in patients with CAD. Intrathoracic far-field electrocardio-grams (FF-ECG) recorded through an electrical circuit betweenintracardiac electrode and implantable cardioverter-defibrillators(ICD) is a promising method for continuous monitoring of myo-cardial ischaemia.Methods: This study reports the ability of an intracardiac rightventricular (RV) electrode to identify the early onset of myocardialischaemia/injury in a cohort of ICD recipients. The primary dataset for analysis included observations from 33 patients (mean age68.0±11.1 years, 6 females). All the patients were followed up for

7.03±3.66 months by trans-telephonic monitoring with theMerlin.net™ system (St. Jude Medical). Results: A total of 195 transmissions, 123 total alerts, and 12 alertsregarding ST monitoring in two asymptomatic patient were collec-ted. One patient underwent three vessel CABG, while anotherpatient underwent an exercise stress test, which was negative formyocardial ischemia, and now he is waiting for coronary TC.Conclusions: Our case illustrates that episodes of asymptomaticischemia were detected by the AnalyST intracardiac ST monitoringalgorithm. The recent development of intracardiac ST segmentmonitoring in an implantable cardioverter defibrillator in combi-nation with remote device monitoring may enable physicians todiagnose and treat asymptomatic myocardial ischemia.

RV THRESHOLD BEHAVIOUR AT LONG TERM:AUTOMATIC VERIFICATION OF STIMULATIONWARRANTS SUPERIOR SAFETY!M. BIFFI, A. Mazzotti, B. Gardini, V. Mantovani, G. Massaro, M. Ziacchi,M. Salomoni, M. Balbo, F. Bonfatti, G. Boriani

Institute of Cardiology, University of Bologna, Bologna, ITALY

Long term (>1 year) behaviour of RV pacing threshold was inve-stigated by pacemakers capable of automatic output reprogram-ming tracked by automatic RV threshold measurement (AVC).Methods: Consecutive patients implanted with steroid-elutingbipolar pacing leads were RV-paced by an AVC algorithm by dif-ferent manufacturers (St Jude Medical, Medtronic, Boston).Automatically-measured threshold was compared to manually-measured RV threshold at each ambulatory follow up (FU). FUoccurred at 6-months after implantation, then yearly until approa-ching ERI. Results: 321 patients aged 73±12years were observed for 49±27months on average. Automatically measured RV threshold waswithin 0.25V of manual measurements in 99% of ambulatorydeterminations, within 0.5V in 100% of determinations.

At implantation, RV threshold was 0.56±0.3V @ 0.4ms at a768±217ohm RV impedance, whereas it was 0.93±0.75V @ 0.4ms at521±198ohm RV impedance at last FU visit. 41/321 patients(12.8%) had a stable RV threshold increase above 1.5V@0.4ms: RVthreshold was between 1.5 and 2.5V in 29/321 (9.5%) patients,whereas it was between 2.5 and 3.5V in 7/321 (2.2%) patients, and>3.5V in 5/321 (1.5%) patients. No RV pacing exit block occurredthanks to automatic RV output adjustment by the algorithms forcapture verification. 19/321 (5.9%) patients had their maximum RV threshold increasewithin 12 months from implantation, whereas 12/321 (3.7%) hadtheir maximum RV threshold increase between the 1st and the 2ndyear from implantation, 8 /321 (2.5%) between the 2nd and the 4thyear, and 2/321 (0.6%) after the 6th year from implantation.Conclusion: Long term increase of the RV pacing threshold occursin about 13% of patients, possibly representing a serious safetyissue in 3.7% of patients when 2.5V@0.4ms is exceeded. AVC algo-rithms can obviate to this safety issue allowing continuous auto-matic tailoring of the pacing output to threshold fluctuations.Patients’ safety eventually is the standpoint to increase device lon-gevity.

CARDIAC PACING AUTOM

ATIC ALGORITHM

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BENEFICIAL EFFECTS OF TILT TRAINING IN PREVENTINGNEUROCARDIOGENIC SYNCOPE: WHAT ARE THEPOSSIBLE MECHANISMS?S. LARANJO1,2, M. Oliveira2, C. Tavares1, V. Geraldes1, V. Silva1, S. Santos2,E. Oliveira2, I. Rocha1, R. Ferreira2

1Autonomic Nervous System Unit - Institute of Molecular Medicine, Lisbon,PORTUGAL, 2Cardiology Department - Santa Marta Hospital, Lisbon, PORTUGAL

Neurocardiogenic reflex syncope (NRS) is a common clinical enti-ty resulting from excessive reflex autonomic responses, particular-ly during orthostatism. Therapeutic options are controversial andof limited effectiveness. Tilt-training (TT) has been advocated as apromising tool to treat these patients (P). However, its mechanismsof action and clinical impact remain elusive.Aim: to characterize hemodynamic, autonomic and baroreflexresponses during a TT-program in NRS-P refractory to conven-tional measures.Methods: 28P (50% male, 41±14 yrs) without structural heart-dis-ease, with recurrent NRS documented by tilt-testing (cardioin-hibitory 50%, mixed 35%, and vasodepressor 15%). The TT-pro-gram included 9 tilt-sessions (3 times/week, 30 min, 60° in 6 ses-sions and 70° in 3 sessions) under continuous ECG and blood pres-sure monitoring, combined with daily home orthostatic self-train-ing (20 min with back support) and 10° head-up during sleep.Systolic-volume, cardiac-output, total-peripheral-resistance(dyne*s/cm5), baroreflex-sensitivity and heart-rate variabilitywere computed. P were followed during 24±12 months (1st monthand every 6 months).Results: After the TT-program there was a significant increase oftotal-peripheral-resistance (1485±225 vs. 1591±187, p<0.05), with areduction of its standard deviation (206±60 vs. 150±42, p<0.05).Variability studies using auto-regression analysis showed anincreased overall autonomic activity, reflected by a progressiveincrease in the variability indices (LF 544.08±146 vs. 914.64±225,p<0.05; HF 5.32±0.7 vs. 7.42±0.8, p<0.05). This increase can also beseen through changes in the baroreflex effectiveness index (61.06±20vs. 69.70±17, p=0.08). Recurrence of syncope occurred in 5P (19%),with a significant reduction in the number of episodes (4.0±3.2/P inthe 12 months before TT vs. 1.4±0.8/P post-TT, p<0.05).Conclusion: In refractory NRS, TT may be an effective option,with long-term benefits due to a better orthostatic tolerancethrough three mechanisms: increased vasoconstrictor reserve andits lower variability combined with increased overall autonomictone and baroreflex activity.

WHICH IS THE MAIN DETERMINANT OF HYPOTENSIONIN TILT INDUCED VASOVAGAL SYNCOPE? THE ROLE OFTHE ARTERIAL AND VENOUS SYSTEMG. NIGRO1, V. Russo1, M. Iovino2, V. Gionti1, M.L. Rosato1, L. Armetta1,F. Colimodio1, V. Giordano1, M.G. Russo1, P. Golino1, R. Calabro’1

1Chair of Cardiology - Second University of Naples, Naples, ITALY, 2BiotronikItalia, ITALY

Introduction: Aim of the our study was to assess the main deter-minant of the fall in blood pressure (BP) responsible for the HUTTinduced syncope. Methods: The study involved 100 patients (mean age 42±3; 41male) with syncope of unknown origin after the first evaluation.According to the response to the diagnostic tilt test, the populationstudy was divided into four groups: Group I: 30 patients (meanage 46±22; 12 male) with mixed vasovagal syncope; Group II: 20patients (mean age 38±18; 11 male) with cardioinhibitory syncope;Group III: 20 patients (mean age 40±20; 4 male) with vasodepres-sive syncope; Group IV: 30 patients (mean age 36±4; 12 male) withno tilt-induced syncope. Finger arterial blood pressure wererecorded during tilt testing. Left ventricular stroke volume (SV),cardiac output (CO), and total peripheral resistance (TPR) were

computed from the pressure pulsations. Results: During syncopal phase, the TPR decreased significantlyin Group III (0,77±0,25 vs 1.02±0.24, U, P=0,01), while increased inGroup I (1.74±1.16 vs 1.20±0.63, U, P=0,04) and in Group II(2.133±0.92 vs 0.92±0.32, U, P=0,0011). CO decreased in Group I(2.15±1.09 vs 5,04±0,98, ml/min, P= 0,000001) and in GroupII.(1.20±0.76 vs 5,163±1,27, ml/min, P= 0,000006), while did notchange significantly in Group III. SV decreased significantly in allgroups.Conclusions: Our data showed that the arterial system appears tobe the main determinant of the blood pressure fall in vasodepres-sive vasovagal syncope; while the impaired constrictive responseof the venous system, leading to reduced venous return to theheart, appears to be the main determinant of blood pressure fall inmixed and cardioinhibitory vasovagal syncope.

UTILITY OF AN EXTERNAL LOOP RECORDER INDIAGNOSING PATIENTS WITH SPORADIC PALPITATIONSOR SYNCOPEA. SETTE, E. De Ruvo, L. De Luca, C. Lanzillo, L. Sciarra, C. Commisso,F. Sebastiani, V. Iuianella, M. Rebecchi, L.M. Zuccaro, A. Fagagnini,M. Minati, F. Guarracini, M. Porfirio, A. Martino, S. Matera, L. Calò

Policlinico Casilino Department of Cardiology, Rome, ITALY

Spider flash (SF) is a external digital ECG event loop recorder. Incase of symptoms, the ECG event recorder could be actived by thepatient (pt) or by trained individuals. The ECG signal is conti-nuously stored on a loop memory.Purpose: to evaluate the utility of SF in the diagnosis of pts withsporadic episodes of paroxysmal palpitations (PP) and or synco-pe/pre-syncope. Materials and Methods: 175 pts (46±18y; 59 males) were studied.140 pts (45±18y; 49 males) with PP; 12 pts (43±15y; 4 male) withsporadic episodes of syncope associated with palpitations; 23 pts(54±20y; 6 males) with sporadic episodes of syncope and/or pre-syncope. Results: Duration of recording: 18±9 days. In the group of pts withPP we recorded: in 28 pts (20%) episodes of paroxysmal supraven-tricular tachycardia (PSVT); in 52 pts (37%) sinus tachycardia; in 11pts (8%) an episode of atrial fibrillation (AF) or atrial flutter; in 17pts (12%) frequent ventricular premature beats; in 11 pts (8%) fre-quent atrial premature beats; in 2 pts (3%) a second degree atrio-ventricular block during sinus tachycardia. In the group of ptswith PP + syncope and or pre-syncope we recorded: in 4 pts (33%)a PSVT one pt had an episode of non sostenute ventricular tachy-cardia an PSVT. In the group of pts with syncope and or pre-syn-cope we recorded: in 2 pts (24%) sinus bradycardia ; in one pt (4%)very fast atrial fibrillation in correspondance to the syncope. Conclusion: SF revealed to be a useful device in patients with spo-radic episodes of paroxysmal palpitations and/or episodes ofunexplained syncope and/or pre-syncope. The possibility of aloop memory (ECG signal continuously stored) permits to recordthe beginning of arrhythmic events that could not be detected by acommon “event recorder”.

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THE USE OF REMOTE CONTROL FOR IMPLANTABLELOOP RECORDER IN MANAGEMENT OF SYNCOPE UNITR. Colaceci1, M. BOCCHINO1, M.G. Romano1, N. Danisi1, G. Pighini1,L. La Rocca2, F. Ammirati1

1Ospedale G.B. Grassi -Dipartimento di Malattie Cardiache-, Ostia (RM), ITALY,2Medtronic Italia S.p.a., Rome, ITALY

Introduction: The new guidelines discuss the role of ILR in thediagnostic flowchart of patients with syncope of unknown origin.When an arrhythmic cause of syncope is suspected but not suffi-ciently proven to allow treatment based on aetiology, it appearsthat early use of ILR in the diagnostic work-up may become thestandard of reference.The remote monitoring system Carelink Network® for ILR isshown to be an effective tool for rapid diagnosis and for optimalmanagement of Syncope Unit.Materials and Methods: After an initial negative screening for anydiagnostic test, the patients with ILR (Reveal DX® Medtronic Inc.)were provided with the Carelink Network Monitor and instructedto transmit the data stored in the device once a week and if theyhave any symptom. Nurses and specialists technicians did thereview of transmissions. In case of clinical relevant events the tran-smissions were submitted to a physician; all the events and medi-cal decisions were recorded through special form in the MedtronicClinical Service project.Results: 36 patients were included in the project by February 2010.Over a period of 5 months, 420 transmissions were recorded. 6 dia-gnoses were made with an average time to diagnosis (fromimplant to relevant event) of 20 days. In all cases the ILR automa-tically recorded the event; only in two cases there were also addi-tionally episodes triggered by patient symptoms (patient activa-ted). The therapeutic actions taken following clinical event were:PMK implant in 5 patients and ICD implant in a patient.Conclusion: The strategy of remote management of patient withILR allowed to optimize the paths of the patient with syncope bylimiting resource consumption and reducing time to diagnosis.

SINGLE-CENTER EXPERIENCE OF LOOP RECORDERIMPLANTATION IN PATIENTS WITH UNEXPLAINEDSYNCOPE AND WITHOUT PALPITATIONS ORSIGNIFICANT CARDIAC ABNORMALITIESG. CAPELLA1, S. Gilardi2, V. Silvestri2, R. Melloni1, R. Fornerone1, R. Seregni1

1Ospedale Fatebenefratelli ed Oftalmico, Milan, ITALY, 2Medtronic ITALY, SestoSan Giovanni, ITALY

Purpose: The efficacy of implantable loop recorder (ILR) inpatients (Pts) with unexplained syncope has been investigated inmany studies. The purpose of our investigation is to study theresult of ILR in a selected group of patients affected by unexplai-ned syncope without palpitations or signs of significant cardiacabnormalities.Methods: In this single-center retrospective analysis we have con-sidered a subgroup of 60 Pts-26 males (43%) and 34 females (57%);mean age 65±16 years-who underwent ILR implantation between2005 and 2009 for unexplained syncope. These pts were selectedwith a protocol aimed to rule out pts with signs and symptoms ofsignificant cardiac abnormalities and those with neurological,hypotensive orthostatic and neurally-mediated syncope. Results: Pts were followed up for a mean of 10±7 months. In 29 pts(48.3%), a diagnosis was obtained by the ILR. In 22 pts, a pacema-ker was indicated: 4 pts had third-degree atrioventricular blockwith asystolic pauses>4 sec; 6 had brady-tachy syndrome withasystolic pauses>4 sec; 1 had 2:1 atrioventricular block (rate <30bpm); 11 experienced episodes of asystole>4 sec preceded by sinusbradycardia. The remaining 7 patients presented: 1 paroxysmalsupraventricular tachycardia, treated with radiofrequency abla-tion; 3 atrial fibrillation with high ventricular response, 1 of them

treated with ablation and 2 with drug therapy; 2 sustained ventri-cular tachycardia, treated with an implantable defibrillator; 1 syn-cope associated with seizure and normal ECG, diagnosed as epi-lepsy. Conclusions: The ILR in this group of pts with unexplained syn-cope, without palpitations or significant cardiac abnormalities,enabled us to identify a considerable number of bradycardia (neu-rally-mediated) and tachyarrhythmias as the cause of syncope.The ILR not only proved to be a powerful diagnostic tool also inthis subgroup of pts but it enabled us to undertake therapeuticinterventions.

THE DIAGNOSTIC VALUE OF ADENOSINE IN THEINVESTIGATION OF POTENTIAL SICK SINUS SYNDROMEIN PATIENTS WITH SYNCOPE/PRESYNCOPEN. FRAGAKIS1, A. Antoniadis2, P. Kyriakoy1, G. Navrozidis1, G. Katsaris2,P. Geleris1

1Cardiology Unit, 2nd Propedeutic Department, Hippokration Hospital,Thessaloniki, GREECE, 22nd Cardiology Department, General Hospital G.Papanikolaou, Thessaloniki, GREECE

Purpose: Adenosine exerts a more pronounced suppressive actionin sinus nodal cells in patients with sick sinus syndrome than inother individuals. However, its effect in relation to a history of syn-cope/presyncope is still under investigation. In this study wesought to assess the diagnostic value of intravenous adenosineadministration as compared to conventional invasive electrophy-siological tests in the investigation of potential sick sinus syndro-me in patients with syncope/presyncope.Materials and Methods: We studied 40 patients with a history ofsyncope/presyncope, 15 males and 25 females, mean age 67.2±10years. We calculated the corrected sinus node recovery time afterintravenous adenosine administration at a dose of 0.15 mg/kg(AD-CSNRT) as well as after atrial pacing (CSNRT). Values >525msec were considered abnormal. Based on the rest clinical andlaboratory assessment 32 subjects were diagnosed as having sicksinus syndrome (Group A) while the remaining 8 were listed assuffering from syncope of unknown origin (Group B).Results: Subjects in Group A had significantly more prolongedAD-CSNRT in comparison with those in Group B (6285±7043 msecvs 112±114 msec, p<0.01). CSNRT was also more prolonged inGroup A than in Group B (1473±2090 msec vs 271±99 msec,p<0.01). Furthermore, patients in Group A were significantly morelikely than in Group B to present with an abnormal AD-CSNRT(odds ratio 61, p<0.001), and also with an abnormal CSNRT (oddsratio 42, p<0.001).Conclusion: Adenosine testing is a non-invasive alternative dia-gnostic tool comparable with electrophysiologic testing which isuseful in unveiling a potential sick sinus syndrome in patients pre-senting with syncope/presyncope.

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SUCCESSFUL MANAGEMENT OF ELECTRICAL STORMUSING ORAL QUINIDINE IN CILOSTAZOL INEFFECTIVEBRUGADA SYNDROME PATIENTSK. HIGUCHI, K. Hirao, O. Inaba, A. Yagishita, Y. Tanaka, M. Kawabata,H. Hachiya, M. Isobe

Tokyo Medical and Dental University, Tokyo, JAPAN

Aims: The proposed mechanism of ventricular tachycardia (VT)and ventricular fibrillation (VF) in Brugada Syndrome (BrS)involves imbalance between the inward (INa and ICa) and out-ward currents, mainly the transient outward current (Ito), at theend of phase 1 of the epicardial action potential. Quinidine andCilosotazol are known to be effective anti-arrhythmic agents forVT/VF after ICD implantation in symptomatic BrS. Quinidinesuppresses the Ito and Cilostazol increases the Ca current in pre-venting VT/VF in BrS.Methods: This study included 12 patients with symptomatic BrSwho were implanted ICD in our facility. The effectiveness ofQuinidine and Cilosotazol for suppression of VT/VF in thesepatients were studied.Results: No anti-arrhythmic agents were used just after ICDimplantation, then appropriate ICD therapies were delivered forVT/VF after ICD implantation in 4 of 12 patients. Cilostazol wasused in 3 of 4 patients at first, however, it was not effective. In 2 of3 Cilostazol ineffective BrS patients, Quinidine therapy with thedosage of 300mg per day was also not effective. However with600mg per day VT/VF were successfully suppressed. In other onepatient, Quinidine therapy with the dosage of 300mg per day suc-cessfully suppressed VT/VF. Gastrointestinal intolerance such asdiarrhea was recognized in 2 patients and thrombocytopenic pur-pura was recognized in one patient as side effects of Quinidinetherapy.Conclusion: In this study, Quinidine therapy had an advantage inthe management of VT/VF after ICD implantation in symptomaticBrS, and the efficacy of Quinidine had the tendency to be depend-ent on the dosage. However there were some side effects such asgastrointestinal intolerance and thrombocytopenic purpura to becared about.

RIGHT VENTRICLE MAPPING IN PATIENS WITHBRUGADA SYNDROMES. FICILI1, M. Galeazzi1, C. Lavalle1, M. Russo1, G. Chiarelli1, L. Santini2,F. Amati3, F. Mele1, C. Pandozi1, M. Santini1

1Dipartimento Cardiovascolare, Ospedale San Filippo Neri, Rome, ITALY,2Dipartimento Cardiovascolare Università Tor Vergata, Rome, ITALY,3Dipartimento Bio-patologia Università Tor Vergata, Rome, ITALY

Background: the role of structural heart desease and sodium chan-nel disfunction in the induction of electrical instability in BrugadaSindrome is still known. However recent paper had showed thatendomyocardial biopsy detected structural alterations in subjetswith brugada syndrome and arrythmias.Objective: to investigate the role of structural alterations in sub-jects with brugada syndrome and inducible at electrophysiologicalstudy (EPS).Methods: we studied 22 consecutive probands (18 males, 4 fema-les) with clinical and istrumentale diagnosis of BrugadaSyndrome. All probands were Caucasian. According to the mostrecently proposed diagnostic criteria, the clinical presence of BSwas based on demonstration on the ECG of a type 1 or a type 2 thatwas converted to type 1 after flecainide test (2mg/kg). All patientswere inducible at EPS.A bipolar voltage mapping was also performed by CARTOsystem. In a subset of patients (6), the eclectroanatomical rightventricular map was integrated with MR/CT image to assure thecontact between the tip of catheter and endocardial tissue. In 2patients intracardiac echo (ICE) was used to investigate the struc-

turale alterations. Genetic study for SCN5A mutational screeningwas also performed onto DNA obtained from peripheral bloodsample of all 14 patients Results: Programmed electrical stimulation induced VF in all thepatients. The electroanatomical mapping showed normal poten-tials of the right ventricle in all the patients. The mean number ofacquired points was (325±25 points) with an average mappingperiod of 24 ±4 minutes. Structural alterations were non detectedby ICE. Genetic study revelead 3 mutation (mutation rate 21,4%)IVS-24/CT in two patients (B6 and B 11) and R 1512 W in onepatient (B15).Conclusion: Substrate right ventricular mapping of Brugadapatients does not highlight any alterations.

ELECTROANATOMIC RIGHT VENTRICULAR MAPPING INPATIENTS WITH BRUGADA SYNDROME: ALTERATIONSAND POSSIBLE CORRELATIONS WITH PROGNOSISL.M. ZUCCARO1, L. Sciarra1, E. De Ruvo1, G. Allocca2, E. Marras2,L. De Luca1, M. Rebecchi1, A. Fagagnini1, M. Marziali1, A. Sette1,C. Lanzillo1, M. Minati1, E. Lioy1, P. Delise2, L. Calo’1

1Division of Cardiology Policlinico Casilino, Rome, ITALY, 2Division ofCardiology Conegliano Hospital, Conegliano Veneto, ITALY

Background: Although Brugada Syndrome (BS) is considered tobe an electrical disease, several investigation show structural rightventricular (RV) alterations in these patients (pts). Aim of our study: to assess the results of Right ventricular bipolarvoltage mapping (RVBVP) in patients with BS and to investigateon possible prognostic implications. Methods: We studied 32 pts (mean age 42±11 years; 18 male) withBS. Seventeen patients showed spontaneous type 1 pattern, while7 showed a coved type pattern after flecainide infusion. The con-trol group (12 pts with mean age 46±15 years; 6 males) withoutstructural heart disease undergone RVBVM during an ablation foratrio-ventricular nodal re-entrant tachycardia. Points were collec-ted when impedance confirmed a good contact. Results: The number of collected points was comparable in bothgroups (160±40 in BS vs 147±25 in controls; p=NS). Low voltageand/or scar areas were present in all pts with BS (100%), and in nocontrol subject. Seven scar areas in 6 pts with BS (25%) were found(5 infero-basal and 2 infundibular). Location of scar and low volta-ge areas: infundibulum in 12 pts (50%), inferior wall in 13 pts(58%), anterior wall in 3 pts (12%), apex in 2 patient (8%). Themean bipolar RV voltage were significantly inferior in patientswith BS when compared to controls (3.3±2.6 mV vs 4.5±3 mV, p<0001). Patients with scars showed a higher incidence of syncope(65% vs 20%; p< 0.01), a higher prevalence of spontaneous type 1ECG (100% vs 67%; p<0.01) and were older (mean age 55±11 vs38±8 years) when compared to BS patients with only low-voltageareas. Conclusions: Unselected patients with BS showed significant RValterations at RVBVM. The degree of electro-anatomic RV altera-tions in pts with BS seems to be correlated to other indicators ofworse prognosis.

THE ROLE OF TWELVE LEADS ECG HOLTERMONITORING TO DIAGNOSE BRUGADA SINDROMEBY REVEALING SPONTANEOUS COVED TYPEELECTROCARDIOGRAML. Sciarra1, M. MARZIALI1, E. De Ruvo1, L. De Luca1, E. Marras2, G. Allocca2,L.M. Zuccaro1, M. Rebecchi1, A. Martino1, M. Minati1, M. Porfirio1,A. Fagagnini1, E. Lioy1, P. Delise2, L. Calo’1

1Division of Cardiology Policlinico Casilino, Rome, ITALY, 2Division ofCardiology Conegliano Hospital, Conegliano Veneto, ITALY

Introduction: Electrical storm (ES) is a relatively rare phenomenonBRUGADA SYNDROME

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that can complicate the clinical course of patients (pts) withBrugada Sindrome (BS). Treatment of such a malignant event maybe sometimes challenging. Isolated reports in literature suggest apotential role of quinidine in the treatment of ES in BS pts. Aim of our study: was to investigate on the role of oral quinidinein the treatment of pts with BS and ES. Methods: Forty three BS pts (mean age 41±7 years; 32 males) wereselected for implantable cardioverter defibrillator (ICD) implanta-tion. In the follow-up 4 pts (mean age 43±13 years; 2 males) withan ICD, experienced an electrical storm. Three of those pts hadshown a spontaneous type 1 ECG, while 1 patient after flecainideinfusion. Results: At the time of electrical storm, in 3 pts a spontaneous type1 ECG was evident, while in 1 patient a type 2 ECG was present.All pts experienced multiple appropriate shocks for sustained VFand were admitted to coronary care unit. They were treated withoral hydroquinidine at a dosage of 250 mg bis in die. In all thepatients studied, hydroquinidine administration was correlatedwith electrical stabilization. No sustained VT/VF relapse and noICD shocks was recorded, both in an acute phase and in a 14±3months follow-up. In 1 of the 3 pts with spontaneous type 1 ECG,the pattern was converted into type 2 ECG during quinidine treat-ment. The patient with spontaneous type 2 ECG showed a type 3ECG after quinidine intake. The mean QTc interval was significan-tly prolonged by quinidine therapy (414±15 vs 461±14 msec; p <0.01). Conclusions: In our experience oral hydroquinidine revealed to bea safe and effective treatment in patients with BS and ES.

RIGHT VENTRICLE HISTOLOGICAL FINDINGS INPATIENTS WITH BRUGADA SYNDROME INDUCIBLEDURING THE ELECTROPHYSIOLOGICAL STUDYM. RUSSO1, S. Ficili1, C. Pandozi1, M. Galeazzi1, C. Lavalle1, C. Bernardi1,L. Santini2, R. Mango3, F. Amati3, G. Novelli3, F. Romeo2, M. Santini1

1Cardiovascular Department-San Filippo Neri Hospital, Rome, ITALY,2Cardiovascular Department-Tor Vergata University, Rome, ITALY,3Biopathology and Diagnostic Imaging- Tor Vergata University, Rome, ITALY

Background: Recent papers indicated that patients (pts) withBrugada Syndrome (BS) and arrhythmias undergoing to endo-myocardial biopsy showed cardiac structural abnormalities athistological level. Our study sought to investigate the presence ofthese abnormalities in subjects with BS inducible during the elec-trophysiological study (EPS). Methods: 14 consecutive pts (12 males) with clinical and instru-mental diagnosis of Brugada Syndrome were studied. Accordingto the proposed criteria, the diagnosis of BS was established afterthe electrocardiographic (ECG) demonstration of type 1 pattern orafter type 2 converted to type 1 pattern by flecainide test (2 mg/kgin 10 minutes). All patients underwent to both EPS and endomyo-cardial biopsy; genetic screening for SCNA5A mutation was per-formed onto DNA obtained from peripheral blood sample of all 14pts. The EPS was performed by dual site (right ventricular apexand outflow tract), dual drive (600-400 msec) protocol stimulationadding up to 3 extra-stimuli with the minimum coupling intervalof 200 msec. In case of induction of sustained (lasting>30 secondsand/or causing hemodynamic collapse) ventricular arrhythmiasthe protocol was repeated in order to assure the diagnostic reliabi-lity. The bipolar voltage map of the right ventricle was constructedby the CARTO system. Endomyocardial biopsies were performedalong the septal-apical area of the right ventricle and at least 3 spe-cimens of myocardial tissue were collected for each pt. The speci-mens were fixed in 10% buffered formalin. The possible diagnosisof myocarditis was established according to Dallas criteria.Results: All but one pts were asymptomatic (1 pt had a syncope).EPS induced ventricular fibrillation in 10 pts and not-sustainedventricular tachycardia in 1 pt. In all the pts endomyocardial biop-

sy showed a normal picture. Even bipolar CARTO Map resultednormal. The genetic analysis revealed mutation in 3 pts (21.4%):IVS2-24C/T in 2 pts and in R1512W in one pt.Conclusions: In our series of pts with BS ECG pattern and ventri-cular arrhythmias inducibility by EPS endomyocardial biopsy did-n’t show any abnormality while the DNA screening identifiedmutations in about 20% of probands. Perhaps, the differences inpts populations may explain the different results in our study incomparison to other reports. A direct comparison between ptswith and without spontaneous ventricular arrhythmias may bewarranted in order to clarify if any difference exists.

BRUGADA SYNDROME TREATED WITH ANENTIRELY SUBCUTANEOUS IMPLANTABLECARDIOVERTER-DEFIBRILLATOR SYSTEME. DE MARIA1, L. Bonetti1, G. Patrizi1, J. Scrivener2, A. Montin3, G. Zuccon3,S. Capelli1

1Cardiology Unit - Ramazzini Hospital, Carpi (MO), ITALY, 2Cameron Health BV,Arnhem, THE NETHERLANDS, 3MedicoPace, Padua, ITALY

Aims: Complications of implantable cardioverter-defibrillator(ICD) therapy are often linked to transvenous lead insertion, leadfailure or infections. An entirely subcutaneous ICD system (S-ICD)avoids the need of electrodes placement within the heart and cantherefore provide clinical advantages and benefits for the patient. Methods and Results: A 45 years old patient with BrugadaSyndrome (type 1 Brugada ECG, syncope during fever, familyhistory of sudden death <45 years old) was implanted with anentirely subcutaneous cardioverter-defibrillator (S-ICD, CameronHealth-USA). A left lateral incision was made over the 6th rib inthe anterior axillary line for pocket creation and pulse generatorplacement. The subcutaneous electrode was placed subcutaneou-sly, parallel to the sternal midline and 2 cm left lateral of thexiphoid midline, and finally connected to the generator. The inser-tion of the system was guided only by anatomical landmarks andno fluoroscopy was required. Ventricular fibrillation was inducedand terminated by a 65-J shock (15-J safety margin). No complica-tion occurred and subsequent course was uneventful. Conclusions: S-ICD is a new system for delivering life-savingshock therapy in patients at risk of sudden cardiac death, withoutthe need of intracardiac leads. Young patients with inheritedarrhythmogenic syndromes could mostly benefit from this system.This is the first case of Brugada Syndrome treated with a S-ICD inITALY.

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LONG-TERM ELECTROPHYSIOLOGIC FUNCTIONOF RIGHT VENTRICULAR LEAD IN HIGH POSTERIORSEPTAL VERSUS APICAL LEAD PLACEMENT IN CARDIACRESYNCHRONIZATION THERAPYH. KRISTIANSEN, T. Hovstad, G. Vollan, S. Faerestrand

Haukeland University Hospital, Department of Heart Disease, Bergen, NORWAY

Purpose: The preferred right ventricular (RV) lead position in car-diac resynchronization therapy pacemakers (CRT-P) is the RVapex (RV-A). There are few data on electrophysiological stabilityand complications of pacing leads in RV high posterior septal (RV-HS) position in CRT-P. Materials and Methods: Two hundred and thirty-five consecutivepatients were included from 1999-2010. Pacing thresholds at 0,5msand 2,5V, sensing electrograms and lead impedances were meas-ured at implant and repeated at 1,3,6,12,18 and 24 months.Electrophysiological measurements of leads located in RV-A andRV-HS were analyzed retrospectively. Different bipolar RV leadswere used. Results: The RV leads were located in RV-A (n=79) and RV-HS(n=156). Average RV pacing thresholds during 6-24 months at0,5ms were 0,86V±0,90V in RV-A and 0,76V±0,34V in RV-HS(p=0,6), and at 2,5V were 0,07ms±0,08ms in RV-A and0,08ms±0,04ms in RV-HS (p=0,002). Average RV electrogram ampli-tudes from 6-24 months were 14,9mV±6,3mV in RV-A and12,0mV±5,5mV in RV-HS (p=0,06). Average RV impedances from 6-24 months were 814Ohm±251Ohm in RV-A and 562±95Ohm in RV-HS (p<0,0001). There were no statistically significant differences inoperative challenges or lead revisions after 2-year follow-up.Conclusions: The RV-HS lead position demonstrated stable andacceptable long-term pacing and sensing function. The associatedcomplications were similar in RV-A and RV-HS. The RV-HS leadposition is feasible in CRT-P.

ASSESSMENT OF MYOCARDIAL VIABILITY WITHGATED SPECT IN PREDICTING RESPONSE TO CARDIACRESYNHRONIZATION THERAPYI. Zupan1, D. ZIZEK1, M. Cvijic1, L. Lezaic2

1University Clinical Centre - Department of Cardiology, Ljubljana, SLOVENIA,2University Clinical Centre - Department of Nuclear Medicine, Ljubljana, SLOVENIA

Background: Myocardial perfusion imaging with gated myocar-dial perfusion single photon emission computed tomography(SPECT) offers quantification of viable myocardium. We studiedrelation between myocardial viability and echocardiographicvariables of cardiac resynchronization therapy (CRT) response inpatients with ischaemic and non-ischaemic cardiomyopathy.Methods: A total of 38 patients (21 non-ischaemic, 17 ischaemic)were evaluated using 99mTc-sestamibi gated SPECT (20-segmentmodel) before CRT implantation. Global myocardial viability wasdetermined by number of segments without scar tissue (tracer acti-vity >50%), whereas regional viability (region of LV pacing lead) wascalculated as the mean tracer activity in the corresponding segments.Segments of LV lead position were determined at implant venogra-phy by using 2 projections (LAO 30 and RAO 30) of coronary sinustributaries. In all patients AV- and VV- optimization was performed1 month after implantation. Echocardiographic parameters wereassessed at baseline and after 6 months of CRT. Results: The number of segments without scar tissue was lower inischemic vs. non-ischaemic myocardium (p<0.05), no significantdifference was detected in regional viability between groups. Thenumber of viable segments correlated with increase in LV functionin non-ischaemic cardiomyopathy (p=0.002), but not in ischaemiccardiomyopathy. In ischaemic cardiomyopathy echocardiographicresponse to CRT correlated with myocardial viability in the LVlead position (p=0.007).

Conclusions: Assessment of myocardial viability with gatedSPECT before CRT should be considered in both aetiologies of car-diomyopathy. In nonischaemic cardiomyopathy the response toCRT is associated with the extent of global myocardial viability,whereas regional ventricular function (region of LV pacing lead) isclosely related to the response in patients with ischaemic cardio-myopathy.

QUADRIPOLAR LEADS IN CRT IMPLANTS FOR CSSTIMULATION: ADVANTAGES?A. CURNIS, L. Bontempi, A. D’aloia, M. Cerini, A. Lipari, N. Berlinghieri,C. Pagnoni, N. Ashofair, M. Mutti, F. Vassanelli, L. Dei Cas

Division and Chair of Cardiology, Spedali Civili - University of Study, Brescia, ITALY

Purpose: Quadripolar leads in CRT implants for CS stimulationoffer the chance to select the best pacing configuration, optimizingelectrical parameters (in case of high pacing thresholds or phrenicnerve stimulation) and hemodynamic conditions with echo eva-luation. The aim was to verify the benefits deriving from multiplepacing configurations in order to obtain the best hemodynamicresponse to different pacing site or to solve issues associated withhigh pacing thresholds or phrenic nerve stimulation with electricalrepositioning.Materials and Methods: From January to September 2010 10patients underwent CRT-D implant with positioning of quadripo-lar lead (St. Jude Medical 1458Q Quartet) in CS tributary vein. Allpatients were suffering for CMPD refractory to drug therapy,NYHA III and depressed EF (30±5%). For each patient the thre-shold test was performed using all 10 programmable configura-tions to evaluate changes in electrical (threshold, diaphragmaticstimulation) and hemodynamic parameters (intra and interventri-cular asynchrony, stroke volume and aortic VTI).Results: Electrical parameters evaluation showed a significant dif-ference in pacing threshold between the different configurations,compared to lead position within the target vessel and tissue cha-racteristics. Three patients showed PNS using standard configura-tions (involving distal electrodes), solved using additional electro-des (proximal rings).Three months after implant a significant increase in EF to 38±5%has been obtained. Moreover CRT resulted in a significant increa-se (4.18±1.21cm) in VTI and in Stroke Volume (12.34„b2.56 ml).This improvement resulted in a mean increase in cardiac flow of1.3±0.7 L/min.Conclusion: The use of quadripolar leads and the choice of diffe-rent pacing configurations were effective in solving the diaphrag-matic stimulation and improving Stroke Volume, VTI and cardiacflow. Furthermore this particular lead allows, through dedicateddevices, to perform a sequential pacing of the LV, that is a multisi-te pacing.

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TRIPLE-SITE CRT PACING IN PATIENTS WITH NARROWQRS: A PILOT STADY IN 12 PATIENTS?Z. CALOVIC1, V. Jovanovic2, G. Nikcevic2, M. Saviano1, E. Kallergis1,G. Vicedomini1, V. Santinelli2, C. Pappone1, G. Milasinovic2

1Arrhytmology Department Villa Maria Cecillia Hospital, Cotignola, ITALY,2Pacemaker Center Belgrade, Belgrade, SERBIA

Conventional CRT tharapy failed to improve clinical and cardiacstatus in group of patients who satisfied criteria for resynchroniza-tion therapy, but have narow QRS complex on EKG (+/-120 ms).Purpose:Aim of the stady was to see wether the electrical stimula-tion with the triple site ventricular pacing (two LV and one RVelectrode) would improve clinical status in this group of patients.Materials and Methods: In 12 connsecutive patients with classicindication for CRT-P/D pacemaker, narow QRS, and tisue dopplerimage (TDI) verification of left vetricular electrical dissynchrony,we implanted two left ventricular pacing leads trough cannulationof CS, one by one. CS electrodes were implanted at two separatelocation of the LV, so the distance beetween the electrodes wouldbe as far as it possible. We use „Y connector“ to connect two CSleads in one LV port of the pacemaker. RV electrode was implan-ted eather in septal or apical portion of the hearth. Six min hool-wolk test and echocardiography were performed, one, 3 and 6monts after the implantation.Results: All implants were succesful. No complications, eitherperi-or post-procedural, were observed in the patients.After 3months folow-up one patients died in hospital becouse of serioushearth failure deterioration (even we stoped the pacing one monthbefore). The rest 11 pts were improved at least one NYHA class,with the inkrise LVEF (27,5% vs 38,3%). There were also significantincrease in 6 min. walking test (p<0.005) one month after.Conclusion: In our observational stady, we found that triple-siteventricular pacing is fisibile and eficaseous durin 6 monts pacingin patients with serious hearth failure, narow QRS and seriousventricular asinchrony on TDI. Furter much biger stady and lon-ger folow-up is needed for pure clarification of this therapy.

SAFETY OF CARDIAC RESYNCHRONIZATIONIMPLANTATION IN OCTOGENARIANSM. El-Chami, M. HOSKINS, M. Kanitkar, D. Delurgio, J. Langberg, A. Leon

Emory University School of Medicine-Division of Cardiology, Atlanta, USA

Pupose: Cardiac resynchronization therapy (CRT) improves sym-ptoms and reduces mortality and morbidity in patients with leftbundle branch block and symptomatic systolic heart failure. Dataon safety of CRT in octogenarians is limited.Methods: We retrospectively evaluated the success and complica-tion rates of LV lead implantation in 96 consecutive patients >=80years old between January 2003 and July 2008. Baseline clinicaland demographic as well as procedural data were collected.Follow-up data included ICD shocks and mortality.Summary of Results: The age of the cohort was 83.1 2.9 years and73% were male. The ejection fraction was 23 10%. Coronary disea-se and hypertension were present in 74% and 76%, respectively.38% of the patients were pacemaker dependent. 62% underwentinitial implantation of a CRT device, while 38% had a pre-existingpacemaker or defibrillator upgraded to a CRT system. 90% of theCRT systems were defibrillators. LV lead implantation was succes-sful in 95 patients (98.9%). The left ventricular capture thresholdwas 1.4 1.0 volts (range 0.2 - 4.4 volts), and the procedural fluoro-scopy time was 19.3 14.9 minutes. Peri-procedural complicationsincluded 1 hematoma, 1 case of pericarditis, and 1 pocket infectionrequiring device extraction. No peri-procedural (<1 month post-op) mortality occurred. After a mean follow up of 39 22 months, 13patients (14.9%) died. Five patients received appropriate ICD the-rapy, 4 of whom were alive at the end of follow up. 3 patients recei-ved inappropriate ICD shocks.

Conclusion: Cardiac resynchronization therapy appears to be safein octogenarians. The clinical and mortality benefits of this thera-py should be considered for appropriate patients, even if they areof advanced age.

APPLICATION OF THE SEATTLE HEART FAILUREMODEL IN PATIENTS ON CARDIACRESYNCHRONIZATION THERAPYL. PERROTTA1, G. Ricciardi1, P. Pieragnoli1, G. Pontecorboli1, M. Chiostri1,T. De Santo2, F. Bellocci3, N. Vitulano3, M. Emdin4, G. Mascioli5,A. Michelucci1, M.C. Porciani1, L. Padeletti1

1University of Florence, Florence, ITALY, 2Medtronic Italia, Rome, ITALY, 3CatholicUniversity of Sacred Heart, Rome, ITALY, 4Fondazione Monasterio, Pisa, ITALY,5Gavazzeni Hospital, Bergamo, ITALY

Background: The Seattle Heart Failure Model (SHFM) is a multi-marker risk assessment tool able to predict outcome in heart failu-re (HF) patients.Aim: to assess whether the SHFM can be used to risk-stratify HFpatients who underwent cardiac resynchronization therapy with(CRT-D) or without (CRT) an implantable defibrillator.Methods: The SHFM was applied to 342 pts with moderate-to-severe HF (NHYA class III-IV) who underwent CRT (23%) or CRT-D (77%) [median age: 72 years (25th-75th: 65 to 77 years); male79%; median Ejection fraction 26%(25th-75th pct: 21-30%); medianQRS duration 160 ms (25th-75th: 140-171 ms)]. Discrimination andcalibration of SHFM were evaluated through c statistics andHosmer-Lemeshow (H-L) goodness of fit test.Primary endpoints were all-cause mortality alone and a composi-te of death from any cause/cardiac transplantation.Results: During a median follow-up of 24 months (25th-75th pct:12-37 months), 78 patients had an event. Discrimination of SHFMwas adequate for both the endpoint (c statistic always rangesaround 0.7). The SHFM was a good fit of the overall mortality anddeath from any cause/cardiac transplantation, with a significantgap (H-L p value <0.0001) only in the 5-years prediction.Conclusions: In patients on CRT/CRT-D, the SHFM offers ade-quate discrimination with a risk underestimation only in long-term prediction.

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ESOPHAGEAL EFFECT OF CRYOABLATION FORPAROXYSMAL ATRIAL FIBRILLATIONZ. CHITOVOVA1, A. Humera2, J. Skoda1, J. Petru1, L. Sediva1, S. Kralovec1,F. Holy1, V. Reddy2, P. Neuzil1

1Na Homolce Hospital, Prague, CZECH REPUBLIC, 2Mount Sinai Medical Center,New York, USA

Background: Cryoenergy is being increasingly used for paroxys-mal atrial fibrillation (PAF) ablation with less thrombogenicity, lessrisk of pulmonic vein (PV) stenosis etc. but the thermal effect ofcryoenergy on the esophagus remains undefined. Aim of the study: This study examines the esophageal effects ofcryoenergy used during AF ablation Methods: Catheter ablation was performed using a cryoballooncatheter (size 23 and 28 mm) in 32 PAF patients with continuousintraesophageal temperature control (multielectrode wirelessesophageal probe has been used [Clever Technologies Inc.]).240-300 seconds applications of cryoenergy has been used withadditional “bonus” lesions. The cutoff temperature to inclussionthe patient into the study was 35° C. These patients underwent in72 hours esophageal endoscopy examination. When the signs ofulcerations has been proofed, another endoscopy was performedin one-two months. Results: Electrical isolation was reached in all 125 PVs. Significantdecrease of the esophageal temperature 35° C has been reached inall patients at least in one PV. The average of the esophageal tem-perature was 35,1° C; except of two patient we never measuredtemperature under 29° C. Temperature continued to decrease aftertermination of cryoablation before recovering to normal. The aver-age of cryoballoon temperature during energy application was 45° C.Temperature decreases were as following: 13 RSPV, 9 LSPV, 10RIPV, 11 LIPV. Post-procedural endoscopy showed esophagealulcerations in 2 of 32 (6.25%) patients. There were no atrial-esophageal fistulas, and all ulcers had healed on follow-upendoscopy. Patients with and without ulceration differed withrespect to absolute temperature nadir (0° C in one and 16° C in theother patient). Conclusion: Cryoballoon ablation also causes significantesophageal temperature decreases but resulting in reversibleesophageal ulcerations in only 6,25% of patients.Based on ourablation strategy we consider temperatures 29° C with extremelylow risk for esophageal ulcer formation.

EVALUATING THE PULMONARY VEIN ANATOMICALVARIABILITY BY MAGNETIC RESONANCE IMAGING INPATIENTS UNDERGOING ATRIAL FIBRILLATIONABLATION: AN ITALIAN REGISTRYR. DE LUCIA1, E. Bertaglia2, F. Gaita3, R. Verlato4, M. Paolucci5, M. Del Greco6,C. Pratola7, E. Soldati1, M.G. Bongiorni1

1Division of Cardiovascular Disease Unit 2, University Hospital of Pisa, Pisa,ITALY, 2Division of Cardiovascular Physiopathology, Hospital of Mirano-Venezia,Mirano-Venezia, ITALY, 3Division of Cardiovascular Disease, University Hospitalof Turin, Turin, ITALY, 4Division of Cardiology, Hospital of Camposampiero,Camposampiero, ITALY, 5Division of Cardiovascular Disease, Hospital ofNiguarda Ca’ Granda, Milan, ITALY, 6Division of Cardiology, Santa ChiaraHospital of Trento, Trento, ITALY, 7Division of Cardiology, S. Anna Hospital ofFerrara, Ferrara, ITALY

Introduction: The aim of this study was to evaluate, by three-dimensional (3D) Magnetic Resonance Imaging (MRI), the preva-lence and characterization of pulmonary veins (PVs) anatomicalvariability (AV) in patients undergoing AF ablation.Methods: 3D MRI was performed in 172 patients (pts) undergoingPVs isolation from January 2008 to January 2010 in 7 ItalianCenters. MRI data were imported into electroanatomic mappingworkstation. Using Carto system, we evaluated the AV of PVs andbranching patterns. For each PV we measured the ostial diametersand circumference, and its neighbouring ridges. The AV analysis

and measurements were performed in each Center according toprevious standardized definitions and modalities. Results: Typical pattern of 4 PVs with 4 separate ostia was foundin 104pts, 18pts had an additional PV (APV), 41pts had a commonPV trunk (CPVT) and 9pts both the anomalies. 100% of CPVT wereleft-sided and 88.9% of APV were right-sided. Three different pat-terns APV were noted: right-sided were 3 anterior, 20 middle and1 posterior, while left-sided were 1 for each pattern. The superiorPVs risulted significantly larger when compared with the inferiorones (both p<0.001); the right-sided PVs risulted larger when com-pared with the corresponding left-sided ones (both p=0.05). Theaverage intra-patient variability in PV diameter was 14.5±5.9mm.The PV ostium was <10mm in 81pts and >25mm in 39pts. Earlybranching was found in 70pts;in 55.2% of these, EB was present inthe right inferior PV. The shortest distance between right-sidedPVs risulted significantly bigger than the same left-sided(7.7±3.9mm vs 5.7±2.5mm,p<0.001).Conclusions: 3D MRI is a pivotal technique for the assessment ofPVs AV before AF ablation. It allows detection of atypical PVs pat-terns and of marked intrapatient AV. Information about AV mayplay a significant role before and during AF ablation procedures.

CARTO 3 AND CARTO RMT IN LEFT ATRIAL MAPPINGAND ABLATION: COMPARISON OF TWO TECHNOLOGIESS. GROSSI, F. Bianchi, A. Sibona Masi, S. Lebini, M.R. Conte

Ospedale Mauriziano Umberto I, Turin, ITALY

Introduction: Fast Anatomical Map (FAM) and Robotic MagneticNavigation (RMN) have been recently developed in order toimprove map reconstruction accuracy, procedure time and Rxexposure, still critical issues in catheter ablation of atrial fibrilla-tion. Our aim was to compare procedure and fluoroscopy timeusing the two different technologies.Materials and Methods: 200 consecutive patients (pts) affected byparoxismal and persistent atrial fibrillation were enrolled in thestudy and submitted to an ablation procedure including pulmona-ry vein encircling and linear lesions. The procedure was perfor-med with Carto 3 system equipped with Fast Anatomical Mappingin 103 pts; in 97 pts with Carto RMT (Biosense Webster, Inc.,Diamond Bar, CA.) and Robotic Magnetic Navigation with NiobeII (Stereotaxis INC St Louis, LO). Results: Mean procedure times were 73,4 ±12,9 min with Carto 3and 80,9 ±18,8 min with Carto RMT (p:NS) ; mean total RX expo-sure times were 2,57±1,1 min with Carto 3 and 3,53±1,7 min withcarto RMT (p.NS) ;mean left atrium mapping time were 5,29±1,2min with Carto 3 and 10,1±1,9 with Carto RMT (p:0,0001); meanRX exposure during left atrium mapping were 33,8±16,8 s withCarto 3 and 91,6±28,4 s with Carto RMT (p:0,006).Conclusions: FAM is more effective than RMN in reducing timeand RX exposure required for left atrial map reconstruction.Despite a trend in favour of FAM, total procedure and total Rxexposure time did non differ significatively.

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RESULTS OF THE FIRST ITALIAN REGISTRY ON ENSITENAVX ATRIAL FIBRILLATION ABLATION PROCEDURES(IRON-AF): 1-YEAR PROCEDURAL OUTCOMESM. MANTICA1, E. Menardi2, N. Trevisi3, M. Faustino4, F. Perna5,M. Santamaria6, G. Carreras7, A. Pappalardo8, C. Pandozi9, G. De Martino10,E. Romano11

1Istituto Clinico Sant’Ambrogio, Milan, ITALY, 2A.O. Santa Croce e Carle, Cuneo,ITALY, 3Fondazione San Raffaele Monte Tabor, Milan, ITALY, 4Clinica Pierangeli,Pescara, ITALY, 5Policlinico Gemelli - Università Cattolica del Scaro Cuore, Rome,ITALY, 6Università Cattolica del Sacro Cuore, Campobasso, ITALY, 7O.Santa Mariadi Loreto Nuovo, Naples, ITALY, 8A.O. San Camillo-Forlanini, Rome, ITALY, 9A.O.San Filippo Neri, Rome, ITALY, 10Clinica Santa Maria, Bari, ITALY, 11St.JudeMedical ITALY, Clinical Dept, Milan, ITALY

Non-fluoroscopic cardiac mapping systems are frequently used asan auxiliary tool for Atrial Fibrillation (AF) ablation. IRON-AF is aprospective registry on a proprietary mapping technology basedon the electromagnetic field (EnSite NavX) able to reconstruct acardiac anatomy 3D model with simultaneous visualization of allcatheters. The aim is to provide a general overview of the AF abla-tion common practice using this system in ITALY. From Nov 2006to May 2008, 551 consecutive patients were enrolled in 16 centers. Baseline, procedural techniques, complication rate and follow-updata from 545 patients (67% male) were analyzed. Patients (age60±10 years, NYHA I: 76%; II: 21%; III: 3%) were classified on thebasis of the arrhythmia’s history: 242 (44%) had paroxysmal AF,234 (43%) persistent and 69 (13%) longstanding persistent (>1year)AF. 363 patients (67%) had no structural heart disease; 93 hyper-tensive disease (17%); 38 CAD (7%); valvulopathy (6%), dilated(6%) and other (3%) cardiomyopathy were also present. Commonsymptoms were palpitations and dyspnea. Echocardiographicdata were collected (LA diam. 44.2±6.3 mm; LVEF 56.6±9%). 501(92%) patients were under antiarrhythmics. 238 patients (44%)were ablated under general anesthesia rather than sedation, witha significant reduction of procedural (186’±67’ vs 205’±74’, p=.004)and fluoro times (45’±34’ vs 54’±36’, p=.008) and a shorter hospita-lization (3,4±2,8 vs 5,3±3,3 days, p=.001). After ablation, 24 (4.4%)patients were still in AF. No procedure-related death was obser-ved. 52 complications occurred in 46 patients (8,4%), with 16(2,9%) pericardial effusions; 14 (2,6%) bleeding events; 4 (0.7%)cardiac tamponade; 3 severe bradycardia (0,6%) and 3 pulmonaryedema; 2 (0.4%) A-V blocks; 2 strokes and 8 other non-fatal com-plications. At 1-year, 3 deaths were reported (1 cardiovascular);considering a 3-months blanking, respectively 165 (68,2%), 165(70,5%) and 41 (59,4%) patients with paroxysmal, persistent or lon-gstanding persistent AF were free from recurrences.

AF ABLATION AND CRITICAL MASS: ROLE OF ATRIALDEBULKING A PILOT STUDYC. LAVALLE1, S. Grossi2, C. Pandozi1, F. Bianchi2, S. Dottori3, A. Gramondo3,M. Russo1, M. Galeazzi1, S. Ficili1, M. Santini1

1Department of Cardiovascural Disease, San Filippo Neri Hospital, Rome, ITALY,2Umberto I° Mauriziano Hospital, Turin, ITALY, 3Biosense Webster, ITALY

Introduction: Pulmonary veins (PVs) isolation, although effectivein maintaining sinus rhythm for paroxysmal AF, has limited suc-cess in non-paroxysmal forms. Different adjunctive atrial modifi-cations, such as wider ablation around PVs, linear lines, ablation ofcomplex fragmented atrial electrograms, have been developed. Aim: the aim of this study is to evaluate the role of atrial debulkingin persistent AF catheter ablation regardless of the ablation strate-gy used.Methods: Eighteen consecutive patients with long standing - per-sistent AF underwent catheter ablation of AF guided by Carto3system. Fast Anatomical Mapping of left atrium (LA) was perfor-med to reconstruct LA anatomy. In a subset of patient, CT wasused to guide the anatomical reconstruction. In all patients LAvolume (V) was measured by using Carto3 features.

The ablation strategy used was: 1) Hospital A: circumferential wide antrum ablation confirmed bycircular mapping catheter;2) Hospital B: circumferential ablation plus roof and mitral istmuslines; Radiofrequency (RF) ablation was performed by means of athermocool catheter used in power controlled mode (30-35W tar-get power, 30mL/min irrigation flow). RF was delivered in eachsite until the local electrograms were reduced under 0,1mV. TotalRF energy (E) was calculated. For each patient, the parameter E/Vwas calculated.Results: For hospital A and B, mean V was 145,96±34,21 mL and132,83±38,53 (p=ns) respectively; mean RF energy was86,74,5±34,65 KJ and 67,64±32,47 KJ (p=ns); mean E/V parameterswere 0,62±0,28 KJ/mL and 0,51±0,16 KJ/mL (p=ns).Conclusion: The amount of energy delivered, defined by the E/Vparameter, does not seem to depend on the strategy used. A corre-lation seems to exist between the amount of energy used (E/V)and the number of relapse at a 6 months follow up.

EFFECTIVENESS AND RELIABILITY OF ASIMPLIFIED APPROACH FOR THREE-DIMENSIONALIMAGE-INTEGRATION USING ANELECTROANATOMIC MAPPING SYSTEME. SOLDATI, G. Zucchelli, R. De Lucia, S. Viani, L. Paperini, A. Di Cori,L. Segreti, L. Misuraca, M.G. Bongiorni

Cardiovascular Disease Unit 2, University Hospital of Pisa, Pisa, ITALY

Background: Image-integration was proven to be helpful duringAtrial Fibrillation (AF) Ablation.Aim of this study is the evaluation of effectiveness and reliabilityof a new simplified and no time consuming method for image-integration using EnSite NavX (St. Jude Medical) electroanatomicmapping (EAM) system. Methods: All pts underwent TC or MRI scan before ablation, andscan data were processed using dedicated software. Virtual 3Dgeometry was reconstructed and geometry was elaborated. Thealignment was performed using 6 fiduciary points, 1 for eachPulmonary Vein (PV) and 2 on the mitral annulus. Alignment’saccuracy was checked by the possibility to navigate inside theatrium and PVs in absence of fluoroscopy and by the distance bet-ween TC or MRI 3D surface reconstruction and the tip of the abla-tion catheter at 10 different point near PVs ostium.Results: The method was used in 42 consecutive pts undergoingablation because of paroxysmal (33) or persistent (9) AF. TC scanwas performed in 6 pts, MRI in 36. The mean time spent for virtualgeometry reconstruction was 7.2min; the alignment requiredmeanly 2.9 additional min. Acute endpoints of the ablation wereobtained in all pts: PVs deconnection with bidirectional block(42/42pts), complete line of block at the left isthmus (8/8pts).Navigation was possible and reliable with no fluoro-imaging in allpts. The mean distance between TC or MRI atrial surface and thetip of ablation catheter resulted 1.8+0.1mm, ranging from 0.4 to4.9mm, and this result was similar to previous experiences repor-ted in Literature.Conclusion: This simplified method for image-integration resul-ted easier and faster than more complex ones, without significantdifferences in accuracy and reliability. It can lead to a reduction inprocedural time and X-Ray exposure.

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CLINICAL CHARACTERISTICS OF 4 CZECH FAMILIESWITH CATECHOLAMINERGIC POLYMORPHICVENTRICULAR TACHYCARDIA AND PILOT RESULTSOF MUTATIONAL ANALYSIS OF RYR2 GENET. NOVOTNY1, P. Kubus2, P. Vit3, I. Andrsova1, A. Florianova1, I. Valaskova4,J. Kadlecova4, R. Gaillyova4, E. Svandova4, J. Spinar1

1Department of Internal Medicine and Cardiology, University Hospital Brno andFaculty of Medicine of Masaryk University, Brno, CZECH REPUBLIC, 2PaediatricCardiocentre, University Hospital Motol, Praha, CZECH REPUBLIC, 3Departmentof Pediatrics, University Hospital Brno and Faculty of Medicine of MasarykUniversity, Brno, CZECH REPUBLIC, 4Department of Medical Genetics, UniversityHospital Brno and Faculty of Medicine of Masaryk University, Brno, CZECHREPUBLIC

Background: Catecholaminergic polymorphic ventricular tachy-cardia (CPVT) is a rare hereditary arrhythmia. The onset of clinicalsymptomes occures usually during childhood, typically related tostress. The aim of our study is to report clinical characteristics of 4Czech families with CPVT and pilot results of mutational analysisof the RyR2 gene.Methods: The probands and their relatives are investigated at theparticipating departments They undergo basic clinical investiga-tion, the history is aimed at possible symptomes of CPVT - syncopiduring stress. Bicycle ergometry is performed to obtain ECGrecordings during adrenergic stimulation. In all the investigatedindividuals blood samples are taken for DNA isolation. Inprobands a mutation analysis of the RyR2 gene has been started.Results: So far 4 families have been investigated - 7 adults, 6 chil-dren. In 3 cases the indication for examination was syncope duringstress, another patient was succesfully resuscitated due to malig-nant arrhythmia. The diagnosis was confirmed using ergometrywith provocation of polymorphic ventricular tachycardia. In onefamily the diagnosis was also confirmed in a fater of the patient.The other relatives did not present any arrhythmias. All 5 afectedindividuals were treated by betablocker, in one of them a car-dioverter/defibrillator was implanted because of recurrent syn-copi. In one of the probands sequence changes were detected:c.14101-6A>G and 14101-21A>G close to 3´-end of the intron 94-95and 14231+12A>C close to 5´-end of the intron 95-96. The detectedsequence changes have not been included in the CPVT mutationdatabase and these have not been published yet.Conclusions: CPVT must be considered in all cases of exerciserelated syncope. For a confirmation of the diagnosis an exercisetest is neccessary. Mutational analysis of related genes can revealasymptomatic individuals in whom betablocker therapy is recom-mended. The research is supported by the grant MSMT 2B08061.

DOES HIGH-FREQUENCY RIGHT VENTRICULAR PACINGINFLUENCE ATRIAL FIBRILLATION INCIDENCE INMYOTONIC DYSTROPHY TYPE 1 PATIENTS?G. NIGRO, V. Russo, V. Gionti, M.L. Rosato, V. Giordano, L. Armetta,F. Colimodio, M.G. Russo, P. Golino, R. Calabro’

Chair of Cardiology - Second University of Naples, Naples, ITALY

Introduction: Aim of our study was to evaluate the influence ofhigh-frequency right ventricular pacing on atrial fibrillation inmyotonic dystrophy (MD1) patients during twelve months followup period.Methods and Results: Fifty MD1 patients (age 51,3±5; 22 F) under-went dual chamber pacemaker implantation were enrolled in thepresent study. At 12 months of follow-up the population studywas divided into three group according to the percentage of atrialand ventricular stimulation: ASVS Group (n: 16; age 55,2±7,7; 9 F)with a percentage of atrial and ventricular stimulation lower than50%; ASVP Group (n: 18; age 50,5±7,6; 10 F) with a percentage ofatrial stimulation lower than 50% and percentage of ventricularstimulation higher than 80% APVP Group (n:16; age 56±4,3; 6 F);

with a percentage of atrial and ventricular stimulation higher than80%. We counted the number of episodes of atrial arrhythmiaoccurred during the collection period and the duration of each epi-sode. We found a statistically significant difference in the numberand the duration of AF episodes between the three groups at 12months follow up. In particular, there were more episodes and lon-ger durations of AF in ASVP Group than in ASVS Group and inAPVP Group. Lead parameters remained stable over time andthere were no displacements of the electrodes after implantation. Conclusions: In a twelve months follow-up comparison we sho-wed a statistically significant increase in paroxysmal atrial fibrilla-tion episodes in MD1 patients with high-frequency right ventricu-lar pacing.

OUTCOMES OF EVALUATION OF RELATIVES WITH AFAMILY HISTORY OF YOUNG SUDDEN CARDIAC DEATH;NEARLY AS MANY ICDS REMOVED AS IMPLANTEDJ. CALDWELL1, N. Moreton2, N. Khan2, L. Kerzin-Storrar2, K. Metcalfe2,W. Newman2, C. Garratt1

1Manchester Heart Centre, Manchester, UNITED KINGDOM, 2Clinical GeneticsDept, Manchester, UNITED KINGDOM

From March 2005, regional genetic arrhythmia clinics were establi-shed across the UK as part of the National Service Framework.Here we examine the role and outcomes of one such clinic. We present data on outcomes of 173 consecutive patients whowere referred to the genetic arrhythmia clinic because of a familyhistory of SCD/aborted cardiac arrest. The mean age of this cohortwas 38±17yrs and mean duration of follow-up was 14 months(range: 1 day-46 months). In terms of family history, the meannumber of SCD/abortive deaths per attendee was 1.6±1.4 and themean age of the “victims” was 32±15yrs. Of these 173 patients, 131 patients were clinically normal and 38(22%) were diagnosed with a potentially inheritable cause of SCD;LQTS 10, Brugada 2, ARVC 6, HCM 9, CPVT 4, DCM 7. Fourpatients had other conditions (left ventricle non-compaction,AVNRT, skeletal myopathy and mild AS). Of the 38 diagnosedwith an inheritable condition, 16 had medication commenced bythe clinic (beta-blockers[16], ACEi/ARB [2]), and 4 had an ICDinserted on clinic recommendation (2 x HCM, 1 x DCM, 1 xARVC). In these 4 patients with ICDs, no appropriate therapies(ATP or shocks) have been administered to date but 1 patient recei-ved an inappropriate shock and also required a lead replacementfor lead fracture. Three individuals had beta-blockade withdrawn after negativegenetic testing for an established familial mutation (2 CPVT, 1LQT), one ICD was removed and one deactivated (both negativefor CPVT).A diagnosis of a potentially inheritable cause of SCD was obtainedin 22% of those with a family history of SCD/aborted cardiacarrest. The number of ICDs inserted was very small (2%) and therehave been no appropriate therapies in this group. Two ICDs havebeen removed/deactivated after exclusion of a known familialmutation.

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CLINICAL CHARACTERISTIC OF 28 CZECH FAMILIESWITH GENETICALLY CONFIRMED DIAGNOSISOF LONG QT SYNDROMEI. ANDRSOVA1, T. Novotny1, J. Kadlecova2, R. Gaillyova2, A. Florianova1,A. Bittnerova2, M. Sisakova1, P. Vit3, J. Spinar1

1Department of Internal Medicine and Cardiology, University Hospital andFaculty of Medicine of Masaryk University, Brno, CZECH REPUBLIC, 2Departmentof Medical Genetics, University Hospital and Faculty of Medicine of MasarykUniversity, Brno, CZECH REPUBLIC, 3Department of Pediatrics, UniversityHospital and Faculty of Medicine of Masaryk University, Brno, CZECH REPUBLIC

Background: Classic symptomes of long QT syndrom (LQTS)include prolongation of QT interval, syncope and cardiac arrestsdue to,torsade de pointes” (TdP) ventricular tachycardia. Weassessed occurence of these symptomes in patients with genetical-ly confirmed LQTS diagnosis.Methods: The investigated group consisted of 96 individuals from28 families with genetically confirmed diagnosis of LQTS. In 20families mutations of KCNQ1 gene were found, in 7 families muta-tions of KCNH2 gene. In one family combined mutation in bothgenes were found. Incidence of following signs was asssessed: 1)pathologic prolongation of QT interval, 2) syncope, 3) cardiacarrest, 4) TdP and 5) sudden cardiac death in family history.Clinical investigation included also exercise test with QT intervalanalysis. Clinical results were corelated with results of mutationanalysis.Results: Only 33 (60%) patients from 56 mutation carriers had atleast 2 ,,typical signs,, of LQTS. Other were oligo- or even asym-ptomatic. From 39 healthy individuals only one fulfilled the clini-cal criteria of LQTS diagnosis, in other 3 intermediate probabilityof the diagnosis was present. Exercise test showed 91% sensitivityand 94% specificity for the LQTS diagnosis.Conclusions: Incidence of classical signs of LQTS is not typical formutation carrier. Therefore proper diagnosis deserves high atten-tion of investigating physician. The exercise test has high sensitivi-ty and specificity. Mutation analysis confirms the diagnosis in cca60% families.The research is supported by grants IGA MZ CR NS/10429-3 andMSMT 2B08061.

THE CLINICAL SIGNIFICANCE OF FAMILIAL HEART BLOCKM. YAHALOM1,3, N. Roguin1,3, R.S. Kaiyal2, J. Bornstein2,3, R. Farah3,4

1Western Galilee Hospital, Pacemaker unit & Cardiology Department, Nahariya,ISRAEL, 2Western Galilee Hospital, Department of Obstetrics & Gynecology,Nahariya, ISRAEL, 3Technion, Faculty of Medicine, Haifa, ISRAEL, 4Departmentof Internal Medicine B, Sefad, ISRAEL

Introduction: Familial abnormalities of the conduction system,both symptomatic and asymptomatic, are sometimes overlookedin daily medical practice.Familial (and congenital) Heart Block (FHB) may be associatedwith other diseases such as: Hypertrophic and DilatedCardiomyopathies, Familial Dysautonomia, Emery-Dreifussdystrophy and Charcot-Marie-tooth disease. Familial Heart Blockmaybe transmitted with collagen disease antibodies in the mother.It may appear at any stage of life.Purpose: To present the clinical and genetic findings, and toemphasize the clinical significance of familial heart block, especial-ly when symptoms exist, even sporadic and minor and in the peri-natal period.Methods and Subjects: The members of three families (9 indivi-duals in 3 generations) with symptomatic heart block are presen-ted, eight of which required permanent cardiac pacemaker thera-py. Last year, a female baby was born to one of our patients. Pre-Natal Fetal Arrhythmia had been noticed and 2nd degree Atrio-Ventricular(AV) block (Mobitz I & II) has been observed on 24-hours Holter monitoring. Conclusions: Careful follow-up is suggested, in all members of

families, in whom FHB is present, especially when symptoms existand even in the Perinatal period.

PECULIAR ELECTROANATOMIC ANDELECTROPHYSIOLOGIC FEATURES OFARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYO-PATHY PATIENTS WITH CLINICAL VENTRICULARTACHYCARDIAP. SANTANGELI2, A. Dello Russo1, M. Casella1, G. Pelargonio2, F. Bellocci2,S. Bartoletti1, M. Pieroni2, M. Zucchetti1, F. Tundo1, G. Fassini1,C. Carbucicchio1, L. Di Biase3, A. Natale3, C. Tondo1

1Arrhythmia Department, Institute of Cardiology, University of Milan, IRCCS-Centro Cardiologico Monzino, Milan, ITALY, 2Catholic University of the SacredHeart, Rome, ITALY, 3Texas Cardiac Arrhythmia Institute, St. David’s MedicalCenter, Austin, TX, USA

Introduction: Despite the typical presence of potentially arrhy-thmogenic right ventricular fibro-fatty scars, it is not clear whyonly a subset of patients with arrhythmogenic right ventricularcardiomyopathy (ARVC) develops sustained ventricular tachycar-dia (SVT). The aim of this study was to compare the electrophysio-logic substrate in ARVC patients with and without SVT.Methods: Detailed electroanatomic mapping of the right ventricu-lar endocardium was performed in 13 ARVC patients (10 males)with spontaneous SVT and in 10 stable control ARVC (6 males)without clinical SVT. Diagnosis of ARVC was established accor-ding to current Task Force of the European Society of Cardiologyand International Society and Federation of Cardiology(ESC/ISFC) criteria. Standard definitions of electroanatomic scarsand fractionated, isolated, and very late potentials were used.Results: Patients with SVT did not differ significantly from controlpatients in terms of baseline clinical variables, including RV enlar-gement and ejection fraction. The extent and distribution of elec-troanatomic scars were similar in the two groups (9±7.5% vs.11±7.1% of RV surface area, p = 0.71). However, patients with SVThad higher prevalence of fractionated potentials (77% vs. 20%, p =0.012), of isolated late potentials (62% vs. 10%, p = 0.029), and ofvery late potentials (69% vs. 40%, p = 0.22). Conclusions: The electroanatomic substrate of ARVC patientswith SVT is characterized by a markedly higher prevalence of frac-tionated and isolated late potentials compared to an otherwisesimilar control group without SVT. These findings may explainwhy only a subset of patients with ARVC develops SVT despitethe presence of potentially arrhythmogenic fibro-fatty scars in allof these patients.

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DO PATIENT CHARACTERISTICS INFLUENCE THEDECISION TO PERFORM DEFIBRILLATION TESTING AT THETIME OF ICD IMPLANT? DATA FROM SAFE-ICD STUDYG. CIARAMITARO1, M. Brignole2, G. Mascioli3, C. Tomasi4, A. Del Rosso5,A. Reggiani6, G. Giudici7, L. Chiodi8, M. D’Acri9, S. Favale10

1A. O. Universitaria Policlinico Paolo Giaccone, Palermo, ITALY, 2Ospedale diLavagna, Lavagna, ITALY, 3Cliniche Humanitas Gavazzeni S.p.A., Bergamo,ITALY, 4Ospedale S.Maria delle Croci, Ravenna, ITALY, 5Ospedale S.Pietro Igneo,Empoli, ITALY, 6Ospedale Carlo Poma, Mantova, ITALY, 7Ospedale Bolognini,Seriate, ITALY, 8Ospedale S. Maria Annunziata, Bagno a Ripoli, ITALY, 9BostonScientific, Milan, ITALY, 10Ospedale Policlinico Consorziale, Bari, ITALY

Aim: The ongoing SAFE-ICD study evaluates the safety of twostrategies consisting in performing or not performing defibrilla-tion test (DT) during first implantation of ICD. Aim of the analysisis 1) to analyze differences between patients who performed or notDT during ICD implantation; 2) find clinical variables predictorsof the decision to avoid DT. Methods and Results: In 39 centres 2130 consecutive first implantsof ICD were considered between April 2008 and May 2009. Patientcharacteristics were: male gender: 80%, ischemic disease: 56%,ejection fraction<=30%: 62%, primary prevention: 69%, NYHAclass>II: 40%, age>70: 44%, cardiac resynchronization therapy(CRT): 42%. In 1276/2115 patients (60%) DT at implant was notdone. Thirteen centers did not perform DT in almost all of theirpatients (>95%). Among those clinical variables, at multivariateanalysis patients with NYHA class>II were associated a higherprobability of not performing DT (HR: 1.75; 95%IC: 1.42- 2.17;p<0.01). Additionally, the center’s practice not to induce all of theirown patients was not influenced by any of the patient characteris-tics. (<chi>2=13.5 p=0.03)Conclusions: In the SAFE-ICD study DT is not performed in asubstantial number of patients. The decision to avoid DT is notinfluenced by most clinical characteristics, except for NYHA class>II. Decision not to induce almost all ICD patients in a hospital isnot driven by patient characteristics but by center’s practice. TheSAFE-ICD study will assess safety of this practice.

PROLONGED BURST - A NEW METHOD FOR ICD TESTINGDURING IMPLANTATIONJ. LUKL1, D. Marek1, M Marcian1, P Schneiderka2

11st Medical department, Faculty Hospital, Olomouc, CZECH REPUBLIC,2Department of clinical biochemistry, Faculty Hospital, Olomouc, CZECH REPUBLIC

Background: Two methods of VF induction are used to test ICDfunction, namely T-wave shock and a short 50Hz burst.Analgosedation is used for both.Aim: To find out whether it is possible to safely narcotize thepatients without analgosedation using a burst prolonged untilpatients become unconscious.Patients and Method: 104 patients undergoing primary implanta-tion or reimplatation were included (80M, 64.6±13.1 years old inaverage). Patients were randomized to 2 subgroups (SG). Patientsin SG1 underwent a prolonged burst without analgosedation. Thetotal time of circulation arrest (CA) was determined as a time fromthe end of burst until ICD shock delivery. Patients in SG2 under-went an analgosedation (fentanyl + midazolam) and a subsequentT-wave shock. Total time of CA was determined as a time from T-wave shock to ICD shock delivery. The ICD shock energy usedwas 10J lower then the maximal ICD energy. Neuronspecific eno-lase (NSE) samples were obtained before the procedure and then6, 24 and 48 afterwards.Results: No difference was observed comparing both SG in basicclinical parametrs (age, sex, NYHA class and underlying cardiacdisease). The total time of CA in both SG was similar (11.7±5.3 ver-sus 10.5±2.7s, P>0.05). The average NSE values after 6, 24 and 48hours showed no statistical difference between the SGs (13.1±6.3and 11.6±5.8, 14.5±7.5 and 13.4±6.0, 14.9±5.9 and 12.2±6.0 g/L., as

well between these values and the basic control value (14.0±5.9and 13.4±4.0).Conclusion: Prolonged burst is a safe method that enables omis-sion of analgosedation at ICD testing during implantation.

DEFIBRILLATION TESTING AT IMPLANT:RESULTS FROM THE FIRST STUDYP. SCIPIONE1, A. D’Onofrio2, G. Ricciardi3, P. Pieragnoli3, I. Rubino5,S. Argnani6, D. Gorini7, O. Piot8, L. Padeletti3

1Ospedale Lancisi, Ancona, ITALY, 2Ospedale Monaldi, Naples, ITALY, 3OspedaleCareggi, Florence, ITALY, 4Ospedale Civile di Lugo, Lugo di Rm, ITALY, 5OspedaleCivile di Faenza, Faenza, ITALY, 6Ospedale M.Bufalini, Cesena, ITALY, 7CCN,St. Denis, FRANCE

Aims: The FIRST Registry is designed to collect routine clinicalpractice data on a standard ICD and CRT population. This subanalysis focused on the application of the defibrillation testing(DT) at implant in the routine clinical practice.Methods: 298 pts (single 37%, double 37% and triple chamber26%) were included and clinical data, DT, median programmedEnergy (E) and% programmed polarity (Normal (N) or Reversed(R)) were collected.Results: Primary (57%) and secondary (43%) prevention popula-tion (65.6±11.6 yrs, 83% male, LVEF 31±11.8%, 11% NYHA I, 54%NYHA II, 33% NYHA III and 2% NHYA IV) were retrieved; prima-ry prevention pts were 65% MADIT II, 17% SCD-HeFT, 9%MADIT I and 9% other, while secondary prevention pts presentedVentricular Tachycardia (VT) in 63%, Ventricular Fibrillation (VF)in 26% and Syncope/Induced VT in 11% of the pts. DT was notperformed in 29% of cases due to i) Medical contra indication(49%), ii) not routinely done (21%), iii) planned to be done (13%),iv) already done (10%), v) other (7%). In 71% of cases DT test wasdone to evaluate defibrillation safety margin (DSM). 63% of ptsperformed 1 DT (E=22J and N=93% and R=7%),4% of pts under-went 2 IDT (E=24J and N/R=93%/7%), 3% of pts underwent 3 IDT(E=24J and N/R=64%/36%) and <2% of pts underwent 4 to 6 IDT(E=26J and N/R=50%/50%).Conclusions: IDT was not performed in 29% of this recent ICDpopulation, and when performed, consisted mainly in only one VFinduction, which again claims for further questioning on the needfor defibrillation testing.

FIRST EXPERIENCES WITH NEW ICDAND DEFIBRILLATION LEADS: THE 4-SITE SYSTEMG. FORLEO1, L. Santini1, A. D’Onofrio2, C. Cavallaro2, L. Bontempi3,F. Caravati4, I. Caico4, F. Zanon5, G. Pastore5, D. Vaccari6, S. Vitadello6,A. De Simone7, V. La Rocca7, F. Cantù8, P. De Filippo8, F. Sebastiani9,L. De Luca9, G. Pelargonio10, M Narducci10, A. Curnis3

1Policlinico Torvergata, Rome, ITALY, 2A.O. Monaldi, Naples, ITALY, 3SpedaliCivili, Brescia, ITALY, 4Osp. Macchi, Varese, ITALY, 5Osp. S. Maria dellaMisericordia, Rovigo, ITALY, 6Ospedale Civile, Montebelluna, ITALY, 7Casa diCura S. Michele, Maddaloni, ITALY, 8Ospedale Riuniti, Bergamo, ITALY,9Policlinico Casilino, Rome, ITALY, 10Università Cattolica Sacro Cuore, Rome,ITALY

Aim: During this year a new ICD lead technology, the 4-SITE™system, has been introduced by Boston Scientific, replying to newstandard four-pole connector DF-4. The aim is to assess the impactof the new technology introduction, the expected benefit and thefeedback after the first use.Methods: From March,15 to April,15 2010, 138 4-SITE™ technolo-gy CRT-D/ICD (53% COGNIS®4-SITE™ CRT-D and 47% TELI-GEN®4-SITE™ ICD) and leads (RELIANCE®4-SITE™ ICD: 65%dual coil, 51% active fixation and 97% GORE™ePTFE covered)were implanted in 27 centres from 35 different operators. The 4-SITE™ system consists of a single lead connection with four-poles. The IS-1/DF-1 connection is replaced by four poles aligned:IM

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the two proximal poles are the pace/sense electrodes and the twodistal poles are the distal and proximal coil. Each operator, before the first procedure and after the fifth, filledin a simple evaluation survey questionnaire.Results: No complications to report at implant. Among all opera-tors, 96% consider the new technology useful for all patients andbelieve that this technology will become a first choice in the next6-12 months. 92% of operators verified a simpler wrapping and insertion of thelead in the pocket; 79% noticed a simpler and more reliable checkof complete terminal pin insertion, both through visual inspectionand through standard traction test, thanks to a better head systemdesign. The greatest advantage verified was the improvement ofpocket bulk (62%) and handiness of use (24%). The major benefitsexpected are the lower rate of pocket complications (46%) and theimproved safety of device replacements (25%).Conclusion: In our multicenter survey the 4-SITE technology deli-vers a simpler and more efficient implant experience, the majoradvantages of one single connection are lead volume and pocketbulk reduction, and expected risk minimization of pocket erosionand failures due to lead abrasion.

NO CONTACT ARRAY ELECTROANATOMICAL MAPPINGDURING CRT-D IMPLANT: A SINGLE CENTER EXPERIEN-CE OF TEN PATIENTS WITH A CLINICAL ANDECHOCARDIOGRAPHICS 2-YEARS FOLLOW-UPC. PRATOLA, T. Toselli, M. Bertini, R. Revelchion, P. Artale, R. Ferrari

Cardiovascular Institute University of Ferrara, Ferrara, ITALY

Aim: We report the two years follow-up of ten patients in whomno-contact (NC) mapping CRT was performed in order to correla-te the left ventricle (LV) electrical activation parameters and CRTresponse.Methods: 10 patients underwent NC Array mapping during CRTimplant were enrolled. At clinical and echocardiographic follow-up a particularly positive CRT response was defined when LVend-systolic volume was reduced >15%.Results: Mean age was 68±8 years. Three patients died during fol-low-up, two of them for worsening heart failure (considered to benon-responders) and one for non-cardiac event. Of the remainingseven patients, five were found to be responders and two non-responders.From the NC analysis, we found that all responders showedduring implant an obvious slow conduction area on the anteriorwall and fusion of the left and right activation front during biven-tricular pacing. However, we observed that there was a greatvariability in terms of interventricular and intraventricular delaypacing from right and LV as well as different degrees of fusionduring biventricular pacing. The non-responders were either ischemic without a clear slow con-duction area (a scar) or patients in whom the only availablevenous coronary branch was anterior.These findings suggest that the absence of a target vein on thepostero-lateral wall, the absence of electrical activation fusionduring biventricular pacing or the presence of a wide scarred areain the left ventricle may be potential reasons for not performing aCRT implant.Conclusions: NC mapping during CRT implant seems to be a use-ful tool to predict favourable CRT response. Further larger studiesare needed to explore the potential role of NC mapping to selectsuitable patients for CRT. Therefore, NC mapping may lead theimplants in order to avoid demanding and risky procedures inpatients with low likelihood of favourable CRT response.

BROKEN LEADS WITH PROXIMAL ENDINGS IN THECARDIOVASCULAR SYSTEM - SERIOUS CONSEQUENCESAND EXTRACTION DIFFICULTIESA. ANDRZEJ KUTARSKI1, B. Malecka2, R. Pietura3

1Dept of Cardiology Medical University of Lublin, Lublin, POLAND, 2Dept. ofElectrocardiology, Institute Cardiology, Jagiellonian University CollegiumMedicum at John Paul II Hospital, Crackow, POLAND, 3Dept. of InterventionalRadiology and Neuroradiology Medical University of Lublin, Lublin, POLAND

Objective: Results analysis of transvenous leads removal with freeendings migrated to the CVS.Methods: A retrospective analysis of a 4-year-old database ofremoval procedures comprising 590pts. and 1032 leads. The studygroup consisted 32pts (16M), aged aver. 61,7y. Extracted leads:PM-BP-63,9%, PM-UP-29,5%, ICD-5,0% and VDD PM-1,6%.83,6%-passive fixation. 45,0%-atrial, 55,0%-ventricular. Leads’ age:103,1+/-63,6mths. No of explanted leads: 44,2%-2, 42,2%-1, 13,6%-3~6. Non-infective indications for extraction-66,6%. Controlgroup-557pts (61,7%M), aged aver. 64,8y. Non-infective indicationfor lead extraction-50,6%.Results: Indication for extraction: Local infection-7, LDIE-7, sud-den loss of pacing-12, potentially dangerous proximal ending-6.Aver. age of migrated leads-126,9 mths. Proximal ending location:subclavian vein-12, anonymous vein-7, RA-2, RV-4, superior cavavein-3, jugular vein-1, pulmonary vein-1, liver vein-1. Condition ofvenous access site: complete SV/AV obstruction-8, moderate-15,insignificant-9. Fixation of proximal ending with CVS wall: verystrong-17, moderate-10, weak-5. End liberation method: pig-tailcath.-7, loop consisted with guide-wire and basket catheter orlasso-25. Pulling for liberated proximal ending in 23pts; in other-the tip of lead liberated as the first, then from contrary side.Grasped lead removal: simple traction using basket or lasso cathe-ter-7, liberation from adhesions using Byrd dilators-6, internalFemoral Working Station catheter -20, both of Femoral WorkingStation cath.-6. Dislodgement of functional lead-4.Conclusions: 1) Dropped-in leads appears in 5% pts referred forlead extraction. Usually asymptomatic or single symptom consistventricular arrhythmia. Most frequent reason of hospitalization isvenous occlusion and necessity of venous access recapture orinfection. 2) Proximal ending often (>70%) grows into vein wallcausing local occlusion. In case of another leads presence the mosteffective technique is draw into SCV using loop of wire bridgedover the lead. 3) Effectiveness of transvenous extraction of drop-ped-in leads without free ending is high (>96%) and percentage ofcomplication is not higher than in another leads.

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IMPLANTATION OF A NOVEL QUADRIPOLAR LEFTVENTRICUALR LEAD AND CRT-D SYSTEM CAPABLEOF DELIVERING LONG-TERM MULTISITE PACINGA. Shetty, S. Duckett, J. BOSTOCK, D. Roy, S. Hamid, C. Bucknall, N. Patel,C. Rinaldi

Guys and St Thomas’ Hospital NHS Foundation Trust, London, UNITED KINGDOM

Introduction: Multipolar leads may deliver site specific and mul-tisite LV stimulation. We report the first implant of the St JudeQuartet quadripolar lead in conjunction with a CRT-D generatorcapable of delivering long-term true multi-site stimulation. TheQuartet has 4 electrodes and is capable of delivering site specificstimulation to avoid phrenic nerve stimulation. It also has thecapability to deliver multisite stimulation through more than onepole simultaneously.Methods: A 56 year old female with a non-ischemic cardiomyopa-thy, LBBB, LVEF 25% and NYHA class III heart failure symptomsunderwent CRT. A quadripolar Quartet model 1458Q LV lead wasplaced in a posterior branch of the coronary sinus. A PromoteQuadra CRT-D system model CD 3239-40Q was implanted in asubcutaneous pocket. A pressure wire placed in the LV to assessthe acute response to pacing. Results: Procedure duration was 198 minutes (radiation dose 1489cGycm2). The final pacing vector was distal tip (D1) to most distalring (M2) of the Quartet lead. Capture threshold at implant was1.25V (0.5ms PW) and impedance was 999 ohms. A 39% improve-ment in +dP/dtmax was seen with AV and VV delays optimised vsbaseline AAI pacing. At 6-week follow-up lead values were stableand symptomatically the patient had improved to NYHA class I.Conclusion: The Promote Quadra CRT-D system can be implant-ed in the same manner as other CRT-D systems and lead pacingparameters appear satisfactory at short-term follow-up. The 10vectors that the Quadra CRT-D system allows to be programmedmay allow problems with PNS or high capture thresholds atimplant to be overcome without the need for lead repositioning.The use of the Quadra device allows the potential for multisitestimulation in the future.

J POST-SHAPING OF STRAIGHT ATRIAL LEADSSCREWED INTO THE RIGHT APPENDAGE:AN ALTERNATIVE LEAD PLACEMENT APPROACHFOR PERMANENT ATRIAL PACINGF. ZOPPO, G. Brandolino, F. Zerbo, A. Lupo, E. Bacchiega, E. Bertaglia

Dipartimento di Cardiologia, Mirano (Venice), ITALY

Background: The current techniques of atrial lead placementmainly use J-shaped systems, with either passive or screw-in fixa-tion. However, both fixation mechanisms carry risks: i.e. leaddisplacement (passive fixation) and pericardial complications(active fixation). We present medium-term data on an alternativeapproach that utilizes straight atrial leads, which are J-post-shapedand screwed into the right appendage, and assess the feasibilityand safety profile of this technique.Study population and methods: From January 2005 to March2010, data from 200 patients were prospectively collected and ana-lyzed. These patients underwent implantation of a new dual-chamber or CRT device and a 52/53 cm, non-pre-shaped, actively-fixed atrial lead (Medtronic 5076/4076 model), which was J post-shaped in the right atrial appendage. Follow-up was scheduled upto the 3rd post-procedural month.Results: The 200 study patients (135 male, 67.5%; mean age74.8±10.5 years) received either a PM (168 cases, 84%) or an ICD(32 cases, 16%); cumulatively, a dual-chamber device was implan-ted in 166 cases (83%), an AAI device in 1 (0.5%) and a CRT devi-ce in 32 (16%). The atrial lead pacing thresholds and impedanceshowed a significant improvement over time (1.2+-0.7 V and610.4+-152 Ohm on implantation vs 0.5+-0.2 V and 537+-115 Ohm

at the 3rd month, p=0.000 for both), while sensing values remainedstable. Only 1 atrial lead-related complication occurred; this was acase of pericarditis. No atrial lead dislodgement occurred.Conclusion: In permanent atrial pacing, the use of straight screw-in leads, which are J-post-shaped in the right atrial appendage, isfeasible and safe and offers good stability.

HEMODYNAMIC SENSOR IN STYLET CHANNEL - ACUTEHUMAN EXPERIMENTD. TOMASIC1,2, B. Ferek-Petric2,3, S. Brusich4,5

1University of Trieste - Department of Electrical and Electronical Engineering andInformatics, Trieste, ITALY, 2Medtronic BV, Zagreb, CROATIA, 3University ofZagreb - Faculty of Electrical Engineering and Computing, Zagreb, CROATIA,4Clinical Hospital Center Rijeka - Department of Internal Medicine, Rijeka,CROATIA, 5University of Rijeka - Faculty of Medicine, Rijeka, CROATIA

Introduction: Cardiac contractions bend the lead body and extendand compress lead conductors and lead strain sensor insertedwithin the lead. Previous studies proved that lead strain measuredby electrostatic discharge sensor (EDS) is representative of cardiaccontractions. The purpose of this study was to evaluate EDS signalin various phases of lead strain utilizing X-ray fluoroscopy videoanalysis.Methods: In 16 patients undergoing single and dual chamberpacemaker implantation, EDS was temporarily inserted withinlead stylet channel. Ventricular and optionally atrial EDS signals,intracardiac electrograms, patient’s ECG and X-ray fluoroscopyvideo were recorded synchronously during routine lead testing.Inner lead’s conductor and conductive proximal end of EDS wereconnected to custom designed amplifier. Correlation of EDSsignals with lead bending in different angles fluoroscopy viewswas analyzed subsequently.Results and Conclusion: EDS signal recording was possible in allpatients and in both chambers. Deflection of the ventricular leadoccurred in its distal segment at curvature within the tricuspidvalve. Ventricular contractions pulled the right ventricular seg-ment of lead in cranial direction thereby flexing the tricuspid andlow atrial segments of the lead. Atrial contractions resulted indeflection of atrial lead in its J-shaped segment. Maximum of EDSsignal corresponds to maximum of the systolic lead deflection cau-sed by cardiac contraction. Minimum of the EDS signal corre-sponds to the end diastole whereby lead is minimally deflected.EDS signal amplitude was proportional to magnitude of the leadbending. Different positions of the lead tip implantation yieldeddifferent lead deflection and different EDS signal magnitude.Periodic variation of EDS signal exactly corresponds to periodicvariation of bending curve of the RV lead. Its parameters dependon cardiac contraction’s mechanical properties. It could thereforebe used as hemodynamic sensor in implantable devices for arrhy-thmia detection and heart failure monitoring.

VIDEOTHORACOSCOPIC IMPLANTATION OF THELEFT VENTRICULAR PACING LEAD FOR CARDIACRESYNCHRONIZATION THERAPYA. DROGHETTI1, A. Reggiani2, M.C. Bottoli1, P. Pepi2, A. Fusco4,C. Bonadiman3, R. Casarotto5, W. Mosaner5, A. Vicentini4, G. Muriana1

1SC Chirurgia Toracica, Mantova, ITALY, 2SC Cardiologia e UTIC, Mantova, ITALY,3SC Chirurgia Generale, Peschiera dG (VR), ITALY, 4SC Cardiologia, Peschiera dG(VR), ITALY, 5SC Anestesia e Rianimazione, Peschiera dG (VR), ITALY

Background: Transvenous placement of the left cardiac pacinglead is sometimes critical due to the absence of satisfactory venousaccess or unfavorable anatomy of the coronary sinus, unstable oruneffective position of the left transvenous lead or diaphragmaticstimulation. The innovative positioning tool FastacFlex®, combi-ned with a screw-in pacing lead, allows epicardial anchoring byvideothoracoscopy surgery.SP

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Patients and Methods: 13 patients, 9 male, median age 64 years,underwent implantation of the left ventricular epicardial pacinglead for cardiac resynchronization therapy.All procedures were performed in general anesthesia with 3 portsvideothoracoscopy surgery (5 mm, 10 mm and 15 mm) on the leftchest wall. Results: The bipolar steroid eluting epicardial lead (Myodex Mod1084T, St.Jude Medical Inc.) was successfully positioned in allpatients, after having identified a favourable postero-lateral posi-tion of the left ventricle. The median procedure time was 63 minu-tes +/- 25. Final measurements showed median threshold valuesof 1,3 V@0,5 ms +/- 0,2 V. Neither complications nor dislocationswere observed acutely. The chest drainage was averagely removedafter 36 hours with no adverse events observed. Median length ofhospital stay was 3 days+/- 2.The average follow-up was 472 days with symptomatic benefitassessed by a reduction in New York Heart Association (NYHA)class from III (preoperatively) to II (postoperatively).Conclusions: The videothoracoscopic placement of a screw-in epi-cardial pacing lead is safe, feasible and effective with comparablepacing thresholds compared to conventional transvenous leads.

LONG-TERM PERFORMANCE OF ENRHYTHM MRISURESCAN SYSTEM IN PATIENTS WITH STANDARDPACING INDICATIONL. SANTINI1, M. Santini2, S. Iacopino3, L. Calò4, L. Piraino5, R. Verlato6,C. Svetlich7, G. Morani8, R. Ricci2, S. Aquilani2, G. Forleo1, F. Sciotto9,M.G. Bongiorni10

1Policlinico Universitario Tor Vergata- Department of Cardiology, Rome, ITALY,2San Filippo Neri Hospital - Department of Cardiology, Rome, ITALY, 3VillaS.Anna Hospital - Department of Elettrofisiologia e Cardiostimolazione,Catanzaro, ITALY, 4Policlinico Casilino - Department of Cardiology, Rome, ITALY,5Ospedale Civico- Department of Cardiology, Palermo, ITALY, 6Ospedale diCamposampiero - Department of Cardiology, Camposampiero, ITALY,7Ospedale Unico della Versilia - Department of Cardiology, Lido di Camaiore,ITALY, 8Ospedale Civile Maggiore - Borgo Trento - Department of Cardiology,Verona, ITALY, 9Medtronic Italia - CRDM, Sesto San Giovanni (MI), ITALY, 10Az.Osp. Universitaria Pisana - Division of Cardiovascular Diseases, Pisa, ITALY

Introduction: Magnetic Resonance Imaging (MRI) has grown intoone of the most widely used non-invasive imaging modalitiesbecause of its unique ability to discriminate soft tissues. It seemstherefore of great interest to follow patients implanted with thefirst MRI safe cardiac pacing system (Medtronic EnRhythm MRISureScanTM) in a group of Italian centers. Since efficacy and safe-ty of this system have already been successfully tested in one ran-domized study, aim of our work is to provide data on the long-term performances of the system and to assess the need and feasi-bility of diagnostic imaging in real clinical practice in patientsimplanted with this pacemaker. Methods: 314 patients whit Class I or II indication for implanta-tion of a dual chamber pacemaker according ACC/AHA/HRSguidelines, regardless of whether they were indicated to an immi-nent MRI or not, received an EnRhythm MRI SureScanTM system.Data were collected at implant and during follow-ups at 1 month,at 6 months after implant and every 6 months, to characterize theatrial and ventricular lead pacing capture threshold, impedanceand sensing amplitude changes through a long term follow-upperiod. In addition, handling characteristics at implant and proce-dural-related complications were collected..Results: All patients (62% male; mean age 70±12) performed fol-low-ups visits (median 8 months, interquartile range, 4 - 9months). At implant and at follow-ups pacing thresholds, sensingand impedances were comparable with literature data. There wereno complications at implant. At follow-ups few cases of atrial leaddisplacement and atrial threshold increase more than 1.0 V havebeen found.

Conclusions: Data collected in this work demonstrates thatEnRhythm MRI pacing system is safe. Lead measurements are sta-ble in the long run. The few cases of atrial displacements and thre-shold increases are most likely due to an initial stage of learningusing the new MRI lead.

DOES STEROID ELUTION HAVE AN EFFECT ONTISSUE HEALING AFTER RADIOFREQUENCY ENERGYEXPOSURE: IMPLICATIONS FOR MRI SCAN ON PATIENTSWITH CARDIAC LEADSP. Yang, N. Kirchhof, J. Golnitz, K. Stokes, R. MCVENES

Medtronic Inc, Minneapolis, USA

Introduction: The induction of radiofrequency (RF) energythrough a lead via magnetic resonance imaging (MRI) can inducepermanent tissue injury resulting in high pacing thresholds.Glucocorticosteroids are known to suppress healing. This studywas designed to determine if the presence of chronic steroid elution(St) from transvenous screw-in leads has any effect on electricalperformance or healing subsequent to RF induced tissue damage.Methods: Transvenous screw-in leads, some with St and somewithout (NSM) were implanted in 10 canine’s right atria and rightventricles. After 12 weeks implant, some leads were injected withcontinuous 64MHz RF energy to cause a threshold increase>1V/0.5ms as indication of tissue heating near the electrodes.Controls were not exposed to RF. Electrical monitors were donevia telemetry from the pulse generator.Results: Threshold increase due to RF injection was similar forboth leads. In the atrium, however, St had lower initial thresholds,so that its RF induced threshold increases were significantly lessthan NSM. In the ventricle, St had no significant effect on RF indu-ced threshold increase. Decreased pacing impedance on test leadswas noted after RF injection, but not on controls.Discussion: Threshold increases measured post RF injection areindications of membrane and ion channel damage. The impedan-ce decreases are indicative of edema resulting from RF inducedinjury at the electrode-tissue interface.Conclusions: Chronic steroid elution has substantial benefits inlowing chronic thresholds with a higher efficacy in the atrium.However, chronic steroid elution has no effects with respect to hea-ling subsequent to RF -induced myocardial injury.

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GENDER DISCRIMINATION IN SELECTION OF ICD RECIPIENTSA. JASWAL, A. Saxena1, R. Singhal1

Fortis Escorts Heart Institute, New Delhi, INDIA

Introduction: In clinical trials of primary and secondary preven-tion of sudden cardiac death, mainly male patients (pts.) havebeen selected to be implanted with a cardioverter defibrillator(ICD), which can be explained only in part by a lower prevalenceof coronary disease in women, in younger age groups. Objective: To evaluate the gender distribution of ICD implanta-tion from a single center in Indian population with left ventricular(LV) dysfunction. Population / Methods: We studied 192 pts with moderate to seve-re LV systolic dysfunction that were implanted ICD in our depar-tment (from 2007-2009) in New Delhi. We analyzed the distribu-tion by gender, age and etiology.Results: Out of 192 pts, the mean age of pts was 65±18 yrs, (7.8%were female and 92.2% were men). There were no significant diffe-rences regarding mean age (56.7 + 11.2 years for females vs. 58.9 +11.8 years for males). 64.5% had ischemic etiology, 30.1% had idiopa-thic dilated cardiomyopathy, 3.5% had hypertrophic cardiomyopa-thy, 1.9% had arrhythmogenic right ventricular cardiomyopathy.Indication for primary prevention was in 35%, while 65% of pts. hadthe ICDs implanted for secondary prevention. 90% of females hadthe ICDs implanted for secondary prevention. The mean ejectionfraction (EF) was 28%±10% as a whole group, while the mean EF forfemales was 25%±5%. 18% of patients were in NYHA functional classI, 45% in class II and 37% were in class III as a group, while in thefemale population, 38% were in class II and 62% were in class III.Conclusion: The rate of implantation of ICDs in females in Indianpopulation is lower than theoretically expected. Also, the femalepopulation was older with higher NYHA class. The guidelinesmust be implemented carefully to avoid gender selection biases.

MADIT II VS SCD-HEFT: HOW MANY PATIENTS WE NEEDTO TREAT TO SAVE A LIFE?G. PANATTONI, D.G. Della Rocca, L.P. Papavasileiou, L. Santini, G.B. Forleo,G. Magliano, A. Politano, V. Schirripa, V. Romano, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Introduction: The implantable cardioverter defibrillators (ICDs)improve survival among patients who are at risk for sudden car-diac death (SCD). The MADIT II study showed that 11 patientsneed to be treated over a 3-years period to save one life, but at 8years, one life is saved for every six patients who receive an ICD.The SCD-HeFT study showed that 14 patients need to be treated tosave a life during a follow-up of 5 years. The aim of our study wasto evaluate the number of patients to treat to save one life, accor-ding to the criteria of MADIT II and SCD-HeFT.Materials and Methods: We analyzed 187 consecutive patients(157 males, age 68.7±9.1 years) who implanted ICDs for primary orsecondary prevention of SCD, between September 2003 and April2010 at our institution. Patients were divided in two groups:MADIT II group (n=100, 91 males, age 68.3±10.7 years) and SCH-HeFT group (n=87, 66 males, age 69.2±8.9 years).Results: During a mean follow-up of 19,23±16,73 months, in SCD-HeFT group 8 patients (9,2%) had appropriate discharge (time to:8,4±5.4 months). In Madit II group 23 patients (23%) experiencedappropriate discharge (time to: 16,2±13.2 months). Two patients(2,3%) in SCD-HeFT group vs 7 patients (7%) in Madit II group hadinappropriate discharge. In our study 11 SCD-HeFT patients need tobe treated to save one life in a mean period of 9 months (range: 3-17.7months), while 4 MADIT II patients need to be treated to save onelife in a mean period of 2 years (range: 0-41.6 months).Conclusion: ICDs treatment improves survival among patientswith risk of SCD. MADIT II criteria seems to be more cost-effecti-ve when compared with SCH-HeFT criteria.

SAFETY OF HIGH RATE CUTOFF ICD PROGAMMING INPRIMARY PREVENTION OF SUDDEN CARDIAC DEATHN. CLEMENTY, B. Pierre, N. Zannad, O. Marie, L. Fauchier, D. Babuty

Service de Cardiologie B, Hôpital Trousseau, Tours, FRANCE

Background: Implantable cardioverter defibrillators (ICDs) areefficient in reducing mortality in patients with left ventricularsystolic dysfunction. High rate cutoff ICD programming may beefficient in reducing inappropriate therapies in these patients, butis underutilized as the long term consequences on morbidity andmortality remain unclear.Materials and Methods: We studied 370 consecutive patients(mean age 61 ±10 years), with ischaemic (64%) or non ischaemiccardiomyopathy, and left ventricular dysfunction (mean ejectionfraction 25 ±7%), implanted with an ICD in primary prevention ofsudden cardiac death (41% single chamber, 31% dual chamber,28% biventricular). All devices were programmed with a shock-only zone over 220 beats per minute and a monitoring-only zonebetween 170 and 220 bpm.Results: During a mean follow-up of 29 months, 34 patients recei-ved appropriate shocks (9.2%), 19 inappropriate shocks (5.1%).Inappropriate therapies were due to supraventricular tachyarrhy-thmia in 7 patients, and noise or oversensing in 12 patients. Forty-three patients (11.6%) died, 24 from end-stage heart failure, and 19from a non-cardiac cause. No sudden cardiac death was reported,and no death resulted from the specific ICD programming. Only 5patients (1.4%) experienced symptomatic ventricular tachycardiain the monitoring zone requiring hospitalization and/or devicereprogramming.Conclusion: High rate cutoff shock-only ICD programming in pri-mary prevention of sudden cardiac death remains safe during along-term follow-up, while maintaining a low rate of inappropria-te shocks, which are known to be deleterious in this population.

ICD INTERVENTIONS IN OLD PATIENTS IMPLANTED FORSUDDEN CARDIAC DEATH PRIMARY PREVENTIONA. ANDRIANI1, F. Giusti2, M. Liccardo3, D. Carretta4, F. Alfano5, P. Gallo6,P. Nocerino3, P. Guarini6

1Presidio Ospedaliero di Policoro, Policoro (MT), ITALY, 2Ospedale San Paolo,Bari, ITALY, 3Ospedale S. Maria delle Grazie, Pozzuoli (NA), ITALY, 4PoliclinicoConsorziale, Bari, ITALY, 5Ospedale Moscati, Avellino, ITALY, 6Casa di Cura Villadei Fiori, Acerra (NA), ITALY

Aim: Several randomized trials and prospective study have pro-ven the efficacy of ICD in reducing the risk of SCD. In clinical prac-tice the patients selected to receive an ICD result to be olderrespect the randomized trials. The aim of this analysis was to eva-luate the incidence of ICD interventions in a specific sub-group ofolder patients.Methods: We enrolled 136 unselected patients implanted with ICDor cardiac resynchronization therapy defibrillator (CRT-D) devicesfor SCD primary prevention. The population was divided in twogroups: older patients (OLD, age>70 years) and younger patients(YOUNG, age<70 years); we collected and evaluated devicesshock therapies for at least 12 months.Results: Main characteristics of enrolled population were: malegender (86%), ischemic heart disease (60%), NYHA>II (53%), meanage (66±9 years), mean left ventricular (LV) ejection fraction(27.8±5.8%), CRT devices implanted (28%). The OLD group (60patients, 75±4 years) and YOUNG group (76 patients, 60±7years)did not differ significantly for any characteristics except for hyper-tension (OLD 46% vs YOUNG25% p=0.009) and NYHA>II (OLD67% vs 42%, p=0.004). Over a mean follow-up of 22±7 months, 26patients (19%) received at least one ICD shock, with 8 (13%) in theOLD group and 18 in the YOUNG (23%), with strong but not signi-ficant difference (p=0.13). If we consider standard ICD (withoutCRT) the situation is different, 21 patients (21%) received at leastIM

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one ICD shock, (5 in the OLD group and 16 in the YOUNG, 12.5%vs 27.6%, p=0.08). The mean time for the first shock is 10±8 (OLD7±7 vs YOUNG 11±9, p=0,29).Conclusion: The incidence of appropriate shock therapies in olderpatients is lower but they receive the first intervention in a shortertime. The benefit of ICD and CRT-D implantation for SCD primaryprevention in older patients is comparable to the whole population.

ICD THERAPY FOR PRIMARY PREVENTION OFSUDDEN CARDIAC DEATH: HIGH INCIDENCE OFSYNCOPE DURING APPROPRIATE ICD INTERVENTIONSW. RAUHE, L. Bertagnolli, M. Manfrin, I. Endrizzi, M. Tomaino,W. Pitscheider

Ospedale di Bolzano - Department of Cardiology, Bolzano, ITALY

ICD therapy has become a standard therapy for primary preven-tion of sudden cardiac death (SD) in patients with severely impai-red left ventricular function. Although many studies have demon-strated a high incidence of appropriate ICD interventions in thesepatients, few data are known on symptoms accompanying ICDdischarges. Purpose: Aim of this observational study was to evaluate the inci-dence of syncope during appropriate ICD interventions in longterm follow-up. Materials and Methods: We followed up 133 patients with ICDimplanted as primary prophylaxis of SD. All patients had severelydepressed left ventricular function (EF<30%). Mean age was64,1±8 years. Results: Over a mean follow up of 35,7 months 43 patients (32,3%)developed at least one sustained ventricular arrhythmia that wasappropriately treated by the ICD. In 49% of these patients the ven-tricular arrhythmia that triggered the ICD therapy has been a fastventricular rhythm, classified by the device as ventricular fibrilla-tion. 16 (36,4%) out of the 43 patients with appropriate therapyexperienced syncope before the successful interruption of the ven-tricular arrhythmia. No event occurred while driving. Conclusions: In patients with ICD implanted as primary prophy-laxis against SD the incidence of appropriate ICD therapy duringlong term follow up is high. More than one third of our patientswith appropriate interventions have had syncope before the inter-ruption of the malignant arrhythmia. Although these 16 patientsrepresent only 12% of the whole study population and no patientwas driving at the moment of the ICD discharge, these results mayhave implications in the development of guidelines that adressesdriving licensing of patients with prophylactic ICDs.

ALL-CAUSE MORTALITY IN CURRENT PRACTICEACCORDING TO DEVICE INDICATIONS:DATA FROM THE ACTION-HF REGISTRYP. NOCERINO1, A. D’Onofrio2, G. Molon3, R. Verlato4, T. Toselli5, C. Storti6,D. Pecora7, G.P. Gelmini8, M. Mantica9, G.L. Botto10

1Ospedale S. Maria delle Grazie, Pozzuoli (NA), ITALY, 2A.O. Monaldi, Naples,ITALY, 3Osp. Don Calabria, Negrar, ITALY, 4Presidio Ospedaliero diCamposampiero, Camposampiero, ITALY, 5Arcispedale S. Anna, Ferrara, ITALY,6CdC Città di Pavia, Pavia, ITALY, 7Fond. Poliambulanza, Brescia, ITALY, 8PresidioOspedaliero di Desenzano, Desenzano, ITALY, 9CdC S. Ambrogio, Milan, ITALY,10Ospedale S. Anna, Como, ITALY

Aim: To show how many patients, implanted with CRT-D in pri-mary prevention and enrolled in the ACTION-HF registry, haveindications similar to COMPANION and MADIT-CRT studies,and to compare the rate of mortality in these subsets.

Methods and Results: Among the 406 patients enrolled inACTION-HF followed for two years, 65.5% were COMPANION-indicated patients, 15% were MADIT-CRT-indicated patients; theremaining 19.5% were ”off label”. Forty-seven patients diedduring the follow up (11.6%). Two year all-cause mortality were12% in the COMPANION group compared to 5.4% in the MADIT-CRT group (p=0.06). Off label patients had a 2-year mortality com-parable to COMPANION group (12%). Patients in the ”off label”group had a significantly narrower QRS with respect to COMPA-NION and MADIT-CRT (132±35 vs 161±29 vs 166±37 ms respecti-vely, p<0.01) and higher left ventricular ejection fraction (32±7 vs25±6 vs 24±4 respectively, p<0.01).Conclusion: CRT-D patients implanted in the clinical setting havedifferent characteristics and only partially match with populationfrom large clinical trials. Follow up showed that these patient sub-sets are exposed to different risk. In particular patient implantedout of the current guideline showed a mortality rate comparable toCOMPANION patients.

IMPLANTABLE CARDIOVERTER-DEFIBRILLATORTHERAPY IN BRUGADA SYNDROME: LONG TERMFOLLOW-UP OF PROPHYLACTIC IMPLANTATIONK.N. TSILONIS, V. Kamperidis, S. Paraskevaidis, V. Vassilikos,S. Theofilogiannakos, L. Mantziari, G. Dakos, G. Stavropoulos, I. Styliadis

Ahepa University Hospital, Thessaloniki, GREECE

Purpose: The purpose of this study is to identify if the implantablecardioverter defibrillator (ICD) implanted in Brugada Syndromedefibrillates usually appropriately or inappropriately afterwards. Methods: Since 2000 all the patients admitted to our centre withBrugada syndrome and had a resuscitated sudden cardiac death orproved to be high risk, implanted with an ICD. Afterwards, thesepatients were referred to our centre whenever they had a defibril-lation. As a result we know whether they had a shock or not, andwhether it was appropriate or not.Results: During the last ten years 9 patients, all male with meanage 51±15 years, were admitted to our centre with BrugadaSyndrome. One of them had resuscitated sudden cardiac deathdue to ventricular fibrillation and type I Brugada ECG pattern atbaseline. He underwent secondary prophylactic ICD implantation.The other eight had syncopal episodes with baseline spontaneousECG pattern Brugada type I 2 of them and type II 6 of them. All ofthem had test procainamide positive, echocardiographic findingswithin normal limits, coronary arteries without critical lesions andno neurologic deficit. Six of them underwent electrophysiologystudy and ventricular fibrillation was induced to all of them apartfrom one. These 8 patients underwent primary prophylactic ICDimplantation. During a mean follow-up of 56±35 months 33% ofthe patients who underwent primary prophylactic implantationhad an appropriate shock. 22% of them had inappropriate shockone due to noise and the other due to lead fracture. The one patientwith ICD for secondary prevention had no shock or ATP therapy.Conclusion: Primary prophylactic ICD therapy resuscitates fewyoung men from sudden cardiac death effectively. Inappropriateshocks are the minority.

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DOES CEPHALIC OR SUBCLAVIAN VEIN APPROACHIMPACT ON DYSFUNCTION RATE OF ICD LEADS?V. ROMANO, L. Duro, M. Sgueglia, L. Santini, G. Magliano, G.B. Forleo,L.P. Papavasileiou, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Background: The leads disfunction, from displacement to fracture,is one of the most serious complication related to pacemaker andimplantable cardioverter defibrillator implantation. Such compli-cations in ICD may lead to oversensing and noise with followinginappropriate shock or a failure in delivering therapies. In thesecases the need of redo is higher, increasing significantly the risk ofinfection. The identification of disfunction predictors might beuseful to prevent these severe complications. Although the majori-ty of fractures occurs in the lateral part of the subclavian vein andsome authors have identified the subclavian access as a risk factorfor leads fracture and disfunctions, nowadays no studies haveinvestigated the role of cephalic access in prevention of these com-plications. Methods: Data collected from 368 patients that underwent ICDimplant between September 2003 and May 2010 were analized.The total number of trans venous electrocatheters implanted was528 (190 using subclavian access and 338 through the cephalicvein). Catheters for coronary sinus were excluded because allimplanted through the subclavian vein. Results: The total atrial catheters implanted were 221: 131 (59%)implanted by cephalic access and 90 (41%) by the subclavian vein.During the follow up one lead displacement per group was noted(cephalic access: 1/131, 0.76%; subclavian access 1/90, 1.11%).Among the 307 defibrillation catheters, 207 (67,5%) were implan-ted through cephalic vein and 100 (32.5%) through subclavian. Wealso reported 5 (2.4%) disfunctions among the leads implanted bycephalic access and 2 (2%) among the one of subclavian access.Between these disfunctions we reported one lead fracture (cepha-lic access) and one disfunction due to noise (subclavian access)that determined inappropriate shock.Conclusion: The analysis of our population showed that the choi-ce of subclavian vein instead of cephalic vein is not significantlyrelated to a higher risk of leads disfunctions.

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WHICH BASELINE PARAMETERS CAN HELP TOPREDICT THE RESPONSE AFTER CARDIACRESYNCHRONIZATION THERAPY?K. GOSCINSKA-BIS, R. Gardas, M. Gibinski, B. Grzegorzewski, W. Kargul,J. Wilczek

Department of Electrocardiology, Katowice, POLAND

Despite constant progress in implant procedure about 30% of suc-cessfully implanted patients meeting current guidelines are notresponding to cardiac resynchronization therapy (CRT). The cau-ses of that phenomenon are not well identified yet. Study purpo-se: To analyse which baseline clinical (etiology of heart failure,gender, age, Body Mass Index, renal function, concomitant disea-ses, QRS width, heart rhythm: sinus, atrial fibrillation, paced) andechocardiographic parameters (left ventricular (LV) ejection frac-tion, LV end-diastolic and end-systolic dimension and volume,right ventricle dimension, systolic pulmonary artery pressure(SPAP), mitral regurgitation, LV diastolic filling time, interventri-cular delay, LV pre-ejection period (LVPEP), the ratio LVPEP/LVejection time) can help to predict the response to CRT. Methods:We prospectively analysed 182 consecutive patients with standardCRT indications implanted successfully in our department fromJuly 2004 to October 2008. All patients had intraventricular dys-synchrony in baseline echocardiography. The clinical response toCRT was defined as follows: patient alive after 6 months with nointerim hospitalization for decompensated heart failure and atleast 1 point decrease in NYHA functional class and a >10% increa-se in peak VO2 consumption or 6 min walk test distance. Resultsand conclusion: Hundred thirty one patients (73%) proved to beresponders 6 months after implantation. Non-responders compa-red to responders had worse baseline renal function (serum creati-nine 1,16 mg/dl vs 1,06; p = 0,023, GFR 68,3 vs 62,8 p = 0,023), big-ger right ventricle (31,6 mm vs 27,7 mm; p = 0,001), higher SPAP(46,5 mmHg vs 39,1 mmHg; p = 0,01), more frequent incidence ofchronic obstructive pulmonary disease (25% vs 9%; p=0,029) andperipheral arterial disease (47% vs 18%; p = 0,001). Other parame-ters had no statistically significant impact on the response to CRT.

NON RESPONDERS TO CRT: BASELINE CLINICALCHARACTERISTICSM. BRAMBATTI, S. Molini, S. Guardiani, F. Guerra, A. Giovagnoli, A.Romandini, G. Pupita, M.V. Matassini, M. Marchesini, A. Capucci

Universita' Politecnica delle Marche, Ancona, ITALY

Aim: to identify the clinical and instrumental parameters predicti-ve of response to cardiac resynchronization therapy (CRT). Methods and Results: 143 consecutive patients (112 males, 31 fema-les) with dilated cardiomyopathy, NYHA functional class III-IV, leftventricular ejection fraction (LVEF) < 35% and QRS > 120 ms wereinvestigated with clinical evaluation, Minnesota Living with HeartFailure Questionnaire (MLHFQ), electrocardiography (ECG), echo-cardiography including tissue Doppler imaging (TDI) and implantcontrol. Mean follow-up was 2.3 years. All patients underwentingCRT experienced an improvement of: a lower NYHA class (from2.60±0.66 to 2.08±0.62) ; a lower MHFLQ score (from 50.25±26.91 to18.63±12.30; p=0.018) ; a higher EF (from 31.39±8.12% to38.64±12.58%); a higher SDaNN assesed by HRV analysis (from48.41±18.91 to 87.61±25.22). Patients undergoing CRT for secondaryprevention have a lower NYHA class (2. 60±0.66 vs. 2.08±0.62) andlower EF (31.39±8.12 % vs. 38.64±12.58 %) than patients in primaryprevention, despite showing similar relative improvements duringfollow-up. Mean intraventricular dyssincrony is significantly lowerat follow-up (73.75±19.20ms vs. 19.20±12.43ms). Among all-patients43% were defined as clinical and echo responders, 30% as echo-onlyresponders, 10% as clinical-only responders and 17% as non respon-ders. Non-responders, defined as absence of both echocardiographi-cal and clinical improvements, are most often male, have lower

systolic and diastolic blood pressure, and have more frequently anhistory of CAD complicated by previous IMA as well as familiarityfor ischemic disease (all p<0.05).Conclusions: After CRT, there was a significant improvement ofSDANN and HRV footprint; instead, the presence of ischemicheart disease complicated by prior necrosis, male sex, lower systo-lic and diastolic blood pressure are associated with lack of echoand clinical response by CRT.

LEFT ATRIAL REVERSE REMODELING AS SUCCESSFULRESULT AFTER CARDIAC RESYNCHRONIZATION THERAPYL. Rossi1, A. Malagoli1, E. Casali2, G. Rusticali1, G.Q. VILLANI1

1Department of Cardiology, Guglielmo da Saliceno Hospital, Piacenza, ITALY,2Department of Cardiology, University of Modena and Reggio Emilia, Modena, ITALY

Introduction Cardiac resynchronization therapy (CRT) is an establi-shed therapy for advanced heart failure with prolonged QRS dura-tion, leading to improvement of left ventricular systolic function andclinical outcomes. The aim of this study was to evaluate the CRT-induced left atrial remodeling, as a feasible and simple marker of leftventricular diastolic improvement. Methods A total of 34 consecuti-ve patients (aged 66,3±12,2 years) with severe heart failure, left ven-tricular ejection fraction < 35% and prolonged QRS duration receivedCRT in our institutions. Two dimensional echocardiographic evalua-tion was performed pre implantation and thirty days after. Left ven-tricular and left atrial function parameters were recorded: in particu-lar atrial function was assessed by measuring maximal atrial volume(LAV max), minimal atrial volume (LAV min), pre systolic volume(LAV pre) and atrial ejection fraction (LAEF), both in 2 and 4-cham-bers apical view. Left atrial volumes were indexed to body surfacearea. Patients who had a reduction of left ventricle end-systolic volu-me > 10% and/or patients who had a reduction in NYHA class of atleast one point were defined as CRT responders. Results One monthpost CRT implantation 25 patients (73%) were CRT responders (8 cli-nical and echo strumental responders, 14 only clinical and 3 onlystrumental responders). All patients had decrease in left atrial volu-metric measurements (LAV max 54,4±8,7 vs 46,5±7,0 ml/m2, LAVmax 44,9±8,8 vs 40,5±8,3 ml/m2, LAV min 36,4±8,3 vs 28,5±7,1ml/m2); these changes were more evident in CRT responders than inCRT non responders. Conclusions CRT produces an atrio ventricularresynchronization that improves left atrial function expressed with asignificant volumes reduction and a better atrial systolic phase. Thispositive atrial reverse remodeling is a marker of better left ventricu-lar diastole. Remarkable left atrial function improvement was notedin CRT responders compared to non responders.

V-V DELAY INTERVAL OPTIMIZATION IN CRTUSING ECHOCARDIOGRAPHY COMPAREDTO QRS WIDTH IN SURFACE ECGD. RAGAB, R. Elhussini, A. Nawar, A. Abdelaziz

Cairo University, Critical Care Medicine Department, Cairo, EGYPT

Introduction: CRT had become a standard of treatment for patientswith heart failure, the presence of many cases of Non-respondersraises the need for device optimization Echocardiography is anestablished tool used to optimize CRT programming, but it is time-consuming. It was not yet defined whether a QRS width-basedstrategy may be a helpful tool for device programming Aim ofstudy : to compare an optimal interventricular delay interval (v-vinterval) obtained by echo with that obtained by QRS width in sur-face electrogram. Methods and Results: 20 patients who implantedCRT were enrolled. All patients underwent echocardiographicoptimization of the (A-V interval) after which 5 different vv-inter-vals (LV+30, LV+60, RV+30, RV+60, L+R0) were compared in mea-sures of Aortic flow velocity as a surrogate for ejection fraction. A12-lead electrocardiogram was recorded and QRS duration wasHO

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measured in the lead with the greatest QRS width. The ECG-opti-mized VV interval was defined according to the narrowest achie-vable QRS interval among 5 VV intervals. A 12-lead electrocardio-gram was recorded and QRS duration was measured in the leadwith the greatest QRS width. The electrocardiographic (ECG)-opti-mized VV interval was defined according to the narrowest achie-vable QRS interval among 5 VV intervals. The echocardiographic-optimized VV interval was left ventricle + 30 ms in 2 patients, leftventricle + 60 ms in 8 patients, simultaneous in 8 patients, rightventricle + 30 ms in 2 patients. ECG results had 85% coincidencewith the Echocardiographic method using QRS width as an indi-cator of the most optimized v-v delay interval (ê = 0.906), (r = 0.81P< 0.001). Conclusion: significant correlation appeared to existduring optimization of CRT between VV programming based onthe shortest QRS interval at 12-lead ECG pacing and echocardio-graphic-guided VV-interval optimization. A combined ECG- andechocardiographic approach could be a more convenient solutionin performing optimization.

SUPER-RESPONDERS AFTER CARDIACRESYNCHRONIZATION THERAPY IMPLANTS:RESULTS OF A SINGLE CENTER STUDYF. MORANDI, D. Pecora, M. Campana, C. Cuccia

Fondazione Poliambulanza, Brescia, ITALY

Purpose: The aim of this study is to assess the characteristics ofCRT super-responders patients based on echocardiography eva-luation.Methods: 149 patients implanted from 2004 to 2009 with CRT, withor without defibrillator back-up, were considered for the analysis.Echocardiographic parameters were collected at baseline andduring scheduled follow-up. We defined as super-responders allpatients alive, without heart failure hospitalizations and with a leftventricle ejection fraction (LVEF) >=45% at follow-up.Results: The main characteristics of enrolled population were:male 75%, age 68±9 years, III NYHA class 81%, ischemic heart disease (IHD) 48%, sinusrhythm 81%, QRS duration 162±28 ms, LVEF 26.2±7.4% and CRT-ICD 69%. At a mean follow-up of 24±15 months, 66% of patientshave improved LVEF of at least 25% respect baseline and 57% ofpatients have reduced LV end systolic volume of at least 15%. Wereported the following echocardiographic parameters variationsfrom baseline to follow-up: LV end diastolic diameter from 69±10mm to 62±10 mm, LV end systolic diameter from 59±11 mm to49±11 mm, LV end diastolic volume from 228±88 ml to 180±75 ml,LV end systolic volume from 170±71 ml to 118±65 ml and LVEFfrom 26.2±7.4% to 38.8±12.8 % (for all differences p<0.0001). In the whole population we have 33% of super-responders withthe following major baseline differences respect the no super-responders group: IHD 32% vs 57% (p=0.027), LV end systolic dia-meter 66±10 mm vs 70±11 mm (p=0.032) and LV ejection fraction29.6±8.9 % vs 25.1±7.0 % (p=0.010).Conclusion: In our experience, in a consistent part of implantedpopulation (33%), we reported a LV ejection fraction at follow-up ofmore than 45% with a nearly complete recovery of LV function. NoIHD, higher LV ejection fraction and lower LV end systolic diameterat implant are the major characteristics of super-responders patients.

GEOMETRIC DISTANCE BETWEEN LEADS FORBIVENTRICULAR STIMULATION AS PREDICTORF CRT RESPONSEG. COVINO1, M. Volpicelli1, P. Belli1, G. Ratti1, P. Tammaro1,C. Provvisiero1, L. Auricchio2, P. Capogrosso1

1Ospedale San Giovanni Bosco, Naples, ITALY, 2Boston Scientific, Milan, ITALY

Aim: The response to the cardiac resynchronization therapy (CRT)

is definitely multifactorial and the optimal pacing leads locationremains controversial. The purpose of this work is to investigatethe possible correlation between the geometric distance (GD) ofleads and the response to CRT in patients with dilated cardiomyo-pathy (DCM) of any aetiology.Methods: We enrolled and implanted with standard indication forCRT-D 39 consecutive patients with the following characteristics:male gender 77%, ischemic DCM 51%, age 67±9 years, left ventri-cle ejection fraction 27±6% and III NYHA functional class 85%.After CRT implant we measured the GD between right and leftventricular leads in two different fluoroscopic orthogonal projec-tions (anterior-posterior: AP and lateral: LL) using a digital radio-logy workstation software and a radio opaque mark with circularshape placed on the patient's chest to reduce the intrinsic error inthe geometric measure.Results: The mean leads distance was 66±31 mm in AP and 69±33mm in LL. The position posterior-lateral for left lead combinedwith outflow tract for right lead, was associated to the greater GD:in the AP projection 108±30 mm respect 56±31 of the others posi-tions (p=0.002). At 12 months follow up, 13 patients (65%) of thefirst 20 patients enrolled were classified responders, based onechocardiogram. The responders were associated with a greatestGD of leads in both projections, where in AP projection the resultshave reached statistical significance: GD responders 84±34 vs41±17 for non-responders (p = 0.006).Conclusions: Interlead geometric distance could result a usefultool to identify CRT responders, even if further evaluation isnecessary to consolidate the preliminary results.

UPGRADE OF CRT NON RESPONDERS:NOVELL “CRT+“ PACING THERAPYZ. CALOVIC1, G. Nikcevic2, V. Jovanovic2, G. Vicedomini1, V. Santinelli1,C. Pappone2, G. Milasinovic1

1Arrhythmology Department Villa Maria Cecilia Hospital, Cotignola, ITALY,2Pacemaker Center Belgrade, Belgrade, SERBIA

Introduction: Althoy cardiac resinhronisation therapy (CRT-P/D)significantely dicrease mortality and morbidity, and increase exer-cise capasity in patentes with sistolic left ventricular disfunctionand wide QRS, high procentige of patients (pts) had no clinicalimprovements on this therapy.Aim: To see weather the implantation of additional pacing lead incoronnary veins would improve left ventricula function in patientswho are CRT non responders Methods: In 9 pts, NYHA III/IV,with LVEF 21,3+/-5,8 % who didnot respond on previous resinchronization therapy during oneyear folow-up, we performed implatation of additional CS lead.using the same technique as during primo-implantation. Intentionwas to plase the second CS lead oposit to first one to be the part oftriangle, together with RV lead formed aorund left ventricul. Toobtained triple-site pacing we connected old LV electrode and thenew one with the Y connector in the LV port of the pacemaker.RVand atrial electrode were connected in usual menner. Results: Implantation of second LV lead was sucsesfyl in 9 pts.Five additional CS leads were implanted at posterolateral, 3 atanterolateral and one at mid cardiac vein. During implantation wehad no complicattions reagrding CS canulation.We found openedcoronary veins in all pts accept in one pts when we failed toimplant the second pacing leads. One month after, in all upgradesthere were improvement in patients LVEF% (p<0.005), and decrea-se of at least one NYHA class.Conclusion: Upgrade of conventional CRT-P/D to bifocal left ven-tricular pacing and unifocal RV pacing is safe and feasibllemethod, we named CRT+ therapy. Early results in theas goup ofpatients are very promising. However, there is need for longerfolow-up and biger number of patients to see the realy benefit ofthis kind of therapy.HO

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THE EFFECTIVENESS OF CRT CANNOT OVERWHELMWORSENING OF END-STAGE CARDIOMYOPATHYH. INO, T. Tsuda, K. Hayashi, N. Fujino, M. Yamagishi

Division of Cardiovascular Medicine, Kanazawa University, Kanazawa, JAPAN

The effectiveness of cardiac resynchronization Therapy (CRT)appears in the late phase in the course of heart failure, despite ofabsence of acute phase effect. We experienced seventy one year old patient with cardiomyopa-thy associated with Bentall operation, gradually improved in heartfailure status by CRT and 3 cases with end-stage cardiomyopathy,resulting in death from heart failure, despite of CRT. The first case is a patient with cardiomyopathy with Bentall opera-tion, without definite etiology. He underwent cardiac pacemakerimplantation because of succeeding complete atrioventricularblock. He had left ventricular ejection fraction <30%, and milddyssynchrony was recognized. Two years ago, He underwentadditional CRT therapy because of concomitant pacemaker leadtrouble. Althouhgh definite improvement of dyssynchrony, He gotbetter sensation in heart failure status and blood pressure increa-sed gradually. Unfortunately, aortic dissection recurred abruptlyand he died.Our 3 cases with end-stage cardiomyopathy had mutations in thesarcomeric gene, Troponin I and T. All 3 patients had decreased leftventricular ejection fraction <0.4. Acute phase effect of CRT wasminimal in these patients. They died of heart failure within one-year after deployment of CRT.According to the first case, the maximum effectiveness of CRTneeds longer time than previously thought, despite of no definiteimprovement of dyssynchrony. We should implant CRT devices asearly as possible, before the left ventricular ejection fraction wasrecognized in cases of cardiomyopathy, the disease causing genemutation of which was determined.

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THE ROLE OF AETIOLOGY IN PATIENTS UPGRADEDFROM RIGHT VENTRICULAR PACING TO CARDIACRESYNCHRONIZATION THERAPYM. Morales, U. Startari, L. Panchetti, M. PIACENTI

IFC-CNR and Fondazione G Monasterio, Pisa, ITALY

Chronic right ventricular (RV) pacing may lead to left ventriculardyssynchrony which is known to determine or worsen left ventri-cular (LV) dysfunction. In RV paced patients (pts) and heart failu-re, upgrading to biventricular stimulation is proposed to improveNYHA Class and LV functional parameters. However, a propor-tion of pts do not show symptomatic improvement or reverseremodeling after cardiac resynchronization therapy (CRT). Aim ofthis study was to assess whether underlying cause of LV dysfun-ction may account for different responses to CRT in pts alreadyRV-paced. 56 consecutive patients, mean age 72°¡1.0 years, in sinusrhythm, under continuous RV pacing from 45.2°¡5.6 months (range3 to 150), mean QRS duration 170°¡12 msec, mean LVEF 25.2°¡0.9%treated by CRT, were enrolled in the study. Cause of LV dysfun-ction was non-ischemic cardiomyopathy (NIC) in 25 and ischemiccardiomyopathy with no active ischemia (IC) in 31 pts.Clinical and functional parameters by 2D echocardiography wereavailable in all patients in 3 conditions: 1) within one month befo-re RV pacing, 2) within one month before CRT and 3) at 12°¡4months follow-up (FU) after CRT. A significant decrease in LVEF (-24°¡2.4%), increase in LV end systolic dimensions (ESD) (+16.5°¡2.3%) and worsening in NYHA Class (from 2.1°¡1.3 to 3.2°¡9, p<0.001) was found before CRT, as compared to pre RV- pacing con-ditions. At FU a °›1 NYHA Class improvement was seen in 39/56patients, with no differences between IC and NIC. However a>10% decrease in ESD - index of consistent LV reverse remodeling-could be observed in 22 pts only: 6 with IC, 16 with NIC (p<.0.001)Thus, in RV paced pts, CRT improves functional class even afterlong lasting pacing. Reverse remodeling - which is known toinfluence prognosis in heart failure - is more likely to occur in NIC.

THE EFFECT OF HEART FAILURE ETIOLOGY ON THEEFFECT OF PACEMAKER UPGRADE IN PATIENTS WITHPERMANENT ATRIAL FIBRILLATION AND ADVANCEDHEART FAILUREB. MALECKA1, A. Zabek1, J. Lelakowski1, A. Maziarz1, J. Bednarek1,M. Pasowicz2, P. Podolec3

1Department of Electrocardiology, Institute of Cardiology, JagiellonianUniversity, John Paul II Hospital, Krakow, POLAND, 2Center for Diagnosis,Prevention and Telemedicine with the Unit of One-Day Diagnostics, John PaulII Hospital, Krakow, POLAND, 3Department of Cardiac and Vascular Diseases,Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow,POLAND

Aims: We analyzed the effect of heart failure (HF) etiology on theeffect of pacemaker upgrade (in clinical and echocardiographicparameters) in pacemaker-dependent patients with advanced HF,permanent atrial fibrillation (AF), after pacemaker upgrade fromright ventricular apical pacing (RVA) to biventricular pacing (BVP)or bifocal right ventricular pacing (BFRVP) over 12 months of fol-low-up.Methods: The study group consisted of 34 patients (8F, 26M),mean age 70.3±8.5 years, with HF (NYHA III - 28 pts and IV - 6 pts)and AF, with RVA (mean 92.2 months), submitted to pacemakerupgrade to BFRVP - 10 pts or BVP - 24 pts. The patients were onventricular pacing over 95% of the time (spontaneous or post-abla-tion atrioventricular block - 12 pts). Ischemic etiology (IEHF) ofadvanced HF was confirmed in 25 patients, in 9 pts the cause ofHF was other than ischemic etiology (NIEHF). Changes in theparameters at baseline prior to pacemaker upgrade and at 12months were evaluated only in those patients who completed theentire follow-up.

Results: At baseline the study groups did not differ significantly inage, duration of AF and RVA pacing, NYHA class, echocardiogra-phic parameters (LVEF, LVESD, LVEDD, MR) and QRS width.However, they differed with respect to therapy. In the IEHF groupBVP was used in 70%, whereas in the NIEHF group in 50% of thepatients. In the IEHF group 19pts (76%) and in the NIEHF group8pts (88.9%) completed the entire follow-up. Conclusion: At 12 months of follow-up after pacemaker upgradepatients in the IEHF group experienced marked improvement inmost clinical and echocardiographic parameters, whereas those inthe NIEHF group experienced improvement only in QRS width,NYHA class and ejection fraction. The difference was probablycaused by the fact that BVP was used in a larger percent of morepatients with IEHF.

INTRA-THORACIC IMPEDANCE AND ULTRASOUNDCOMET-TAIL IN HEART FAILURE MONITORINGM. MAINES1, D. Catanzariti1, C. Angheben1, S. Valsecchi2, J. Comisso2,G. Vergara1

1Santa Maria del Carmine Hospital - Division of Cardiology, Rovereto (TN),ITALY, 2Medtronic ITALY, Rome, ITALY

Purpose: Echographic examination of the lung surface may revealmultiple ‘comet-tail images’ originating from water-thickenedinterlobular septa. These images were demonstrated to be usefulfor noninvasive assessment of interstitial pulmonary edema.Similarly, the correlation between implantable defibrillator (ICD)-measured intrathoracic impedance and pulmonary capillarywedge pressure (PCWP) was demonstrated in heart failure (HF)patients. The aims of this analysis were to assess the agreementbetween ICD-detected impedance decrease and the presence ofcomet-tail images, as well as to compare the performance of theimpedance detection algorithm and the comet-tail images asses-sment in predicting HF worsening.Materials and Methods: We studied 23 HF patients (NYHA class2.6±0.8, ejection fraction 25±6%, QRS duration 151±32ms) implan-ted with a CRT-ICD device capable of intra-thoracic impedancemeasurement and alerting for fluid accumulation diagnosis. Atregular follow-up and at visits for HF decompensation or devicealert, clinical status was assessed, chest ultrasound was performedand PCWP was noninvasively estimated with Doppler echocar-diographic.Results: During 23±11 months of follow-up, 45 visits were perfor-med: 16 episodes of impedance decrease (fluid index above a thre-shold of 60Ohm*days) were detected and the presence of comet-tail images was revealed during 22 tests. The number of comet-tailimages resulted significantly correlated to the paired PCWP esti-mations (r=0.917, p<0.001) and to the impedance fluid index(r=0.669, p<0.001). During follow-up, 12 episodes of HF decom-pensation were reported in 12 patients. The impedance-alert detec-ted clinical HF deterioration with 92% sensitivity and 69% positi-ve predictive value. The presence of >= 5 comet-tail images sho-wed 83% sensitivity and 91% positive predictive value.Conclusion: These data demonstrate the correlation betweenintrathoracic impedance and the number of comet-tail images atchest ultrasound, and comparable performance of the impedancedetection algorithm and the comet-tail images assessment in pre-dicting HF worsening.

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INTRA-THORACIC IMPEDANCE ALERT: CLINICALUSEFULNESS IN PATIENTS WITH HEART FAILURE ANDNO INDICATION TO RESYNCHRONIZATION THERAPYL. LEONI1, G. Molon2, M. Santini3, W. Rahue4, D. Facchin5, L. Tomasi6,V. Calvi7, S. Iacopino8, A. Curnis9, A. Varbaro10, G. Imbimbo10

1Azienda Ospedaliera di Padova, Padua, ITALY, 2Sacro Cuore Don Calabria,Negrar (VR), ITALY, 3San Filippo Neri, Rome, ITALY, 4San Maurizio, Bolzano,ITALY, 5Santa Maria della Misericordia, Udine, ITALY, 6Ospedale Borgo Trento,Verona, ITALY, 7Ospedale Ferrarotto, Catania, ITALY, 8S. Anna Hospital,Catanzaro, ITALY, 9Spedali Civili, Brescia, ITALY, 10Medtronic Italia, Milan, ITALY

Purpose: Heart failure (HF) patients implanted with cardioverter-defibrillator (ICD) for primary prevention of sudden death but noindications to resynchronization therapy (CRT) are at risk of HFevents, although less symptomatic (NYHA class II-III) and with noventricular dyssynchrony. Recently an alert for pulmonary fluidoverload detection, based on intra-thoracic impedance monito-ring, has been shown to reduce the rate of HF events in CRTpatients. The aim of our study is to evaluate the clinical impact ofthis alert feature in patients indicated to a single or dual chamberICD in primary prevention. Materials and Methods: 221 patients (86% male, 66±11 years, 58%ischemic, 78% NYHA II, LVEF 28±5%) implanted with a single ordual chamber ICD in primary prevention were included in thisanalysis. 123 patients received an ICD with pulmonary fluid over-load alert capability (OptiVol) while 98 received ICD without thisfeature (Control). In case of alert, OptiVol patients performed in-office visits in order to check clinical status and to increase diure-tic dosage, if necessary. Results: Patient clinical characteristics and follow-up observationperiod (17±11 months) were similar between groups. 27 hospitali-zations or accesses to emergency room due to acute HF eventsoccurred in 20 patients. At Kaplan-Meier event free survival ana-lysis, patients in the OptiVol Group had significantly lower rate ofhospitalizations or emergency room admissions due to HF (Logrank test p= 0.044 vs Control Group).Conclusion: This analysis seems to confirm in ICD patientswithout CRT indications that the HF management using the intra-thoracic impedance alert capability permits to reduce the numberof HF events, by allowing timely detection and therapeutic inter-vention.

EFFECTS OF ACE-INHIBITORS PLUS ANGIOTENSINRECEPTOR BLOCKERS IN EARLY PHASE OF ACUTEMYOCARDIAL INFARCTIONN. SINISCALCHI1, F. Oliviero, A. Del Gatto, T. Cerciello, L.I. Siniscalchi,L. Misso1Dipartimento di Gerontologia, Geriatria e Malattie del Metabolismo IIUniversità di Napoli., Napoli, ITALY, 2Ospedale Civile di Sarno, Sarno (SA),ITALY, 3Ospedale Civile di Cava dei Tirreni, Cava dei Tirreni (SA), ITALY

In early phase of acute myocardial infarction (AMI),Angiotensine IIcan adversely affect the balance of myocardial oxygen demande,cause coronary vasoconstriction, increase the inotropic state of theheart and increase ventricular wall stress. Sudden restoration ofcoronary blood flow after AMI can result in serious structural andfunctional derangements, leading to ventricular fibrillation. ACE-inhibitors without a sulphydryl group have antiarrhythmic proper-ties and beneficial effect on the reduction of reperfusion arrhy-thmias which contribute significantly to early mortality after AMI.The aim of our study was to assess if Ace-inhibithors plus angioten-sin receptor blockers can show an antiarrhythmic effect after AMI.Methods: We performed a double blind study in 12 patients (Ps)with Q-wave myocardial infarction. Ps, both males and females,aged between 61±7, had neither previous myocardial infarctionnor clinical heart failure and had normal blood pressure.Additional therapy with oral Captopril 25 mg plus Valsartan 20mg/daily or oral placebo 48 h after the onset of symptoms wasrandomly assigned to Ps. Left ventricular volums and ejectionfraction were assessed by means of two-dimensional echocardio-graphy at regular intervals during four weeks of treatment.Results: The placebo group showed a significant reduction(p<0,05) in left ventricular end-systolic volume with ejection frac-tion increased significantly(p<0,01). Captopril plus Valsartanreduced arrhythmias caused by sudden restoration of coronaryblood flow in two Ps. The main treatment effect was evident at 6weeks of follow up. Conclusion: Authors showed that Captopril plus Valsartan mayhave a beneficial effect on left ventricular function and on reperfu-sion arrhythmias in the early phase of AMI(within the first 48 hfrom the onset of symptoms) in Ps without contraindications inaddiction to routine treatment and contribute significantly to redu-ce early mortality after acute myocardial infarction.

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THREE-DIMENSIONAL DYNAMIC POSITIONASSESSMENT OF THE CORONARY SINUS LEAD INCARDIAC RESYNCRHONIZATION THERAPY:METHODS AND FIRST CLINICAL EXPERIENCESC. TOMASI1, C. Corsi2, D. Turco2, S. Severi2, S. Argnani1, M. Margheri1

1Cardiovascular Dept, S Maria delle Croci Hospital, Ravenna, ITALY,2Department of Electronics, Computer Science and Systems, University ofBologna, Bologna, ITALY

Purpose: CS lead movements can cause overt dislodgement aswell as minor changes in lead-vein interactions, which could affectCRT processes. This work focuses on a new technique for depic-ting and measuring real-time CS lead movements in 3D space. Methods: Ten patients (6 male; age 72±7 years, 6 ischemic, LVEF27±4%, III NYHA class, 8 CRT-D) were studied. X-ray real-timeimages were acquired by chest fluoroscopy (30° LAO and RAOviews) and using a radio opaque tattoo and a grid. For each dyna-mic acquisition, in both views, the lead tip was manually selectedin one frame and automatically tracked applying region-matchingtechniques, determining the tip-coordinates time-course throu-ghout several cardiac cycles. Signals were filtered from fluctua-tions due to respiration and the data obtained from the two viewswere synchronized. One cardiac cycle was manually selected ineach view and the 3D dynamic tip coordinates reconstructed usingstereo-photogrammetric rules. This resulted in 3D lead tip trajec-tory throughout the cardiac cycle. Procedure accuracy and resolu-tion (as the mean accuracy ±2 SD) were assessed at implant bycomparing 3D tip trajectory in four consecutive cardiac cycles. The repeatability of the method was tested in three patients withno significant changes in LV echo function at 6 months follow-up,measuring the difference (d) in tip trajectory. Results: Acquisitions were feasible, with a mean fluoroscopy time=35±12 sec. The accuracy was 0.3±0.1 mm, and the resolution 0.5mm. Intra- and inter-observer variability were 2.2±1.5 mm and5.5±3.6 mm. FU measures showed minimal variation (d<5 mm) inone patient, a moderate change in another (5<d<10 mm) and acomplete dislodgement in the third (d=88 mm).Conclusions: The proposed method for measuring the CS leaddynamic placement in 3D space seems accurate and reproducible.Investigating CS lead 3D dynamics could provide further insightsinto CRT mechanics.

AN OBSERVATIONAL REGISTRY ON EFFICACY ANDSAFETY OF THE RIGHT VENTRICULAR OUTFLOW TRACTFOR ICD LEADS: RESULTS OF THE EFFORT REGISTRYG. Mascioli1, G. GELMINI2, A. Reggiani3, V. Giudici4, A. Spotti5, A. Mocini6,R. Marconi7, F. Ruffa8, G. Zanotto9

1Cliniche Humanitas Gavazzeni, Bergamo, ITALY, 2Ospedale di Desenzano delGarda, Desenzano del Garda, ITALY, 3Ospedale Carlo Poma, Mantova, ITALY,4Ospedale Bolognini, Seriate, ITALY, 5Ospedale Civile, Cremona, ITALY, 6Osp.Villa Scassi, Sampierdarena, ITALY, 7Osp Mazzoni, Ascoli Piceno, ITALY, 8OspManzoni, Lecco, ITALY, 9Ospedale di Legnago, Legnago, ITALY

Aim: The aim of this observational study has been to comparesafety (primary combined end point: efficacy of a 14-J shock inrestoring sinus rhythm (SR), R wave amplitude >4 mV and pacingthreshold <1V at 0.5 ms) and efficacy (effectiveness of a 14-J shockin restoring SR after induction of VF, secondary end point) of twodifferent sites for ICD lead positioning: right ventricle outflowtract (RVOT) and right ventricular apex (RVA). Methods: The study involved 185 patients (153 males; aged 67±10years). Site of implant was left to physician’s decision. Afterimplant, VF was induced with a 1-J shock over the T wave or, ifthis method was ineffective, with a 50-Hz burst, and a 14-J shockwas tested in order to restore sinus rhythm. Sensing and pacingthresholds were recorded in the database at implant, together withacute (within 3 days of implant) dislodgement rate.

Results: The combined primary end point was reached in 57patients in the RVOT group (70%) and in 81 patients in the RVAgroup (79%). The 14-J shock was effective in 159 patients, 63 in theRVOT group (77%) and 86 in the RVA group (83%). Both differen-ces in the primary and the secondary end points are not statistical-ly significative. R wave amplitude was significantly lower in theRVOT group (10.9±5.2 mV vs. 15.6±6.4 mV, p<0.0001), and pacingthreshold at 0.5 ms was significantly higher (0.64±0.25V vs0.52±0.20V, p<0.01), but these differences do not seem to have a cli-nical meaning, given that the lower values are well above theaccepted limits in clinical practice. Conclusion: Efficacy and safety of ICD lead positioning in RVOTis comparable to RVA. Even if we observed statistically significantdifferences in sensing and pacing threshold, the clinical meaningof these differences is, in our opinion, irrelevant.

EPICARDIAL LEAD IMPLANTS WITHVIDEO-THORACOSCOPIC TECHNIQUEA. REGGIANI1, A. Droghetti1, G. Martini2, G. Muriana1, R. Zanini1

1A.O. Carlo Poma, Mantova, ITALY, 2Boston Scientific, Milan, ITALY

Aim: The transvenous lead implant fails in 10-12% of cases due toanatomical difficulties or due to patient intolerance to sustainedinterventions as described in literature. Main objective of video-thoracoscopic intervention is to reduce implant time with the goalto reach the appropriate functional anatomical target. Methods: From 2009 to date, 14 patients, from many Italianimplant centres, have been implanted with epicardial lead on leftventricle through the video-thoracoscopic technique. They havebeen seen in the following months to verify the stability of the elec-trical parameters of lead and to assess the effectiveness of the CRT. Results: The 14 patients had the following characteristics: 11 (80%)males, with ischemic aetiology (65%) and III NYHA functionalclass 70%. The interventions were performed under general anae-sthesia, and the surgical technique had three operational access of5, 10 and 15 mm without toracotomia. The technique allowedanchoring lead on the left lateral wall with an implant averagetime of 30±10 minutes. Electrical measurements have proven to bestable with an impedance average 600±50 Ohm and a stimulationthreshold of 1.3±0.3 V at 0.5 ms. The hospitalization average timewas 4±2 days. The average follow-up was 572 days with evidenceof stability of electrical measurement.Conclusions: Video-thoracoscopy technique implant, allow to pla-ces a left lead in the anatomic target, delivering CRT with a verypoor invasive procedure that have an average duration of 30minutes and with stable electrical parameters over time.Patients with anatomic difficulties, which could not tolerate sustai-ned procedures or in which the transvenous procedure has failed,could benefit of this technique.

SINGLE CENTER EXPERIENCE OF CARDIACRESYNCHRONISATION THERAPY (CRT-P/CRT-D) OF FIVEYEARS (2005-2009) - A DEMOGRAPHIC PROFILER. SINGHAL, A. Jaswal, A. Saxena

Fortis Escorts Heart Institute, New Delhi, India

Introduction: Cardiac resynchronization therapy (CRT-P/CRT-D)constitutes one of the emerging and proven modalities of treatmentin patients(pts.) with severe left ventricular (LV) dysfunction. Inour center we tried to evaluate the demographic profile of cardiacresynchronization therapy in our pts. over a period of five years. Objective: To evaluate the overall demographic profile of the pts.being referred for CRT-P/CRT-D in our center.Population / Methods: We studied total of 280 pts. with severe LVdysfunction that were implanted biventricular pulse generatorwith or without ICD in our department (from 2005-2009) in NewCA

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Delhi. We analysed the distribution by percentage of pts. whoreceived CRT-P/CRT-D, their age, gender distribution, NYHAclass, QRS duration(QRSd) and etiology. In pts. with QRSd betwe-en 120-150 msec, we analysed mechanical dyssynchrony withTissue Doppler Imaging (TDI). The parameters chosen for TDIwere atrioventricular (AV, <40% of cardiac cycle), interventricular(>40 msec) and intraventricular dyssynchrony (>140 msec). Pts.fulfilling 2 out of 3 dyssynchrony parameters were incuded.Results: Out of 280 pts. the mean age of pts. was 61±19 yrs, (87.8%were males and 12.2% were females). The pts. who received car-diac resynchronization therapy (CRT-P/CRT-D) were 73% diabeticand 65% hypertensive. CRT-P was given to 82% and CRT-D to18%. 70.2% had ischemic etiology, 29.8% had idiopathic dilatedcardiomyopathy. The mean ejection fraction (EF) was 24±10%,mean QRSd 142±18 msecs. 64% were in NYHA class III and 36% inambulatory NYHA class IV who received CRT-P/CRT-D.Conclusion: We analysed the demographic profile of the pts. beingreferred for CRT-P/CRT-D in our center. The rate of implantationof CRT-P/CRT-D in females in Indian population is lower thantheoretically expected. Also, the female population was older withhigher NYHA class. The guidelines must be implemented careful-ly to avoid gender selection biases.

BENEFITS OF CRT IN ELDERLY HEART FAILURE PATIENTSE. CASALI1, M. Liccardo2, P. Gallo3, F. Franchi1, P. Nocerino2, G. Sibilio2,P. Guarini3

1Policlinico Universitario, Modena, ITALY, 2Ospedale S. Maria delle Grazie,Pozzuoli (NA), ITALY, 3Casa di Cura Villa dei Fiori, Acerra (NA), ITALY

Aim: In almost all randomized trials on cardiac resynchronizationtherapy (CRT), elderly patients are minimally represented even ifin clinical practice they are often considered to receive a CRT devi-ce. The purpose of this work is to assess the clinical and echocar-diographic benefits of CRT in this kind of patients.Methods: We considered for the analysis 75 unselected patientswith symptomatic heart failure despite optimal drug therapy, leftventricle ejection fraction (LVEF) <35%, and QRS width >130ms,implanted with CRT-D devices and followed for at least 12 monthswith quarterly follow-up. The population was divided into two sub-groups depending on the age: Old group (age >70 years) and Younggroup (age <=70 years). At 12 months follow-up were defined:instrumental responders (ECHO-R) all alive patients that had impro-ved the LVEF at least of 30% or alternatively that had reduced the LVend systolic volume at least of 15%; clinical responders (CLIN-R) allalive patients with no hospitalizations for congestive heart failurethat had improved by at least one point the NYHA class. Results: The enrolled population characteristics were: male (74%),mean age (67±10 years), mean LVEF (25±6%) and ischemic aetiolo-gy (51%). The Old population (32 patients, 77±5 years) and Young popula-tion (43 patients, 60±8) characteristics were comparable with morefemales and ischemic aetiology in the Old group. Nine deathsoccurred at 12 months follow-up (6 in the Old group and 3 in theYoung group: 9.4% vs 6.9%, p = NS). At 12 months follow-up theresponders ratio comparable in the two groups: in all populationwe observed 56% of ECHO-R (Old 59.4% vs Young 53.5% p = NS)and 60% of CLIN-R (Old 53.1% vs Young 65.1%, p = NS).Conclusions: Our experience shows that even the elderly patients,with good life expectancy, can benefit from the CRT as youngerpopulation.

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PREDICTORS OF SINUS RHYTHM RESTORATIONAND LONG-TERM MAINTENANCE BY ABLATION OFLONGSTANDING PERSISTENT ATRIAL FIBRILLATIONM. FIALA, M. Sknouril, R. Nevralova, V. Bulkova, J. Chovancik, J. Gorzolka,J. Pindor, D. Vavrik, S. Krawiec, M. Dorda, O. Jiravsky, J. Januska

Department of Cardiology, Hospital Podlesi, Trinec, CZECH REPUBLIC

Aims: This study ascertained variables associated with successfulsinus rhythm (SR) restoration by ablation and outcome in long-standing persistent atrial fibrillation (LSPAF). Methods: In a prospective study, 101 patients (pts) (59+10 years)underwent left atrial (LA) or biatrial (BA) ablation of LSPAF last-ing 34+22 months. After 29+9 month follow-up and repeat abla-tion in 65 pts, 91 pts have stable SR. Pts were distributed into SRrestoration (48) vs. non-restoration (53) groups, resp. groups offavorable (32) vs. unfavorable (69) outcome of a single ablation.Age, gender, persistent AF duration, prior failure of cardioversionto restore SR, medications, cardiovascular/other diseases,CHADS(2) score, height, weight, BMI, BSA, LA, echocardiograph-ic (echo) dimensions and functional parameters, VO2 max,NTproBNP, LA and RA volumes and voltages from electroanatom-ic mapping, appendages AF cycle lengths (AFCL), LA or BA abla-tion, and RF delivery time were analyzed.Results: Non-restoration group had more prior cardioversion fail-ures (34, P=0.05), larger LA (187+39 ml; P=0.04) and RA (182+32ml; P=0.005) volumes, larger LA and RA echo dimensions, shorterLAA AFCL (155+22 ms, P=0.02), lower maximum RA voltage(5.2+2.5 mV; P=0.05), trends to lower proportion of LA or RApoints >1mV (P=0.06 resp. 0.07), and lower LAA peak velocity(42+18 cm/s; P=0.09). Patients with favorable outcome were older(62+9; P=0.005), had more frequently history of cardiomyopathy(38%; P=0.05), worse CHADS(2) score (1.5+1.1; P=0.02), lower VO2max (17.7+5.9; P=0.006), and trend to lower LAA peak velocity(40+18 cm/s; P=0.06). Conclusion: SR restoration by ablation was associated with betterbiatrial structure and function, longer LA AFCL and prior abilityto convert AF into SR by cardioversion. In contrast, long-termfavorable outcome of a single ablation was achieved in olderpatients with worse functional characteristics. This work was supported by a grants IGA MZ NR9143-3/2007,and IGA AGEL N. 15/2007

TIMING AND FEATURES PREDICTING SUCCESSOF CATHETER ABLATION OF ATRIAL FIBRILLATIONE. MENARDI, A. Vado, G. Rossetti, E. Racca, M. Bobbio

A.S.O. Santa Croce e Carle - Cardiology, Cuneo, ITALY

One of the less investigated aspects of catheter ablation of atrialfibrillation (AF) is the timing to address patients to this therapeu-tic strategy. The aim of this study was to evaluate clinical andinstrumental features helpful for clinicians in selecting patientsthat could more benefit by left atrial (LA) ablation and time forintervention. Each patient undergoing AF ablation in our centre from August2005 to September 2008 was considered for clinical and instrumen-tal data collection, including antiarrhythmic drug therapy in the 12months before the procedure, number of electric cardioversions(ECV), number of hospitalizations in the 12 months before proce-dure and LA dimensions evaluated by echocardiographic exami-nation. These data were related to 12-months follow-up results. A total of 168 patients were enrolled, 69% with persistent AF and31% with paroxysmal AF. Multivariate analyses showed that sinusrhythm at 1-year follow-up was present in 86.4% of patients whounderwent either no or at least one electric cardioversion in the 12months before the procedure; only 70.6% of patients who under-went two or more ECVs in the 12 months before the procedure (OR= 0.25; p < 0.01).

The only other variable that was found to be associated with amajor risk of AF recurrence was LA dilatation (OR = 6.9; p < 0.01). In conclusion, our data suggest that catheter ablation of AF shouldbe considered as therapeutic option in a relatively initial stage ofthe natural history of this arrhythmia. Furthermore, left atrialdilatation relates to poorer outcomes.

BENEFIT FROM ABLATION OF LONGSTANDINGPERSISTENT AF IS BETTER THAN IN PAROXYSMALAF 2-YEARS EVALUATION OF QUALITY OF LIFEV. Bulkova1,2, M. FIALA3, D. Wichterle2, J. Chovancik3, J. Simek2,S. Havranek2, J. Gorzolka3, J. Pindor3, H. Tolaszova2, J. Brada4, K. Ivanova2

1Department of Cardiology and Angiology II, General University Hospital andCharles University School of Medicine, Prague, CZECH REPUBLIC, 2Institute ofSocial Medicine and Health Policy, Palacky University, Olomouc, CZECHREPUBLIC, 3Department of Cardiology, Hospital Podlesi, Trinec, CZECH REPUB-LIC, 4Czech Technical University in Prague, Faculty of Biomedical Engineering,Prague, CZECH REPUBLIC

Aims: This study evaluated quality of life (QoL) before and 24months after ablation of longstanding persistent atrial fibrillationLSPAF versus paroxysmal AF (PAF). Methods: The study included 89 patients (pts) with LSPAF and 56pts with PAF, who underwent first ablation in the year 2007. Atbaseline, cardiomyopathy 16 vs. 3%; P=0.03) and higher pulse fre-quency (87+17 vs. 81+20; P=0.005) occurred more frequently inLSPAF group. Repeat ablation was done in 19 (34%) LSPAF pts vs.23 (26%) PAF pts. QoL was assessed using EQ-5D questionnaire. Results: At 6,12,18, and 24 months, the questionnaire was returnedby 79%, 70%, 84%, and 78% PAF pts, vs. 77%, 70%, 86%, and 77%LSPAF pts. At baseline, objective and subjective QoL was insignif-icantly better in PAF patients (table). In comparison with baseline,in objective QoL, PAF pts improved significantly at 6th to 18thmonth (P=0.05, 0.01, 0.03); LSPAF pts improved from the 12th to24th month (P= 0.003, <0.001, 0.003). In subjective QoL, PAF ptsdid not achieve significant improvement at any stage, whileLSPAF pts displayed trend to improvement at 12th and 18thmonths (both P=0.09), and significant improvement at 24th month(P=0.01). After 2 years, QoL in both components was insignificant-ly better in LSPAF pts. Days of hospitalization and working inca-pacity decreased significantly in both groups.Conclusion: At baseline, LSPAF pts were more symptomatic andhad lower QoL, however, at the expense of insignificantly higherreablation rate, they achieved better QoL improvement after 2 years.

Objective QoL Subjective QoLPAF LSPAF P PAF LSPAF P

Baseline 71 + 10 67 + 16 0,10 67 + 16 64 + 12 0,076 months 75 + 15 73 + 15 0,50 71 + 15 68 + 8 0,3912 months 77 + 15 87 + 13 0,18 73 + 13 71 + 11 0,7018 months 76 + 18 80 + 17 0,25 73 + 17 72 + 11 0,4824 months 75 + 18 80 + 17 0,31 70 + 17 73 + 13 0,33

ALTERATIONS IN ATRIAL EXCITATION PATTERNSFOLLOWING CIRCUMFERENTIAL PULMONARYVEINS ISOLATIONV. VASSILIKOS1, G. Dakos1, I. Chouvarda2, S. Paraskevaidis1, I. Chatzizisis1,G. Stavropoulos1, N. Maglaveras2, I. Styliadis1

11st Cardiology Dept Aristotle University of Thessaloniki, Thessaloniki,GREECE, 2Laboratory of Medical Informatics Aristotle University ofThessaloniki, Thessaloniki, GREECE

The aim of this study was to investigate possible changes in atrialexcitation patterns following ablation for paroxysmal atrial fibril-lation (PAF). Methods: We studied 23 patients (14 males,mean age 53.4±7 years)who underwent circumferential pulmonary veins (CPV) isolationCA

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because of non-responsive to drugs AF. The recordings wereobtained during sinus rhythm before and after PV isolation with a3 - channel digital recorder for 10 minutes and digitized with a 16-bit accuracy at a sampling rate of 1000 Hz. The PVs were isolatedin pairs using the Nav-X mapping system. The P wave was ana-lyzed using the Morlet wavelet and wavelet parameters express-ing the mean (MN) and max energy (MX) of P wave were calculat-ed in the three orthogonal leads (X, Y, Z) and in the vector magni-tude (VM), in three frequency bands (1st: 200-160 Hz, 2nd: 150-100Hz and 3nd: 90-50 Hz). Paired t-test was used for comparing con-tinuous variables, while p<0.05 was considered significant. Results: Following PV isolation, P wave duration was shortenedsignificantly at X, Y and Z axes (98.1±20 vs 87.9±12msec,p=0.001,103±15 vs 91.6±12msec, p<0.001 and 101.4±18 vs94.4±16msec,p=0.019 respectively), while MN and MX in the 1st(MN1: 3.77±3.9 vs 1.76±1.01, p=0.03 and MX1: 12.2±4.8 vs 9.29±2.8,p=0.018, respectively) and 2nd frequency bands at X (MN2:8.41±8.4 vs 3.98±2.4, p=0.026 and MX2: 16.75±6.7 vs 13.2±4.1,p=0.006, respectively) and Y axes (MN1: 4.76±3.3 vs 2.99±2.19,p=0.03 and MX1: 14±5.6 vs 10.7±3.9, p=0.002, respectively andMN2: 12.6±9.5 vs 6.89±5.4, p=0.018 and MX2: 20.67±8.7 vs 15.9±5.9,p=0.007 respectively) were significantly lower. Conclusions: It seems that CPV isolation apart from the ectopicfoci elimination, results in the substrate modification through sig-nificant alterations in atrial conduction, as suggested by the short-ening of P wave duration and the lower energies.

IS THE PRESENCE OF ABNORMALITIES OF THEP WAVE IN LEAD V1 NECESSARILY INDICATIVE OF THEEXISTENCE OF BLOCK OF INTERATRIAL CONNECTIONSLOCATED IN PROXIMITY OF FOSSA OVALE?P. PIERAGNOLI, G. Ricciardi, L. Perrotta, G. Mascia, L. Padeletti,A. Michelucci

University of Florence, Florence, ITALY

Background: Abnormalities of the P wave in V1 suggest the exis-tence of a delay of conduction through connections located in thevicinity of fossa ovale (FO). Methods: To confirm utilized ECG criteria we performed, duringsinus rhythm, left atrial (LA) activation map before pulmonaryvein ablation in 11 patients with paroxysmal atrial fibrillation anda P wave with a +/- morphology in lead V1. LA volume indexedto body surface area (LA index, cm3/m2) was measured usingCARTO system.We measured, amplifying ECG, duration (D) and amplitude (A) ofthe second part (negative) of P wave in lead V1. Abnormality of Pwave in V1 (possible block of interatrial connections located in thevicinity of FO) was considered if there were: D > 0,04 sec, A > 1mm, product of D and A (D x A) > 0,04 sec x mm. P wave durationand morphology in D3-aVF and maximal P wave duration (P max,msec, all ECG leads) were evaluated.Results: In all patients, parameters in V1 were abnormal, suggest-ing the existence of a block of interatrial conduction in FO.Duration of P wave in D3-aVF was > 120 msec in 9 cases but no caseshad a +/- morphology, excluding, at least by ECG, the existence of acomplete block of Bachmann bundle(Bach). CARTO map indicatedthat activation of LA was nearly exclusive via Bach in 7 cases and viaFO connections in 4 cases. In Bach patients DxA was (meanvalues±SD) 0,152±0,083 secxmm, LA index 42,2±17,4 cm3/m2, and Pmax29±22 msec. In FO patients: DxA was 0,129±0,025 secxmm, LAindex 32,7±11,9 cm3/m2, P max 125±17 msec.Conclusions: Despite the presence in all patients of an ECG pat-tern of complete conduction block in the proximity of FO, the elec-tro-anatomic map does not confirm this absence of conduction in36% of patients.

EARLY EXPERIENCE OF RESPIRATORY EFFECTREDUCTION ON FAST ANATOMICAL 3D MAPPINGE. DE RUVO1, S. Dottori2, M. Rebecchi1, L. De Luca1, L. Sciarra1,L.M. Zuccaro1, A. Faganini1, G. Sabino3, P. Terrosu3, M. Minati1, F.Guarracini1, M. Porfirio1, F. Sebastiani1, R.V. Iulianella1, C. Commisso1,A. Sette1, F. Nuccio1, C. Lanzillo1, E. Lioy1, L. Calò1

1UOC Cardiologia, Policlinico Casilino ASL RM/B, Rome, ITALY, 2BiosenseWebster Italia, Johnson & Johnson Medical, Milan, ITALY, 3Divisione diCardiologia, Ospedale Civile SS. Annunziata, Sassari, ITALY

Introduction: Electroanatomical mapping system is widely usedto guide RF ablation of complex arrhythmias. The Carto3 mappingsystem allows volumetric 3D reconstruction of the cardiac cham-bers. During fast anatomical mapping (FAM), volume data may beaffected by respiration. Aim: Aim of this study is to analyze the effect of Respiratory EffectReduction (RER) feature on FAM reconstruction in conscious notventilated patients. Moreover, we tested the utility of showing thereal time graph, that displays the amplitude of catheter motionrelated to respiratory pattern.Methods: Six consecutive patients were referred to our lab (1 atyp-ical atrial flutter, 2 persistent AF procedures, 3 typical right atrialflutter). Before FAM, the training phase of respiratory motion wasperformed by recording the mapping catheter movements at thecoronary sinus ostium. After the training period, the system dis-plays the respiratory training graph which plots the respiratoryamplitude over time. A specific threshold was set for selectiveacquisition of data as much close as possible to the end of expiri-um phase. We performed a qualitative and quantitative compari-son between FAM with and without RER feature enabled in termsof volume of the chambers.Results: Anatomical reconstructions were performed for the RA(n=4) and LA (n=2) by using RER. Total mapping and fluoroscopytime was 11.5±4.9 and 0.75±1.4 minutes respectively. The differ-ence between FAM performed with and without RER feature wasmainly concentrated in the anterior and inferior regions of thechambers. Mean volume showed statistically difference betweenthe two mode (109,55±34,83 ml vs 94,73375±33,12 ml; p< 0.005)Real time graph showed a good visual correlation with thecatheter movement during mapping and ablation.Conclusions: RER allowed accurate 3D reconstruction of cardiacchambers and real time monitoring of catheter movements in rela-tion to respiration.

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SUPRACLAVICULAR VEIN APPROACH TO OVERCOMEIPSILATERAL SUBCLAVIAN VEIN OBSTRUCTION WHENIMPLANTING PACEMAKER-ICD LEADSD. ANTONELLI, N.A. Freedberg, Y. Turgeman

Ha Emek Medical Center, Afula, ISRAEL

Aims: Total subclavian vein occlusion represents a difficult obsta-cle when a lead has to be inserted into the ipsilateral vein.We report our experience with supraclavicular vein approach ofsubclavian vein puncture to overcome its ipsilateral chronicobstruction when implanting pacemaker-ImplantableCardioverter Defibrillator (ICD) leads.Methods and Results: The subclavian vein obstruction was docu-mented by venography.The skin was punctured by a 18 gauge needle, 1cm laterally to thelateral head of the sternocleidomastoid muscle and 1cm craniallyto the clavicle.The needle was directed closely under the claviclepointing to the sternal notch. Once the vein was successfully punc-tured, medially to the obstruction, a 0.38 inch guide -wire wasinserted into the venous bed. Subsequently a peel away sheathwas indwelled using the Seldinger technique. The leads wereplaced in the standard fashion; they were secured by suture to thesubcutaneous tissue of the fossa supraclavicularis major using aprotective sleeve. The proximal portion of the lead was tunneledover the clavicle down to the device prepectoral pocket.Lead insertion was performed in 5 patients (twice in one patient)with total left subclavian vein obstruction; their mean age was64.6±10.6 years; an ICD was implanted previously in 3 patients,while it was a de novo implant in 2 patients; the site of the obstruc-tion was in the mid segment of the left Subclavian vein in 3patients; in the axillary and distal segment of the subclavian vein in1 patient, in the distal segment of the Subclavian Vein in 1 patient.The mean follow-up was 2 years. There were no complications ofthe surgical wound and the leads parameters remained stable.Conclusion: In our experience the supraclavicular approach of thesubclavian vein puncture to overcome the ipsilateral total occlu-sion is feasible and safe.

ROADMAP FLOUROSCOPY FOR PLACEMENTOF PACEMEAKER AND ICD LEADSA. SALACATA, S. Keavey

Great Lakes Heart Center of Alpena, Alpena, USA

Majority of pacemaker and ICD leads are placed through canula-tion of the subclavian vein. This approach however carries the riskof a pneumothorax, crush damage to the leads and injury to sur-rounding structures. Since the axillary vein (AV) is located outsidethe thorax, AV canulation potentially eliminates these risks.Roadmap (RM) is an operating mode in which a fluoroscopic mapis obtained and superimposed on subsequent images, emphasiz-ing the blood vessel. Its utility in device implantation has not beendescribed. Methods We retrospectively reviewed 150 pacemakerand ICD cases. This report summarizes our experience in 29 casesusing RM after failed SV access.Results: Using RM we access the AV on 100% of our attempts. Thepatients in our series were older with significant morbidity (aver-age age 74.3±9. years, CAD in 62%, chronic AF in 21%, EF =38±18.5%). Different devices were implanted: 13 (44.8%) single ordual chamber pacemakers, 12 (41.4%) new ICD, 2 (6.9%) CRT-Dand 2 (6.9%) upgrades to an ICD. These required 21 new atrial, 13ventricular, 16 ICD and 2 LV leads. Each procedure averaged95.4±36.1 minutes, and utilized of 46.5±22 cc of non-ionic contrast.This amount of contrast did not appreciably affect renal functionas measured by the pre- and post-procedure creatinine (1.29±0.51vs. 1.42±0.66 mg/dl, p=0.6). Within the first 30 days post proce-dure there were 2 cases of pocket hematomas that did not requireintervention and one case of atrial lead dislodgement that required

reoperation. There were no cases of a pneumothorax, ventricularperforation, lead failure or infection.Conclusion: RM can reliably access the AV for lead implantation,requiring a small and well tolerated amount of contrast andshould be considered as the alternative method for accessing thecentral circulation.

PERIOPERATIVE ORAL ANTICOAGULANT THERAPY DUR-ING PACEMAKER AND DEFIBRILLATOR IMPLANTATIONSG. BENCSIK, R. Pap, A. Makai, L. S·ghy, G. Klausz, T. Forster

2nd Department of Internal Medicine and Cardiology Center, University ofSzeged, Szeged, HUNGARY

Introduction: In patients with significant thromboembolic risk theperioperativ anticoagulation can be achieved by heparin or oralanticoagulant therapy (OAT). The aim of our investigation was toanalise the correlation between OAT and postoperativ hematomas.Patients / Methods: In our retrospectiv study we analized datafrom 598 patients who underwent pacemaker or ICD implanta-tion/replacement in our institution. In 71% of patients we per-formed new implantation and in 29% replacement. 87 patients(14,5%) had high and 511 (85,5%) had intermediate or low throm-boembolic risk. We performed implantation in 100 patient withOAT and in 498 patient without any anticoagulation. We analisedthe correlation between INR (measured on the day of intervention)and postoperativ hematomas. Results: In all we observed 11 postoperativ hematomas (1,83%)from which 2 required reoperation. 9 hematomas occured in agroup with OAT (9%) and only 2 in a group without anticoagula-tion(0,40%). The mean INR value in the group with OAT was2,17±411. Within this group of patients we were not able to provestatistical correlation between level of INR and occurence ofhematomas (2,23±41 vs. 2,11±40; p=0,372), although 2 reoperatedpatients were both anticoagulated.Conclusion: Risk for hematoma formation during pacemaker ordefibrillator implantation/replacement performed under OAT issignificantly lower (9% vs.20%) than in procedures performedunder effect of heparin (known from literature). In our surveythere was no correlation between occurence of hematomas and alevel of anticoagulation.

THE FACTORS ASSOCIATED WITH REOPERATIONAFTER DE NOVO PACEMAKER IMPLANTATIONC. SUGA1, T. Hirahara1, Y. Sugawara1, J. Ako1, S. Momomura1, T. Kurata2

1Jichi Medical University Saitama Medical Center, Saitama, JAPAN, 2Japan LifeLine Co Ltd, Tokyo, JAPAN

Background & Objectives: Reoperation during early stage afterpacemaker (PM) implantation may cause problems including PMinfection, extended hospitalization, increased medical cost, andpatients affliction. Therefore, we should devote every effort to pre-vent reoperation during perioperative period. We evaluated ifthere are any factors associated with reoperation.Methods: This study included 197 patients who underwent denovo PM implantation at our institution from Jan, 2008 to July,2010 (96 Males, mean age 72.2+/-9.7 years). Patient characteristicsand perioperative information including indication for PM,echocardiographic measurements, pacing mode, laterality ofimplanted site, lead location, procedural time, required bed restduration, and use of anticoagulants or antiplatelets were com-pared according to presence or absence of reoperation within 1month after PM implantation.Results: All patients received active fixation atrial and/or ventric-ular lead(s). 11 among 197 patients (5.6%) underwent reoperation.Reasons for reoperation were lead dislodgement in 10 patients,and perforation in 1 patient. Mean duration from PM implantationCA

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to reoperation was 0.4+/- 0.8 days. There were no significant dif-ferences between patients with and without reoperation in age,gender, height, weight, indication for PM, LA dimension, LVdimension, LVEF, TR-PG, implanted site, nonconventional leadlocation, and use of anticoagulants or antiplatelets. Patients neces-sitating reoperation had shorter bed rest duration (1.0+/-0.0 vs7.2+/- 10.2hrs, p<0.05), longer procedural time (120.5+/-39.2 vs103+/-30.0min, p=0.07), and smaller BMI (19.6+/-3.7 vs 23.6+/-2.8, p<0.05).Conclusions: Careful attention should be paid if they necessitatereoperation in patients with longer procedural time, shorter bedrest duration, and smaller BMI. Interestingly, it seems difficult topredict the need for reoperation according to lead location and useof anticoagulants or antiplatelets. Extremely shorter bed rest dura-tion should be avoided to prevent reoperation especially inpatients with longer procedural time and smaller BMI.

ATRIO-VENTRICULAR SEARCH HYSTERESIS ALGORITHMMINIMIZES RIGHT VENTRICULAR PACING IN PATIENTSIMPLANTED WITH A DUAL CHAMBER PACEMAKER:RESULTS FROM A PROSPECTIVE STUDYP. LE FRANC1, J. Casassus2, G. Kaltofen3, K. Bel Hadj4, O. Bizeau5,E. Espaliat6, A. Guillemot7, P. Pepi8, E. Mouton9, L. Coutrot9, O. Thomas10

1Clinic Saint Hilaire, Rouen, FRANCE, 2Clinic Aressy, Aressy, FRANCE,3Kardiologische Gemeinschaftspraxis, Chemnitz, GERMANY, 4Clinic LouisPasteur, Essey les Nancy, FRANCE, 5Hospital La source, Orléans, FRANCE,6Clinic des CËdres, Brives La Gaillarde, FRANCE, 7General Hospital, Dinan,FRANCE, 8AO Carlo Poma, Mantova, ITALY, 9Boston Scientific France,Montigny Le Bretonneux, FRANCE, 10Clinic Ambroise Paré, Neuilly, FRANCE

Purpose: High right ventricular pacing percentages (Vp) may bedeleterious for ventricular function. BELUGA prospective, obser-vational registry primary objective was to evaluate in real life theimpact on Vp of atrio-ventricular search hysteresis algorithm(AVSH) available in Insignia dual chamber pacemakers.Methods: Cumulative Vp throughout 12 months was comparedbetween patients with AVSH active (ON) vs AVSH inactive (OFF).Results: Overall, 899 patients with PR< or = 250ms were followedduring a mean period of 10.8±2.8 months (Mean age: 77±9 years,56% male, PR interval: 196±33 ms, 41% sinus node dysfunction,18% bradycardia/tachycardia syndrome, 36% paroxysmal atrioventricular block, 1% chronotropic incompetence, 4% other/mixedindications). AVSH was permanently ON for 729 (82%) pts andOFF for 115 (13%) pts. Pts in group ON were younger (76±9 yearsvs 78±9, p<0.05) and had less history of ventricular arrhythmia(11% vs 26%, p<0.001). Median Vp was 40% in group ON vs 100%in group OFF, p<0.001. Significant reduction (60%) of the medianVp was obtained when AVSH was active.Conclusions: These results obtained in real life, suggest that Vp issignificantly reduced when AVSH is activated. AVSH algorithmshould also help to increase pacemakers longevity.

IMPACT ON VENTRICULAR PACING OF ANATRIO-VENTRICULAR SEARCH HYSTERESISALGORITHM ACCORDING TO IMPLANT INDICATIONSIN PACEMAKER RECIPIENTSM. MAINES1, P. Le Franc2, G. Vergara1, D. Catanzariti1, A. Reggiani3,P. Pepi3, M. Pasqualini4, D. Pozzetti4, P. Belli5, C. Provvisiero5, G. Saint-Cricq6, P. Berdague7, M. Abinader8, U. Appl9, L. Coutrot9, O. Thomas10

1APSS Provincia di Trento, Rovereto, ITALY, 2Clinic Saint Hilaire, Rouen,FRANCE, 3O.A.Carlo Poma, Mantova, ITALY, 4Pieve di Coriano, Coriano, ITALY,5S. G. Bosco, Bosco, ITALY, 6Clinic Pont de Chaume, Montauban, FRANCE,7General Hospital, Béziers, FRANCE, 8Polyclinic Arc en Ciel, Oloron SainteMarie, FRANCE, 9Boston Scientific International, Diegem, BELGIUM, 10ClinicAmbroise Paré, Neuilly, FRANCE

Purpose: High right ventricular pacing percentages (Vp) may bedeleterious for ventricular function. Atrio-ventricular search hys-teresis algorithm (AVSH) aims to avoid unnecessary ventricularpacing. One objective of BELUGA international, prospective reg-istry was to evaluate the impact of AVSH on Vp in dual chamberpacemakers (PM) patients (pts) with sino-atrial disease (SAD)compared to those with paroxysmal atrio-ventricular block andPR<250 ms (AVB). Method: The cumulative percentage (%) of Vpthroughout 12 months was compared in SAD vs AVB pts. PM pro-gramming was left to the discretion of the investigator.Results: Overall, 899 patients were followed during 10.8±2.8months (mean age: 77±9 years, 56% male, PR interval: 196±33 ms,54% SAD, 32% AVB, 14% other/mixed indications). Significant dif-ferences in demographic data were observed: AVB pts were moreoften males (64% vs 51%, p<0.001); presented less supraventricu-lar arrhythmias (23% vs 58%, p<0.001) and longer PR interval(203±32 ms vs 189±32 ms, p<0.001). PM programming was thesame regardless of the pts specific condition, except for AVSH, andwas stable throughout the study. Median Vp in pts with AVSH ONwas 57% in AVB group and 33% in SAD group (p<0.001). MedianVp in pts with AVSH OFF was 100% in AVB group and 99% inSAD group (p=0.01). As expected, for both SAD and AVB popula-tion, Vp was significantly lower (p<0.001) in pts with AVSH ON.Conclusion: These results conducted in a real life registry suggestthat ventricular pacing may be reduced when AVSH is activated inboth SAD and AVB pts.

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ACCEPTANCE AND SATISFACTION OF PATIENTSWITH IMPLANTED DEVICES REMOTE MONITORINGL. MORICHELLI, A. Sassi, L. Quarta, A. Porfili, N. Cadeddu, F. Saputo,S. Aquilani, M. Magris, V. Altamura, C. Pignalberi, R.P. Ricci, M. Santini

Department of Cardiology, San Filippo Neri Hospital, Rome, ITALY

Introduction: Since 2007, the CareLink NetworkÆ remote monitor-ing system was introduced in our cardiology outpatient clinics.Objective of this analysis is to evaluate patients’ acceptance and sat-isfaction of the remote control system by a specific questionnaire.Materials and Methods: The questionnaire is composed of twelveitems and analyses five aspects of patient’s acceptance and sati-sfaction of remote control. Each item is set on a five point scalefrom the worst satisfaction level to the better one. The questionnai-re was submitted to 163 patients (147 male, 71±12 years) implan-ted with ICD (38 biventricular devices) and followed by theCareLink NetworkÆ. Sixty-one patients have a higher educationlevel and 127 patients are in retirement.Results: In a median follow-up of twenty months (25th-75th per-centile=13-26 months), all patients reach a higher level of satisfac-tion (maximum total score was 45/50). The only independent pre-dictor of acceptance and satisfaction is the presence of a biventric-ular device. The main result is confirmed by the five differentaspects: (i) relationship with healthcare provider (3.3±0.7); (ii) easyof use of CareLink NetworkÆ technology (3.5±0.5); (iii) relatedpsychological aspects (3.5±0.4); (iv) implication of general health(3.4±0.6); (v) overall satisfaction (3.8±0.3). The patients with high-er education level manifest a better relationship with healthcareprovider (p= 0.011), and who received a biventricular device thinkthat the CareLinkÆ Network system has a important and positiveeffects on his health more than the other patients.Conclusions: Patients with ICD followed by CareLink NetworkÆshow a higher level of acceptance and satisfaction for the remotecontrol. In our experience this new technology could help thehealthcare provider team in management of the therapy and alsoeach patient in his daily life.

THE REMOTE CONTROL IN THE MANAGEMENT OFHEART FAILURE AND ARRHYTHMIAS IN PATIENTSWITH IMPLANTABLE CARDIAC DEVICESS. AQUILANI, L. Morichelli, A. Porfili, L. Quarta, C. Pignalberi, B. Magris,V. Altamura, R.P. Ricci, M. Santini

Department of Cardiology S. Filippo Neri Hospital, Rome, ITALY

Introduction: The increasing number of patients implanted withimplantable cardioverter defibrillators (ICD) and their relative fol-low-up induces a great burden to the organization for cardiologyoutpatient clinics. The remote monitoring system CareLinkNetworkÆ and the ClinicalServiceÆ project aim to improve theclinical management of these patients and to evaluate and opti-mize the use of resources. Objective of this analysis is to assess theimpact of the remote control on the management of heart failureand arrhythmias in patients with implantable cardiac devices.Materials and Methods: Patients implanted with a wireless ICDwith Optivol Diagnostics aiming to monitor pulmonary conge-stion due to HF, received a CareLink Monitor. The devices wereable to send a CareAlert in case of AT/AF episode, VT/VF shockepisode and Optivol Alert. Expert nurses reviewed programmedremote transmissions and transmissions associated withCareAlerts and, following a specific flow-chart, submitted to theattending physician critical CareAlert cases or transmissions asso-ciated with clinically relevant device diagnostics data. Everyaction taken was collected. Results: 200 patients were included in this analysis since July 2009.In a median follow-up of 8 months (25th-75th percentile= 4-10months), 232 CareAlert Optivol were detected in 150 patients.Symptoms were reported by 63 patients (47%) in 90 events (39%),

AT/AF and VT/VF were detected in 36 patients (24%) in 35 events(15%) and RR reduction in 17 patients (11%) in 16 events (7%). Theclinical response after these CareAlert was: the change of medicaltherapy in 54 patients (36%), a non-programmed in-office visit in60 patients (40%) and hospitalization in 11 patients (7%).Conclusions: The strategy of patients remote management hasallowed us to optimize the Hearth Failure patient care by reducingconsumption of resources.

A REMOTE MONITORING EXPERIENCE WITH HEARTFAILURE PATIENTS IMPLANTED WITH ICD AND CRT-DDEVICES CO-MANAGED BY PHYSICIANS AND NURSESA. Locatelli1, V. GIUDICI1, P. Neri1, B. Casiraghi1, S. Gilardi2, L. Viscardi3,P. Rocca3, C. Malinverni3, M. Tomaselli1, A.M. Durante1, M.T. Villa3, M. Pisoni3

1Azienda Ospedaliera Bolognini - Department of Cardiology, Seriate, ITALY,2Medtronic - Italia, Sesto San Giovanni, ITALY, 3Azienda Ospedaliera Bolognini- Department of Cardiac Rehabilitation, Seriate, ITALY

We describe our experience of ICD and CRTD patients co-manage-ment using remote monitoring system with an organization thatinvolves both Heart Failure (HF) and Electrophysiology (EP) nurs-es and physicians. In February 2009 we started using the Medtronic CareLinkNetwork system to remotely manage pts implanted with a deviceand we decided to rearrange our organization. Nurses from EPoutpatient department are in charge of 3 main tasks: to train ptsabout monitor use, to arrange transmissions schedule, to dailycheck possible CareAlert transmissions. Depending on the kind ofCareAlert, they involve in the transmission revision process the EPor the HF team. When necessary, pts are called by the appropriatephysician/nurse to assess symptoms, weight changes, blood pres-sure and drugs compliance. If necessary, drug therapy can bechanged or a new in-office visit can be scheduled.In two years 305 pts have been admitted to the HF department(77% Male, age 68.22±18.5, 22% NYHA III-IV, EF 35.72%). 81 pts(26.5%) were implanted with a device and 59 of them received aCareLink Monitor. After a mean follow-up of 9.5±5.8 months, wehave received 277 transmissions.48 of them (in 19 pts) were auto-matically sent due to Optivol Alert (possible fluid accumulation)and 5 (in 3 pts) due to a new onset of Atrial Fibrillation. RegardingOptivol transmissions, 45% were managed with a phone contactmade by the HF nurse. In the remaining cases the HF cardiologistwas involved. In 25% of the cases an in-office visit was scheduled.Ventricular arrhythmias was detected in 6 pts but no shocks weredelivered (7 episodes were resolved by a Burst) The introductionof a Remote Monitoring system offers the opportunity to adopt anew workflow that allows an effective and efficient collaborationbetween EP and HF department, which results in a better pts man-agement.

CLINICAL UTILITY OF REMOTE MONITORING BYIMPLANTABLE CARDIOVERTER DEFIBRILLATOR IN AGROUP OF PATIENTS WITH CHRONIC HEART FAILUREV.E. SANTOBUONO, M. Iacoviello, F. Nacci, M. Anaclerio, G. LuzzI,A. Puzzovivo, F. Monitillo, F. Quadrini, R. Memeo, S. Favale

Cardiology Unit, University of Bari, Bari, ITALY

Purpose: To evaluate, in a population of chronic heart failure(CHF) pts, the usefulness of the information obtained byimplantable cardioverter defibrillators (ICD) remote monitoring(RM).Materials and Methods: We enrolled 55 pts with ICD (87% male,age 67±13 years, 53% with ischemic etiology, NYHA class 2.7±0.4,left ventricular ejection fraction 32±9%, 28 of them with biventricu-lar pacing). In 28 RM was obtained by Medtronic CarelinkNetwork, in 11 by Boston Scientific Latitude, in 9 by BiotronikIM

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Home Monitoring and in 7 by St. Jude Medical Merlin.net PCN.Pts were selected on the basis of the presence in the six monthsbefore the enrollment of at least an episode of acute decompensa-ted HF and/or of atrial fibrillation (AF) and/or sustained ventri-cular tachycardia or fibrillation. Received alarm, every pt was con-tacted by telephone and, if necessary, an ambulatory evaluationwas scheduled within 48 hours.Results: During follow-up (8±3 months) we received 84 alarmsfrom 22 pts (40%) and performed 34 ambulatory evaluations thatallowed to optimize medical therapy in 14 pts (25%) and to pre-vent the occurrence of major events in 6 (11%). In fact, in 2 earlyrecognition of deterioration of right ventricular catheter was diag-nosed before inappropriate DC shocks. In 2 an AF> 6 hours wasobserved for the first time and oral anticoagulation therapy wasstarted. In one pt a low percentage of biventricular pacing report-ed (<90%) was corrected by electronic programming of device(EPD) with improvement of functional status (NYHA class from IIIto II). In 1 the recurrence of inappropriate DC shock was obtainedby optimization of therapy and EPD.Conclusions: This study shows that RM is an instrument able toprovide useful information for better management of CHF pts,thus strengthening the hypothesis that the routine use of RM couldallow an optimization of clinical-instrumental follow-up.

LATITUDE PATIENT MANAGEMENT SYSTEM: A USEFULTOOL IN THE MANAGEMENT OF HEART FAILUREPATIENTS WITH CRT-D DEVICESL. ZUCCARO, M. Sforza, A. Martino, E. De Ruvo, L. De Luca, L. Sciarra,S. Matera, M. Minati, M. Rebecchi, A. Fagagnini, E. Lioy, L. Calo’

Department of Cardiology, Casilino Hospital, Rome, ITALY

Purpose: The Latitude system allows remote implantable devicefollow-up. This is the first heart failure (HF) management tool touse wireless telemetry present in cardiac resynchronization thera-py defibrillator (CRT-D) device that is linked to remotely collectweight measures, permitting a single transmission reportingdevice data.Our aim was to assess whether Latitude system inCRT-D device recipient could present more advantages than stan-dard method in HF management. Methods: We analysed 22 patients with CRT-D devices supportedby the Latitude System.The mean follow-up period was 180±24days.The majority of patients were classified as NYHA Class III.Clinical data were transmitted via the Latitude communicator.More specifically a weight change of >2 kg in two days was consid-ered an indication for close review of the patient’s management.Results: 22 patients performed 60 remote-follow-up transmis-sions. During the follow-up patients performed about 1500 trans-mission with weight scale monitor. The majority of clinical eventswere related to tachyarrhythmias episodes (38%).Of these events,in two cases (22%) in-hospital visits were requested while in 7(82%) no action was needed and no additional in-clinic visits werescheduled. 4 patients (57%) with weight gain alert reported symp-toms with initial clinical decompensation and were managedremotely adjusting diuretics therapy without scheduling addition-al visits. In three of these patients, the weight gain alert was asso-ciated with reduced daily activity and, in one of these, also with apercentage of biventricular pacing below programmed value.During the follow-up, one patient died because of refractory HFand two patients had to be hospitalized because of acute HF.Conclusions: Our experience provide preliminary clinical dataremotely collected with Latitude System. Although our findingssuggest that Latitude System could improve the clinical manage-ment of HF in CRT-D patients, randomized controlled trials arewarranted to evaluate the clinical impact of Latitude System whencompared with standard method.

REMOTE CONTROL OF PM PATIENT FROM START-UP TOCLINICAL PRACTICE: A SINGLE CENTER EXPERIENCES. BACCILLIERI1, P. Turrini1, A. Cattin1, M. Martignon1, D. Marangon1,D. Canovese1, M. Bernardi1, A. Libralon1, A. Menegazzo1, E. Caliari2,J. Comisso2, R. Verlato1

1Interventional Electrophysiology Unit, Cardiovascular Department, ASL 15 Veneto,Camposampiero (PD), ITALY, 2Medtronic Engineer, ITALY

Background: The rate of implantation of cardiac device is expec-ted to rise sharply in Europe due to ageing of population and theassociated increase in age-related health conditions. Monitoringpatients and devices is essential to detect any clinical or device-related problems. Among consequences we can find an increase ofwork load in management of in-clinic follow-up of these patients.Remote monitoring offers the possibility to monitor patient’s devi-ces directly at their home.Aim: To describe our starting -up experience of PM remote moni-toring and to evaluate the feasibility in the clinical practice.Methods: We decided to propose remote monitoring to all ourpatients wearing a compatible PM in order to avoid in clinicaldevice check FU. According ERHA and AIAC recommendation,we scheduled for every patient 1 and 3 month post implantation inclinic FU to verify the condition of pt and to optimize the PM para-meters. 6 nurses and 3 physicians were involved in the starting upof this virtual fu clinic. In particular, first we contacted patientsand or caregivers with a short phone interview to asses their inte-rest in remote monitoring and then we organized patient/caregi-ver in hospital meeting. In this meeting we grouped 10 patientsand we explained them what the remote control is from a clinicalpoint of view, how and when to use the monitor. Moreover we col-lected the written signature of informed and privacy consensus.We scheduled the remote fu every 6 months.Results: We included all patients previously implanted with acompatible PM, and we proposed the remote control to newlyimplanted PM reaching the number of 128 patients. In a mediumFU of 6 months we received 76 transmissions. 33 transmissionswere without events, while 43 reported some conditions revealedby PM diagnostic. In particular 19 pts reported atrial arrhythmicepisode, 21 pt non sustained ventricular tachycardia and 3 ptsobservation about % of VP pacing. Only 3 revisions of remote tran-smission were followed by a phone contact of pts. In two cases, weasked pts to modify his therapeutic plan dismissing amiodaroneand increasing the BB after a diagnosis of permanent atrial fibrilla-tion. The other case is related to Biventricular PM with a ventricu-lar pacing percentage < 90% due to an atypical atrial flutter. Thepatient was called to schedule an AV node ablation. In this way 76follow- up device checks were substituted by remote FU.Conclusions: In our first experience the remote management ofPM patients seems to be reliable from a technical and organizatio-nal point of view. More pts and a larger FU should be evaluated toasses the real value of remote monitoring in clinical practice.

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VENTRICULAR TACHYCARDIA ABLATION TARGETINGENDOCARDIAL AND EPICARDIAL LATE POTENTIALSP. VERGARA, N. Trevisi, F. Baratto, F. Petracca, A. Ricco, G. Maccabelli,P. Della Bella

San Raffaele Hospital - Arrhythmology Department, Milan, ITALY

Aim: We sought to describe efficacy of radiofrequency VT ablationtargeting complete LP activity abolition.Methods and Results: Thirty-five patients (pts) (32 male; age65.5±13.9 years) with recurrent VTs and presence of LPs at elec-troanatomic mapping (EAM) were included in the study; 23 ptshad coronary artery disease (CAD), 9 pts had idiopathic dilatedcardiomyopathy (IDCM) and 3 pts had arrhythmogenic right ven-tricular cardiomyopathy (ARVC). After substrate mapping and programmed ventricular stimula-tion, radiofrequency ablation was performed with the endpoint ofall LP activity abolition. Complete abolition of LPs was possible in 30/35 pts; LP were notabolished in 2 pts despite of ongoing ablation, in 1 patient becauseof localization near an apical thrombus and in 2 pts because of pos-sible phrenic nerve injury. At the end of procedure, prevention of inducibility of any VT wasachieved in 20/24 pts with previously induced VT at baseline; VTwas still inducible in 2 of the 5 pts (40%) with incomplete LP abo-lition and in 2 of the 30 pts (8%) with complete LP abolition(p=n.s.).After a follow-up of 6.7±2.3 months (range 3-11 months), 6 pts(20%) had a VT recurrence and one of them died after surgical VTablation; 3 (50%) pts with clinical recurrence had an incompleteabolition of LPs (positive predictive value 60%, negative predictivevalue 90%, sensibility 50%, specificity 93.1% p p=0.026); VT wasnon inducible after RF ablation in 3 of the 5 pts (60%) with VTrecurrence (PPV 50%, NPV 85%, sensibility 40%, specificity 89.5%,p=n.s.).Conclusions: LP abolition is an effective endpoint of RF VT abla-tion and its prognostic value compares favourably with pro-grammed electrical stimulation.

VT ABLATION: EVOLUTION OF PATIENTS, SUBSTRATEASSOCIATED TO VT AND PROCEDURES IN THE LASTYEARSC. LAVALLE, S. Ficili, M. Russo, M. Galeazzi, T. Coppi, G. Chiarelli, F. Venditti,C. Pandozi, M. Santini

Department of Cardiovasular Disease, San Filippo Neri Hospital, Rome, ITALY

Background: The characteristics of patients with recurrent ventri-cular tachycardia (VT) submitted to RF ablation have changedover time as well as the modality and technical aspects of the abla-tion procedures. We studied the substrate, modality of ablationprocedure and outcome of all the patients (pts) referred for VT orBEV ablation in our Institution during the last 3 years (2008-2010).Methods: Pts population was composed by 145 patients. Of these33% had no structural heart disease (SHD), 61% had ischemicheart disease (ICMP) and 39% had non ischemic heart disease(NIHD). The mapping methods utilized in this patient populationwere the following: activation mapping and pace-mapping in noSHD pts, entrainment mapping, substrate mapping and pace map-ping in ICMP and NICMP pts. Epicardial mapping was performedvia the venous system or via the sub-xifoid approach in 10 (7%)pts. Results: the mean number of inducible morphologies of VT orBEV was 3.2±2.0 in ICMP pts, 2.9±1.8 in NICMP pts and 1.3±0.4 inno SHD pts; only mappable VT were present in 82% of patientswith no SHD and in 32% and 36% of patients with ICMP andNICMP, respectively. The ablation procedure abolished inducibleVT or BEVs in 78% of pts. Abolition of all inducible VT or BEVswas achieved in 85% of pts with no SHD and in 74% and in 66% of

pts with ICMP and NICMP, respectively. The recurrence rate in ptswith an acutely successful procedure during a mean follow-up of13 months was 15% in no SHD pts and 30% and 35% in ICMP andNICMP pts.Conclusions: Clinical and electrophysiological features of pts withVT or BEV referred for ablation of their ventricular arrhythmiashave changed in the last years. Induction of multiple VT morpho-logies as well as the impossibility to map the induced VT are nomore contraindication to VT ablation. The acute success rate ishigh although the long-term success of VT ablation is lower whenprogression of the underlying heart disease occur. The use of epi-cardial mapping is spreading and could increase the success rateof VT ablation, particularly in pts with no SHD and NICMP.

SUBSTRATE MAPPING AND ABLATION OF VENTRICULARTACHYCARDIA IN RECIPIENTS OF IMPLANTABLEDEFIBRILLATOR IN PRIMARY PREVENTIONB. PEZZULICH, R. Maggio, F. Gugliotta

Maria Pia Hospital -GVM Care&Research, Turin, ITALY

Aim: of the study was to assess efficacy and safety of substratemapping in pts with an ICD implanted in primary prevention andmore than one episode of ventriculat tachycardia/three months.21 consecutive pts were enrolled from 4/2009 to 5/2010. Clinicalcharacteristics are as follow:Clinical characteristicsMale 18/21Age 71 5 yrsMean LVEF 21 5Etiology Coronary artery disease 12/21Cardiomyopathy 8/21Other 1/21Mean VT episodes 5 3

With programmed ventricular stimulation a mean of 3,2 differentmorphologies were induced. Anatomical and voltage map of leftventricle was created with the use of Navx system, and scar tissuewas identified (voltage <0,5 mV). Pace mapping was performedalong the border zone and linear lesions were created with an irri-gated tip catheter along the scar to join vital tissue and/or anatom-ical barriers (i.e. mitral anulus), when possible. End points were a)local potential < 75% after RF b) non inducibility of VT.Results: A total of 58 VTs were successfully mapped and ablated(89%). Mean procedural time was 108 25 min, mean radioscopytime was 5,2 4 min, mean erogation time was 210 59 sec. (range160- 720 sec). No complication was observed. During the follow up (8 6 months) three pts died from congestiveheart failure, one pts died from cancer. 3 pts suffered from VT, treat-ed with ATP, with cycle length different from the previous ones.Conclusions: Substrate mapping is an useful clinical tool to reducearrhytmic burden in ICD pts.

ROLE OF INTRACARDIAC ECHOCARDIOGRAPHY ASELECTROANATOMICAL MAPPING INTEGRATION FORVENTRICULAR TACHYCARDIA ABLATIONE. SOLDATI, A. Di Cori, G. Zucchelli, L. Segreti, L. Paperini, S. Viani,R. De Lucia, L. Misuraca, M.G. Bongiorni

Cardiovascular Disease Unit 2, University Hospital of Pisa, Pisa, ITALY

Background: Electroanatomical mapping ablation of ventriculartachycardia (VT) is time consuming requiring a point-by-pointreconstruction of virtual anatomy and substantial fluoroscopyexposure. Aim of the study was to evaluate whether two-dimen-sional intracardiac echocardiography (ICE) may be helpful asimaging integration tool. CA

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Materials and Methods: 13 consecutive patients (ICE Group, 10men, mean age 61±14 years, LV ejection fraction 47±9%) had abla-tion of nonidiopathic VT guided using a system integrating 3Dmapping and ICE, and were compared with 8 matched patientswho had ablation of nonidiopathic VT guided using a standard 3Delectro-anatomical mapping (No ICE Group, 4 men, mean age55±19 years, LV ejection fraction 46±9%). ICE probe with a locationsensor tracked by the mapping system was positioned in the rightheart. Endocardial contours traced on gated images of the RV andLV were used to generate a registered 3D anatomy. Results: 3D echo maps were created in 15±3 min, before enteringRV or LV. All patients underwent a successful ablation procedure.Procedural time (197±43 vs 232±39 minutes) and fluoroscopy time(20±19 vs 28±12 minutes) were compared between the 2 groups.No ICE related complication was observed. One major complica-tion (cardiac tamponade requiring pericardiocentesis) wasobserved in the non ICE group. Conclusions: Combined ICE imaging is safe and feasible during3D anatomical VT ablation, allowing easier navigation and reduc-ing fluoroscopy and procedural time.

FLUOROSCOPY-FREE RIGHT VENTRICULAR MAPPINGAND ABLATION OF PREMATURE VENTRICULARCONTRACTIONS ORIGINATING FROM THE RIGHTVENTRICULAR OUTFLOW TRACT: A PILOT STUDYE. De Ruvo1, S. Dottori2, A. FAGAGNINI1, L. Sciarra1, L. De Luca1,L.M. Zuccaro1, M. Rebecchi1, R.V. Iulianella1, F. Sebastiani1, A.M. Martino1,M. Minati1, S. Matera1, F. Guarracini1, G. Pendenza1, M. Porfirio1,G. Navone1, F. Nuccio1, A. Sette1, E. Lioy1, L. Calo’1

1UOC Cardiologia, Policlinico Casilino ASL RM/B, Rome, ITALY,2Biosense Webster ITALY, Johnson & Johnson Medical, Milan, ITALY

Purpose: Mapping of right ventricle (RV) and radiofrequency (RF)ablation of premature ventricular contractions (PVCs) originatingfrom the right ventricular outflow tract (RVOT) may be associatedwith prolonged fluoroscopy times. The use of 3D-systems allowsprecise catheters visualization and volumetric reconstruction ofthe cardiac chambers. The aim of this pilot study was to assess thefeasibility of fluoroscopy elimination by using a single catheterapproach with Carto3 system.Materials and Methods: This study involved 8 consecutivepatients referred to our lab for right ventricular EP procedure: 3Brugada Syndrome patients (Group 1, 2 males, mean age 42±14years); 5 patients with frequent PVC (Group 2, 1 males, mean age47±19 years). All patients underwent to right ventricular/RVOTelectroanatomical substrate /activation mapping using Carto3system and a single catheter approach. Fast anatomical reconstruc-tion of right atrium was used both to define anatomical landmarksand to guide the movement of the mapping catheter through thetricuspid valve inside the RV. Results: In Group 1 and Group 2 patients, 165±8 and 20±10 elec-troanatomical points were collected. High density substrate map-ping of the RV in Group 1 patients did not reveal area of low volt-age. Seven PVC morphologies were studied in Group 2 patients, 3found in the anteroseptal and 4 in posteroseptal region of theRVOT. RF application was successfully without complication in allpatients. Total procedural and RV mapping time was 90±30 minand 34±8 min for Group 1. Total procedural and RVOT mappingtime was 85±48 min and 13±8 min sec for Group 2. Total fluoroscopy time for Group 1 and Group 2 patients was 0 secand 15±22 sec, respectively. The procedure was performed withoutfluoroscopy in the last 6 patients.Conclusions: Fluoroscopy free RV mapping and ablation of fre-quent PVCs is feasible and safe, and does not significantly prolongprocedural time.

VENTRICULAR TACHYCARDIA UNIT: AN EFFECTIVEMODEL FOR ADVANCED VT TREATMENTF. BARATTO, F. Petracca, G. Maccabelli, N. Trevisi, C. Bisceglia, M. Cireddu,P. Della Bella

Ospedale San Raffaele, Milan, ITALY

Introduction: Catheter Ablation (CA) is a curative strategy forpatients (pts) with recurrent Ventricular Tachycardia (VT). Patientswith structural heart disease and recurrent VT may benefit of aspecific treatment and care Unit.Methods: Since January 2007, VT pts were referred to the VT Unit(VTU) at our institute. Based on clinical and functional character-istics and co-morbidities, high risk pts were sent to emergencyablation. In 3 pts ablation was performed with ExtraCorporealMembrane Oxygenation support. Surgical Ablation was reservedto pts with indication to cardiac surgery or after Endo-epicardialCA failure. Acute efficacy was assessed by programmed ventricu-lar stimulation. Successfully ablated pts without VT recurrencewere discharged without Anti-Arrhythmic Drugs. Pts underwentfollow up (FU) visits, ICD interrogations and phone calls inter-views at 4 months intervals. Results: Within 45 months, 374 / 430 pts with structural heart dis-ease (32% with EF< = 30%), consecutively admitted to VTU,underwent VT ablation [endocardial in 257 pts (69%), epicardial,in 94 (22%), surgical in 23 (9%)]. Induction of VT after CA was pre-vented in 292 (78%) pts; residual in 61 (16%) and not tested in 21(6%). Thirty four patients (9%) showed acute VT recurrence with-in one month after ablation and were further treated by a secondablation procedure. Seven pts died acutely due to heart failure. At15±10 months of FU 60 pts (16%) presented VT recurrence. At uni-variate analysis ablation outcome was the only predictor of longterm VT recurrence (p=0.043). Thirty two pts died during followup: 9 pts due to cardiac arrest, 18 to heart failure, 5 to extra-cardiaccause. Survival was strongly associated to LVEF>30% (p <0.001). Conclusions: The VTU meets the nationwide VT pts needs andallows satisfactory long term outcome, providing a specific treat-ment of VT, improving pts outcome and survival.

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INTEGRATED MANAGEMENT OF A CARDIOLOGYOUTPATIENT CLINIC THROUGH THE USE OF REMOTEMONITORING SYSTEMS OF THE PATIENT WITH THEIMPLANTED DEVICE: THE SOCIAL IMPACTL.M. Zuccaro, M. SFORZA, L. La Rocca, L. San Giovanni, F. Stirpe,S. Matera, L. De Luca, L. Sciarpa, E. De Ruvo, M. Rebecchi, L. Calò

Casilino Hospital, Rome, ITALY

Introduction: The increase in use of implantable devices creates asignificant growth and consequent demand for resources to mana-ge relative follow-up. It will generate a greater work for cardiolo-gy outpatient. The remote monitoring system will be an innovati-ve tool to improve the clinical management of patients by optimi-zing the use of available resources.Methods: Patients with single chamber ICDs, dual chamber andbiventricular were equipped with remote control system, able totransmitt data from the implanted device to a Web site with secu-re access for the phisician. Data were sent according to a program-mable session or in case of alert. At first outpatient visit, an anony-mous questionnaire was submitted to patients to evaluate thesocial impact of the new monitoring system.Results: In an observation period of 12 months (May ‘09 - May‘10), 111 patients were included in the project. The hospital wasreached by its own resources in 85.5% of patients (95 pts). 14.5% ofpatients (15 pts) paid bus, or taxi, or train.The median time neededto reach the hospital is 30 minutes (IIQ 20 - 60), the average distan-ce is 43.17 Km. The average waiting time in hospital before a visitwas 20 minutes (IIQ10 - 30). Patients referred to the cardiologist tocontrol some parameters of the device was absent from work in13% of cases (14 pts), while the remaining 87% was retired or hou-sewives. 76% of patients (84 pt) needs to be accompanied to thehospital, and coaching in 34% of cases are absent from work. Incurrent practice, the standard controls required 451 access ambu-latory (with or without problems), while only 135 accesses for thepatients controlled by remote monitoring were recorded.Conclusions: Remote management strategy for patient with ICD,will limit resources consumption for all patients and clinics, provi-ding an high social impact service.

IMPACT OF REMOTE MONITORING SYSTEM OFIMPLANTABLE CARDIOVERTER DEFIBRILLATORS ONQUALITY OF LIFEG. PANATTONI, M. Sgueglia, V. Schirripa, A. Politano, A. Giomi,L.P. Papavasileiou, L. Santini, G.B. Forleo, G. Magliano, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Introduction: Patients with implantable cardioverter defibrillators(ICDs) often experience psychological distress and poor quality oflife (QoL) due to fear of receiving shocks, fear of death, dependen-cy on a device and routine follow-up visits. Remote monitoringmay allow earlier detection of device malfunction or clinical prob-lems than during the scheduled routine follow-up visits, optimiz-ing patient safety.The aim of the study is to evaluate if remote monitoring mayimprove QoL of patients with ICDs. Materials and Methods: We investigated 65 consecutive patientswho received ICDs between December 2005 and August 2010 atour Institution. Forty-one (36 males, mean age 67.0±6.6 years) sub-jects with remote-monitoring system (Group 1) and 24 (20 males,age 63.4±11.2 years) without remote-monitoring system (Group 2)were interviewed after ICD implantation using the Short-FormHealth Survey (SF-36). The SF36 includes eight independent scales.Results: There were no statistically significant differences betweengroup 1 and group 2 for physical functioning (49,47±27,43 vs46,33±27,97 p=ns), for role limitations due to physical health(26,32±34,83 vs 28,33±38,56 p=ns), for role limitations due to emo-tional problems (24,56±48,89 vs 24,44±39,76 p=ns), forenergy/fatigue (45,53±20,20 vs 56,33±25,53 p=ns), for emotional

well-being (55,58±16,43 vs 64,53±19,83 p=ns), for social function-ing (56,58±29,18 vs 70,00±25,36 p=ns), for bodily pain (70,13±24,43vs 65,17±27,45 p=ns), for general health perceptions (49,47±17,47vs 51,00±11,51 p=ns)Conclusion: We can conclude that from a patient’s perspective,QoL is not influenced by the use of remote monitoring system.However, remote monitoring offers a safe, time-saving and cost-effective solution for ICDs follow-up and the application in theclinical practice could change the management of patients withICDs.

REMOTE MONITORING OF ICDS AND CARDIAC CRT-DDEVICES: LATITUDE SYSTEM EVALUATIONL. ZUCCARO, M. Sforza, L. De Luca, L. Sciarra, M. Rebecchi, E. De Ruvo,F. Guarracini, A. Martino, F. Stirpe, A. Fagagnini, E. Lioy, L. Calo’

Casilino Hospital, Rome, ITALY

Purpose: Latitude system allows remote implantable device fol-low-up. This is the first device remote monitoring that is linked toremotely collect blood pressure and weight measures. We assessthe ease of use of the system, the clinical practicability and satis-faction of patients and clinicians. Methods: We analysed 40 patients with implantable cardioverterdefibrillators (ICDs) and biventricular defibrillators (CRT-D)devices (49% and 51% respectively) supported by the LatitudeSystem remote-monitoring service.Thirty patients received homemonitoring equipment including a weight scale and blood pres-sure monitor. The mean follow-up period was 180±30 days.Thepatients were visited in hospital every 3 months. Device data wereprospectively evaluated. The ease of use with Latitude systemwere assessed by a questionnaires completed by the patients andhospital staff. Results: 40 patients performed 120 remote-follow-up transmis-sions.The overwhelming majority of events were prompted byweight gain over 2 days (32%) and tachyarrhythmias episode(24%). After remote data review, in thirteen cases drug therapywas adjusted by phone and in four cases no action was needed. Infour patients an in-hospital extra visit was scheduled. In thirteencases the patient could be managed remotely avoiding a visit tothe hospital. In the overall analysis, events related to abnormaldevice status and to system configuration were low (12%). Thedata available for remote review were judged adequate to providealmost the same standard of care as that offered in traditional in-clinic visit. Regard ease of use of the system, the majority of thepatients found the clarity of the written instructions very clear.Physicians found the data comparable to traditional device inter-rogation in the majority of the cases.Conclusions: Our experience provide preliminary data related toICD and CRT-D remotely monitored with Latitude System. Thesystem is well accepted and offers a feasible solution to ICD andCRT-D in office follow-up.

HOMEGUIDE REGISTRY: RATIONALE, OBJECTIVES,DESIGN, TIME SCHEDULINGR.P. RICCI1, L. Morichelli1, D. Vaccari2, G. Zanotto3, M. Brieda4, A Curnis5,F. Di Pede6, F. Ammirati7, E. Marras8, D. Melissano9, A. Gargaro10,A. D’Onofrio11

1San Filippo Neri Hospital, Rome, ITALY, 2Civil Hospital, Montebelluna, ITALY,3Mater Salutis Hospital, Legnago, ITALY, 4Civil Hospital, Pordenone, ITALY,5Spedali Civili, Brescia, ITALY, 6Civil Hospital, Portogruaro, ITALY, 7G.B. GrassiHospital, Ostia, ITALY, 8Civil Hospital, Conegliano, ITALY, 9Ferrari Hospital,Casarano, ITALY, 10Biotronik Italia, ITALY, 11Monaldi Hospital, Naples,Vimodrone, ITALY

Background: Remote monitoring of patients with implantable car-diac devices potentially implies great benefits both for patients andfor health care providers. However, it requires important changesin ordinary patient management. Currently, a reference model forBE

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ambulatory organization implementing remote monitoring has notbeen defined yet. The ongoing HomeGuide Registry is an Italiansurvey in centres adopting a pre-defined organization model forimplementing a widely spread technology for remote monitoring(Biotronik Home Monitoring [HM]) in ordinary follow-up activi-ties. The aim of the Registry is to estimate the ambulatory manpow-er of this model and its clinical effectiveness in terms of sensitivity,positive predictive value and expected utility of all the clinical anddevice-related events occurring during follow-up.Methods and Results: The HomeGuide model for ambulatoryorganization consists of personnel with defined rules: initialpatient training, regular visits of HM website, resolving persistenttransmission interruptions, immediate submission of HM alerts orunclear data to the responsible physician(s) are among the maintasks of an operator (including an expert nurse or a physician).General supervision, recalling patients for unscheduled follow-ups, medical decisions lie with a responsible physician(s). All thepatients are monitored remotely with HM, with doubled intervalsfor scheduled in-hospital visits. Each centre received a specifictraining and custom software for electronic data capture, includ-ing automatic storage of HM session durations. Currently, 65 cen-tres are participating to the survey which has included 1063patients so far with a mean follow-up duration of 16 months.Enrolment will stop depending on the tolerance of the desired esti-mates, reasonably obtained with 1500 patients expected in June2011. First results available by the end 2011.Conclusions: HomeGuide Registry proposes a model to organizeambulatory for HM daily practice and will soon provide soundestimates of manpower and clinical efficiency for event detectionand management.

THE REMOTE CONTROL OF IMPLANTABLE DEVICES:ORGANIZATIONAL IMPACT AND RESOURCECONSUMPTION CARDIOLOGY OUTPATIENT CLINICSL. MORICHELLI, A. Porfili, L. Quarta, A. Sassi, N. Cadeddu, F. Saputo,C. Pignalberi, B. Magris, V. Altamura, S. Aquilani, R.P. Ricci, M. Santini

Department of Cardiology, San Filippo Neri Hospital, Rome, ITALY

Introduction: The increasing number of patients implanted withdefibrillator (ICD) and their relative follow up involves a greatcommitment to the organization for cardiology outpatient clinics.The remote monitoring system CareLink Network aims toimprove the clinical management of these patients and to optimizethe use of resources. Objective of this analysis is to evaluate theorganizational impact and resource consumption in a cardiologyoutpatient clinics.Materials and Methods: The patients received a six-items que-stionnaire, designed with the purpose to demonstrate that theremote control could be effective from an economical point ofview. The questionnaire, projected for self completion by respon-dents, was provided at the end of an office follow-up. The que-stionnaire was submitted to 163 patients (147 male, 71±12 years)implanted with ICD (38 biventricular devices) and followed by theCareLink NetworkÆ system. Sixty-one patients have a highereducation level and 127 patients are in retirement.Results: In a median follow-up of twenty months (25th-75th per-centile=13-26 months), 105 patients didn’t request any other kindof visits in addition to regular follow-up in-office or by CareLinksystem (1.8±3.7 visits per patients). In 20 cases, the patients declarethat the reason of the in-office visit was an optivol alert, in 11 casesan arrhythmias (three times due to shock), in 10 cases dyspnea, in10 cases device’s reprogramming, and finally 3 cases of hyperten-sion and of illness respectively.After the introduction of this new technology, the cardiology out-patient clinics staff has been reorganized according to the arisingneeds. 158 patients have appreciated the new organization anddeclared that no further changes in the organization are requested.

Conclusions: The strategy of patients remote management hasallowed us to optimize the patient care by reducing consumptionof resources.

FOLLOW-UP OF IMPLANTABLE DEVICES: NEWMANAGEMENT WITH REMOTE MONITORING SYSTEMR. Colaceci1, M. Bocchino1, M.G. Romano1, N. DANISI1, G. Pighini1,L. La Rocca2, F. Ammirati1

1Ospedale G.B. Grassi - Dipartimento Malattie Cardiache, Ostia (RM), ITALY,2Medtronic Italia S.p.a., Rome, ITALY

Introduction: The increasing number of patient implanted withdefibrillator and pacemaker and the consequent increase in num-ber of relative follow-up, is a growing resource consumption forambulatory of electrophysiology.To improving efficiency in the management of chronic disease andensure continuity of care, Medtronic offers the service MedtronicCareLink NetworkÆ.Materials and Methods All the patients implanted with Pacemakerand Defibrillator from April 2010 to July 2010 were provided withCareLink Monitor. All the transmission (scheduled and unsched-uled) were review by an expert technician and, in case of an rele-vant clinical event, the patient were contacted to obtain the mainclinical information related to medical therapy or symptoms.All relevant clinical transmissions were submitted to a physician:all the data about the review of transmission and medical deci-sions were recorder on designed forms of Medtronic ClinicalService Project.Results: 50 patients were included in the project. In a period of 4months, 32 Care Alert Optivol were detected in 25 patients.Symptoms were present in 15 events of 20 patients, atrial or ven-tricular arrhythmias in 13 episodes in 15 patients. FollowingOptivol alarm, the clinical response was the telephone change ofdrug therapy in 17 patients, hospitalization in 2 patients and therequest for examination in the hospital in 5 patients.Conclusion: In order to monitor the health of patients, improvingtheir quality of life and avoid unnecessary in office follow-up, theRemote control of the pacemakers and defibrillators will be effi-ciency tool, well integrated with the other patient managementsystem.

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CARTOSOUND UTILIZATION IN ABLATION PROCEDURES:TWO YEARS EXPERIENCE OF A SINGLE CENTREC. PRATOLA1, L. Pirani1, P. Artale1, C. Cavazza1, M. Bertini1, E. Baldo2,T. Toselli1, R. Ferrari1

1Institute of cardiology S.Anna University Hospital, Ferrara, ITALY, 2LagosantoCardiology, Ferrara, ITALY

Introduction: CartoSound consists in a 64 element linear phased-array intracardiac echocardiography probe with a CARTO naviga-tion sensor embedded close to the phased-array (SoundStarTM,Biosense-Webster). It allows surface reconstruction by interpola-tion of differences slices to obtain virtually every anatomical struc-ture. After anatomical reconstruction, mapping and ablation canbe performed almost without fluoroscopy.Methods: We report our experience with CartoSound technologyin 200 procedures performed between august 2008 e august 2010.130 were supraventricular arrhythmias (80% atrial fibrillation 20%atrial tachycardias, typical and atypical atrial flutter) and 70 wereventricular arrythmias (ischaemic and non ischaemic tachycardias,RVOT, LVOT). We evaluated procedural data as duration, fluoroscopy time, com-plications and results. Results: After a short learning curve, all the anatomical structureswere very easily reconstructed with CartoSound technology. Amean of 11 minutes (range 5-15 minutes) was spent to get the sli-ces necessary for interpolation. After reconstruction, mapping andablation phases were performed almost without fluoroscopy andthe overall Xrays exposure was 9 minutes (range 3- 13 minutes)considering also the time necessary for catheter positioning.The total procedural time was 120 minutes (range 70- 180 minu-tes). In two cases a pericardial effusion was promptly recognizedby echo scanning and procedure was stopped without necessity ofpericardial dreinage. In atrial fibrillation ablation all the procedural endpoints were rea-ched and after one year follow up, 80% of patients are free from cli-nical symptomatic relapses. In Ventricular tachycardia proceduresmore than 90% of ectopies or ventricular morphologies were suc-cessfully ablated. Conclusion: CartoSound technology allows easy and fast anato-mical recontruction of every cardiac structure with short procedu-ral and fluoroscopy times and with very good clinical results.Complications can be quickly recognized and treated.

“NEAR ZERO” FLUOROSCOPIC EXPOSURE INSUPRAVENTRICULAR ARRHYTHMIA ABLATION USINGTHE ENSITE NAVXTM MAPPING SYSTEMM. CASELLA1, A. Dello Russo1, G. Pelargonio2, A. Scarà2, S. Bartoletti1,M. Moltrasio1, P. Santangeli2, S. Riva1, P. Zecchi2, A. Natale3, C. Fiorentini4,C. Tondo1

1Centro Cardiologico Monzino IRCCS, Cardiac Arrhythmia Research Centre,Milan, ITALY, 2Università Cattolica del Sacro Cuore, Institute of Cardiology,Rome, ITALY, 3Texas Cardiac Arrhythmia Institute, St David’s Medical Center,Austin, USA, 4University of Milan, Department of Cardiovascular Research,Milan, ITALY

Purpose: In patients undergoing radiofrequency catheter ablation(RFCA) procedures, radiation exposure carries a small but measu-rable risk of malignancy and germinal cell DNA damage. A fewstudies in children already showed the feasibility of supraventri-cular arrhythmia ablation using a three-dimensional mappingsystem as the primary guide for catheter positioning. This studyaims to evaluate the feasibility and safety of RFCA of supraventri-cular arrhythmias in young and middle-aged patients, guided bya 3D mapping system, using ”near zero” fluoroscopic exposure.

Methods: Forty-seven patients (mean age 33 years, range 14-49)with supraventricular tachycardia (22 with AVNRT, 16 with Wolff-Parkinson-White syndrome, 6 with typical atrial flutter and 3 withright-sided atrial tachycardia) underwent RFCA using the EnSiteNavXô system as the primary guide for catheter positioning, withfluoroscopy functioning as a critical adjunct. In all patients a trans-femoral approach was employed; a trans-jugular approach couldalso be used in selected cases depending on operator preferenceand procedure type.Results: RFCA was successful in all patients, with no major com-plication. Accessory pathway ablation was performed on the rightside in 11 patients (6 postero-septal sites, 2 lateral sites, and oneeach of postero-lateral, mid-septal and antero-septal sites) and onthe left side through an arterial retrograde approach in 5 patients(4 lateral sites and 1 postero-septal site). Mean procedural timewas 116±37 minutes. Mean mapping time was 18±8 minutes. Meanradiofrequency time was 544±454 seconds. In 35 patients fluoro-scopy was not used at all; in the remaining 12 patients, the meanfluoroscopy time was 144±123 s (range 12-380 s).Conclusions: Our study showed in a small number of patients thatEnSite NavXô guidance can be used safely and effectively as theprimary catheter visualization tool during RFCA of supraventricu-lar arrhythmias. This effectively eliminates radiation-related risksfor both patients and staff.

A NEW 3D MAPPING SYSTEM FOR CATHETERABLATION OF VENTRICULAR ARRHYTHMIASL. DE LUCA1, L. Sciarra1, E. De Ruvo1, P. Pitrone2, S. Dottori2, M. Rebecchi1,L. Zuccaro1, C. Lanzillo1, A. Fagagnini1, F. Guarracini1, F. Pigozzi3, F.Quaranta3, E. Lioy1, L. CalÚ1

1Department of Cardiology, Policlinico Casilino, Rome, ITALY, 2BiosenseWebster, Johnson & Johnson Medical, Milan, ITALY, 3Università degli StudiForo Italico, Rome, ITALY

Introduction: Three-dimensional (3D) reconstruction of heartchambers is critical for radiofrequency catheter ablation (RFCA) ofcomplex arrhythmias, such as ventricular tachycardias (VTs). Thenew Carto3 mapping system allows a new volumetric 3D recon-struction of the cardiac chambers: the fast anatomical mapping(FAM). The FAM anatomical shell of right ventricle (RV) and leftventricle (LV) could guide electroanatomical mapping (EAM)during VTs procedures.Aim: The aim of the study was to test the utility of FAM in RFCAof VTs.Methods: Twenty patients (63±16 mean age, 16 males) were refer-red to our lab for RFCA of VTs with ECG morphology suggestinga ventricular outflow tract origin. During FAM, volume data wererecorded continuously based on the position of the location sensorembedded in the mapping catheter. FAM (resolution 14) and EAM,both in a stable mode, were performed to guide RFCA. Results: In 13 patients the origin of the tachycardia was in the RVoutflow tract (3 anteroseptal, 7 posteroseptal, 2 anterolateral, 1posterolateral), in 7 patients in the LV outflow tract (4 anterosep-tal, 1 posteroseptal, 2 anterolateral). A total of 30 maps (20 RV)were obtained using FAM and EAM (mean points number 60±45for RV, 61±50 for LV). Mean procedure and fluoroscopy time were96±23 and 28±12 min, respectively. The mean anatomical and acti-vation mapping time was 16±5. Acute success of target arrhythmiaRFCA was 100%.Conclusion: The new Carto3 FAM provides a simple and fast real-time cardiac reconstruction of ventriclular anatomy. Carto3 is auseful tool to guide RFCA of complex ventricular arrhythmiaswith a high success rate.

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FLUOROSCOPIC TIME REDUCTION IN CATHETERABLATION FOR SIMPLE SVT COMPARING CARTO-XPAND CARTO3 NAVIGATION SYSTEMSF. Solimene, C. MARRAZZO, G. Donnici, G. Shopova, A. Natalizia, P.Pitrone

Electrophysiology Unit, Cardiology Department, Clinica Montevergine,Mercogliano (AV), ITALY

Purpose: Non fluoroscopic intracardiac navigation systems havereduced the dose of radiation in most ablation procedures. Theaim of this study is to evaluate the fluoroscopic time reduction incatheter ablation for simple SVT comparing CartoXP and Carto3electro-anatomical mapping systems. The new system Carto3 hasadditional features as the stable mode catheter visualization andACL-advanced catheter location displaying all catheters with highaccuracy. We also evaluated the procedure and ablation time, thesuccess and complication rate. We used the navigation systems asa guidance method in the management of all catheters, and todisplay landmarks like HBE and CS as anatomical references. Materials and Methods: We retrospectively included 50 patientsin Group A using CartoXP for the procedures and 50 patients inGroup B using Carto3. After diagnostic catheter insertion the EPstudy was performed. The total time of the procedure was measu-red as the sum of the diagnostic procedure time and the ablationtime. Results: The fluoroscopy was rarely used during procedures andthanks to the new navigation system Carto3 we achieved a fluoro-scopy time reduction in comparison to CartoXP. For AVNRT weobtained a 35% fluoroscopic time reduction from 4,6±3,8min usingCarto XP to 3,0±2,1min using Carto3, for FLUTTER 29% reductionfrom 6,0±4,3min to 4,2±2,8min and for WPW 57% reduction from11,9±6,6min to 5,0±3,9min. There was no significant difference inthe total time of RF applications. The procedure time also decrea-sed, for AVNRT we obtained a 31% procedure time reduction from58,8±19,0min to 40,7±3,0min, for FLUTTER 18% reduction from69,2±6,0min to 57,0±4,2min, and for WPW 1% reduction from75,4±11,9 to 75,0±5,0min. The success rate was 99% with no com-plications.Conclusion: The principal finding of this study is that catheterablation for simple SVT guided by navigation system is safe andeffective and that the navigated approach using Carto3 system redu-ces fluoroscopy and procedure time in comparison to Carto-XP.

DETERMINATION OF OCCURRENCE DEPTH OFAN ECTOPIC SOURCE IN CASE OF VENTRICULAREXTRASYSTOLE BASED ON NONINVASIVEENDOCARDIAL AND EPICARDIAL MAPPINGA. SH. Revishvili, V.V. KALININ, O.S. Lyadzhina, G.YU. Simonyan,O.V. Sopov, E.A. Fetisova

Bakulev Cardiovascular Surgery Research Center, Moscow, RUSSIA

Methods of cardiac electrophysiological study that are based oninverse electrocardiography problem solution in terms of poten-tials are of a great value in the diagnosis of cardiac arrhythmias.Two such methods are used in today’s clinical practice: no-contactendocardial mapping (Ensite) based on recordings of electrogramsat the surface of a bag catheter introduced into the cardiac cham-ber and non-invasive epicardial mapping based on surface ECGmapping (BSM). However, BSM findings may enable reconstruc-tion of both epicardial and endocardial electrograms.Research objective To study the possibility of determining theoccurrence depth of an ectopic source based on the findings ofnoninvasive endo-epicardial mapping.Materials and Methods: 23 patients with frequent noncoronaryventricular premature ventricular contactions (PVC) were exami-ned. All patients underwent BSM using a 240-lead system and car-diac and thoracic computer tomography. An extrasystolic ventri-

cular complex without P waves was selected and epicardial andendocardial electrograms were restored. The depth of an ectopicsource was determined by using the several parameters: thicknessof the cardiac chamber wall, myocardial excitation propagationspeed (we adopted v equal to 0.75 m/s), and the time of endocar-dial and epicardial activations.Results: The ectopic source was determined in the right ventricleoutflow tract for 12 patients, in 3 patients it was discovered on theright side of the interventricular septum, in 9 patients near thesinuses of Valsalva and in 3 patients near free walls of the right andleft ventricle. The subepicardial position was determined in 6 cases(PVC generating from free walls of the right and left ventricle, left-side and noncoronary sinus of Valsalva). In other instances, suben-docardial position was observed. Localization diagnosis findingsmatched efficient catheter ablation findings to a precision of5.2±2.1 mm.Conclusion: The possibility to determine the occurrence depth ofan ectopic source was demonstrated in patients with noncoronaryventricular extrasystole based on noninvasive endo-epicardialmapping.

KOCH TRIANGLE ACTIVATION IN PATIENTS WITHAND WITHOUT AVNRTM. GALEAZZI, S. Ficili, M. Russo, C. Lavalle, S. Dottori, B. Verbo, T. Coppi,G. Chiarelli, F. Venditti, A. Pandozi, C. Pandozi, M. Santini

Dipartimento Cardiovascolare, Ospedale San Filippo Neri, Rome, ITALY

Background: The presence of conduction block at the level of theKoch’s triangle (KT). Purpose: We investigated the propagation ofthe sinus impulse into the KT in patients with and without atrio-ventricular nodal tachycardia (AVNRT).Methods: 32 patients (16 AVNRT; 16 NON-AVNRT) underwent asinus-rhythm electroanatomic mapping of the right atrium (RA).Conduction velocities (CV) in the RA and in the KT were evalua-ted quantitatively on activation maps and qualitatively on isochro-nal/propagation maps. Results: A mean of 149±44 points were sampled in the RA while amean of 79±21 points were collected inside the KT. A propagationblock at the level of CT was not found in any patient, while a slowconduction inside the KT was found in all (Mean CV: 126.5 [89.1-170] cm/s outside the KT vs 60.0 [40.9-90] cm/s inside the KT,p<0.001). Propagation and conduction velocities inside KT werenot different between patients with and without AVNRT.Conclusion: No conduction block is present inside the KT inpatients with and without AVNRT. Slowing of conduction is pre-sent during the propagation of the sinus impulse inside the KT. Nodifference was found between patients with and without AVNRT.

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FREE PAPERSFriday, December 3

FIVE YEARS AFTER ABLATION WITH CRYOBALLOON;WHO IS THE BEST PATIENTA. BERKOWITSCH, T. Neumann, M. Kuniss, S. Zaltsberg, D. Pajietnew,T. Eckhard, H.F. Pitschner

Kerckhoff Heart Center, Bad Nauheim, GERMANY

The use of cryo-balloon ablation became more popular in the lasttime. However, there are controversial data on efficiency of thecryo-balloon ablation. Aim of the study was to identify cohort ofpatients in whom cryoballoon-ablation may be as effective as RFbased ablation. A total of 640 consecutive patients (440 male, age58 y, PAF=494, PersAF=146, CAD=62,Hypertension= 422, leftatrial size(LAS)=20.8 cm2, BSA=2.05) were included. PVI was per-formed in 423 patients with irrigated tip catheter (in 144 Lassocatheter and in 279 HD Mesh catheter were used for mapping),remaining 217 patients were treated with cryoballoon. We strati-fied patients according to AF burden (total time spend in AFwithin last 3 months prior ablation and normalized left atrial area(NLA=LAS/BSA)). After median follow up time of 45 months atotal of 348 (55%) of patients were free of AF recurrence. However,in patiwents with AF burden <500 hours/3 months and NLA<11.5success rate was distributed as follows:(RF-Lasso:58%; RF Mesh72%; Cryoballoon-74%; p>.30). In patients with PAF but AF bur-den >500 h, in patients with persistent AF and in patients withNLA>11.5 successrate in cryoablation groop was < 35%, whereas55% of those in RF Mesh group was free of recurrence. In 25/217(11%) patients treated with cryoballoon we observed pfre-nic nerve pulsy. Alone predictor for this complication was increasedleft atrial site (7% vs. 17%, p=.022; NLA</> 11.5,. respectively) We conclude that, Cryoballoon isolation of pulmonary veins iseffective option for invasive treatment of atrial fibrillation.However, the patients with high burden atrial fibrillation (paroxy-smal AF with time spent in AF > 500 h/ 3 months orpersistent/permanent AF) and critically enlarged left atrium(NLA>11.5) should not be considered for this therapy option.

CRYOABLATION OF PAROXYSMAL ATRIAL FIBRILLATIONS. FICILI, C. Lavalle, M. Galeazzi, M. Russo, A. Pandozi, G. Chiarelli, T. Coppi,C. Pandozi, M. Santini

Cardiovascular Department San Filippo Neri Hospital, Rome, ITALY

Catheter ablation of AF has been established as an important the-rapeutic strategy. New technical developments have been used inorder to simplify pulmonary vein isolation (PVI) and to reduce theprocedure time by using an anatomically based ablation approach.Catheters designed as balloons might be more effective and safe touse for circumferential ablation. The purpose of the present studywas to investigate the effectiveness and the safety of cryoballoonablation. Methods: The study enrolled 15 consecutive patients with sym-ptomatic and drug refractory paroxysmal or AF All patientsunderwent transthoracic echocardiography to determine LA dia-meter. To assess PV size and geometry, magnetic resonance ima-ging (MRI) or computer tomography images were obtained beforeintervention. Exclusion criteria were structural heart disease orenlarged left atria (>45 mm, parasternal long axis by echocardio-graphy), moderate or severe valvular heart disease, and pacema-kerimplantation. All patients received transesophageal echocar-diography at least 1 day before the procedure to exclude left atrialthrombi. All patients were treated with a double walled cryoballo-on (Arctic Front; Medtronic, Minneapolis, Minnesota, USA), either23 mm or 28 mm in size as size of the PVs. Both femoral veins wereused for venous access.During the catheter procedure, an infusion of heparin was main-tained to achieve an activated clotting time±300 s. Measurementswere performed every 30 min routinely.Optimum position of the cryoballoon in the PV antrum was con-

firmed by PV angiography and verification of vessel occlusion.Cryoablation was applied for 5 minutes at least 2 times for eachvein. When occlusion was not as desired, the wire was changed toa different side branch or position of balloon or the flexion of thesheath was changed to ensure better occlusion. The ablation pro-cedure was always started in the left superior, then left inferior,then right superior, and finally right inferior PV. After all PVs weretreated with the cryoballoon, the balloon was exchanged for thedecapolar mapping catheter, and entrance block into the veins andexit block from the veins were checked by pacing from the decapo-lar mapping catheter. CARTO bipolar voltage mapping was per-formed before and after the procedure in all the patientsResults: The mean duration of ablation procedure was 242,87±48,9minutes, and the fluoroscopy time was 68±13,9 minutes. The mini-mum temperature achieved by cryoballoon ablation was not diffe-rent in the superior or inferior and right or left PVs. However, therewas a trend for a higher minimum temperature achieved in theright inferior PV. The efficacy of cryoballoon PV isolation wasshown by circular cathehet mapping and by CARTO bipolar volta-ge mapping. During a mean follow-up of 60±12 days, we had threepatients with recurrence of symptomatic AF episodes (86%).Conclusion: The cryoballoon ablation is safe and effective in thetreatment of patients with atrial fibrillation. Further studies areneeded to assess the advantages and disadvantages of this new AFablation strategy compared to the usual RF PVI.

EVALUATION OF ELECTRICAL PV ISOLATION OBTAINEDWITH CRYOBALLOON BY ELECTRO-ANATOMICALVOLTAGE MAPPING WITH CARTO SYSTEMG. ARENA1, C. Bartoli1, V.M. Borrello1, M. Ratti1, C. Andriani1, V. Molendi1,R. Tongiani1, N. Gigli1, M. Mazzini1, S. Berti2

1Cardiologia, ASL1, Massa Carrara, ITALY, 2Fondazione CNR Regione ToscanaGabriele Monasterio, ITALY

Introduction: Pulmonary vein isolation (PVI) achieved using acryoballoon has been shown to be safe and effective. The aim ofthis study was to evaluate the extent of ablation of left atrial surfa-ce obtained using a single 28 mm cryoballoon catheter.Materials and MethodsThirteen patients with drug refractory, symptomatic, paroxysmalAF were enrolled. All patients underwent computed tomographyto assess pulmonary vein anatomy and size. Reconstruction of leftatrium with PV anatomy was performed using the CARTO-MERGE module (Biosense Webster) and the PV ostia were measu-red using the clipping plane tool. A 3D electroanatomic high den-sity voltage map (CARTO XP or Xpress, Biosense Webster) recon-struction of the left atrium was made before and after PVI with the28 mm cryoballoon catheter (Arctic Front, Medtronic). PVI wasconfirmed by circular mapping distal to ablation using the Lasso(Biosense Webster) decapolar variable diameter catheter and byexit block using pacing techniques. Local voltages of <0.1 mV wereconsidered as ablated tissue. Follow-up was planned as outpatientclinic visits at 1, 3, 6, and 12 months after the procedure, includingan interview, physical examination, 12-lead ECG, 24-hour Holtermonitoring and Echocardiogram. Results: The mean maximum diameter of the PV was: 17.5±4.1mm LSPV, 16.6±2.5 mm LIPV, 19.7±2.6 mm RSPV, 17.4±4.0 mmRIPV. A common ostium was present in 9 pts, 9 left and 9 right; themean maximum diameter of the common ostia was: 30.3±3.1 mm.The mean left atrial surface area before and after ablation wasrespectively 188.1±64.2 cm≤ and 213.5±61.7 cm≤. A total number of52 PVs were targeted; 49 (94.2%) PVs were successfully isolatedusing the cryoballoon alone. The remaining 3 PVs (2 right inferiorand 1 left inferior), were isolated using an open irrigated-tip radio-frequency catheter. The total mean time of cryoenergy applicationwas 52±17 minutes. The mean ablated surface area was 38.0±18.3cm≤ around RPVs and 25.8±17.7 cm≤ around LPVs, respectivelyNO

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17.8±5.9% and 12.1±4.8% of the total left atrial surface area afterablation. The smaller ablated area around the LPVs was probablyrelated to the higher prevalence of left common ostium causing amore distal ablation because of the bigger dimensions. 11/13 pts(84.6%) were in sinus rhythm with no documented episodes of AFafter a median follow-up of 3 months. One patient had two episo-des of non sustained AF and one patient presented sustained aty-pical atrial flutter.Conclusions: The present study confirms acute high success rateof PVI by cryoballoon catheter. Clinical results need longer follow-up. However, the demonstration of breakdown of electrical poten-tials <0.1 mV in almost 30% of total left atrium surface area sug-gests that this balloon-based ablation technology may contributeto a substantial modification of the arrhythmogenic substrate inmany forms of atrial fibrillation.

CONTRAST REAL-TIME INTRACARDIACECHOCARDIOGRAPHY IN SUPPORTING AFCRYOABLATION OF PV. A RANDOMIZED STUDYM. MAINES, D. Catanzariti, C. Angheben, C. Cirrincione, G. Broso,G. Vergara

Cardiology Division - Ospedale S. Maria del Carmine, Rovereto (TN), ITALY

Background: Balloon-based cryoablation (CBA) has been recentlyintroduced for pulmonary vein (PV) isolation. High radiationexposure for detailed analysis of PV ostium and extensive use ofcontrast medium for confirmation of balloon occlusion are usuallyneeded by PVs angiography-guided CBA, with the associatedpotential risks of biological tumors induction and nephro-toxicity.We compared intracardiac echocardiography (ICE) versus fluoro-scopy alone for guided cryoballoon ablation (ICE-CBA).Methods: 20 consecutive patients (17 men, mean age 57±11 years)undergoing to CBA for paroxysmal atrial fibrillation (AF) were ran-domly divided for imaging guidance to CBA into 2 subgroups: iodi-nate medium contrast ICE and angiography (group 1 - 10 pts) versussaline solution contrast ICE alone (group 2 - 10 pts). A single “big bal-loon” procedure using a 28 mm cryoballoon was performed.Results: a total of 72 PVs were treated by cryoballoon ablation(CBA) with 227 complete mechanical occlusions (CMO), including42 occlusions of 16 main branches of PV left common trunks and 7occlusions of one long PV left common trunk. Acute procedural suc-cess rate in PV isolation was 100% in each group. Patients in group1 had significantly longer fluoroscopy time (41.9±8.7 vs 30.4±10.9minutes, P<0.05) and higher use of contrast medium (191±45 vs90±24 ml, P<0.001). No significant variations of the PV flow wereobserved by pulsed wave doppler ICE before and after ablation.Conclusion: Contrast real-time intracardiac echocardiography-supported cryo-balloon ablation for atrial fibrillation appears to beassociated with lower fluoroscopy time and contrast medium use,with similar efficacy rates, when compared to standard angiogra-phy-based cryo-balloon ablation.

ISOLATION OF THE PV N OBTAINED WITH A NOVELPHASED RF /DUTY CYCLE MAPPING AND ABLATIONCATHETER: PRELIMINARY EXPERIENCEF. Solimeno1, C. Paolillo2, G. Donnici1, G. Shopova1, N. MARRAZZO1,P. Rubino1

1Cardiologia Interventistica - Clinica Montevergine, Mercogliano (AV), ITALY,2Cattedra di Cardiologia- Seconda Università di Napoli, Naples, ITALY

Introduction: Catheter ablation for paroxysmal atrial fibrillation iswidely used for patients with drug-refractory paroxysms of arrhy-thmia. Recently, a novel multielectrode catheter that delivers duty-cycled bipolar and unipolar radiofrequency (RF) energy has beenintroduced to the market that aim to simplify and shorten the pro-cedure.

Objective: The purpose of this study was to evaluate feasibility,safety and clinical outcome of this novel technology.Methods: Patients eligible for catheter ablation of paroxysmal AFafter screening with magnetic resonance imaging and transeso-phageal echocardiography were included in the study. A decapo-lar (3-mm electrode, 3-mm spacing, 25-mm diameter), circular,over the-wire mapping and ablation catheter was deployed in theantrum of each PV. Ablation was performed with 60-second, 60°Capplications of duty-cycled bipolar/unipolar RF in a 4:1 ratiosimultaneously at all selected electrode pairs until local activitywas no longer observed. At 6 months, 7-day Holter monitoringwas performed to determine freedom from AF without use ofantiarrhythmic drugs.Results: Twelve patients (mean age 59±9 years, 7 men) were inclu-ded in the study. The patients had comparable baseline clinicalcharacteristics, including left atrial dimensions and left ventricularejection fraction. Total procedural and fluoroscopic times were108±32 minutes and 17±6 minutes respectively. The AF recurrencewas documented in 23% of patients at six month. No serious com-plications were noted.Conclusion: Clinical success rates of PV isolation are comparablewith data obtained using a traditional ablation strategy whenusing multipolar circular PV ablation catheter in patients withPAF, and results in short procedural and fluoroscopic times with asafe profile, even in the learning curve.

PV MAPPING AND ISOLATION USING A NOVEL PHASEDRF/DUTY CYCLE CATHETER WITH NAVX MAPPINGSYSTEMG.B. FORLEO1, L. Santini1, F. Romeo1, A. Avella2, A. Pappalardo2,F. Laurenzi2, P.G. De Girolamo2

1University of Rome “Tor Vergata”, Department of Internal Medicine, Divisionof Cardiology, Rome, ITALY, 2St. Camillo-Forlanini Hospital, Division ofCardiology, Cardiac Arrhythmia Centre and Heart Failure Unit, Rome, ITALY

Background: The electrical disconnection of the pulmonary veins(PV) is an established ablation strategy of paroxysmal atrial fibrilla-tion (PAF). Despite technological advances in equipment for ablationof atrial fibrillation (AF), conventional PV isolation (PVI) with point-by-point radiofrequency application encircling the PV ostia remainsa complex procedure requiring a high degree of operator skill andexperience and does not always result in isolation of the targeted PV.Objective: The purpose of this multicenter study, at an early stageyet, is to evaluate the efficacy of the ablation and the reduction offluoroscopy time, using a novel Phased RF/duty cycle catheterwith a 3D imaging system.Methods: Patients eligible for catheter ablation of PAF will beincluded in the study. A decapolar, circular, over the-wire mappingand ablation catheter (Pulmonary Vein Ablation Catheter - PVAC;Medtronic Ablation Frontiers, Inc., Carlsbad, CA, USA) will beused for mapping and isolation of the PV. In sinus rhythm, electro-anatomical bipolar voltage map of the PV and left atrium (LA) willbe acquired with PVAC using the multi-point mapping tool ofNavX navigation system (Ensite Velocity Mapping System, St JudeMedical, St Paul, MN, USA). PV isolation will be performed usingthe PVAC and demonstrated by the absence of PV potentials insinus rhythm. Entry block will be assessed by pacing from theright interatrial septum for the right-sided PV and pacing from thedistal coronary sinus for the left-sided PV. In addition, exit blockwill be assessed by pacing at maximum output (10 V at 2.0 ms)from all electrode pairs of the PVAC positioned proximal in the PV.After PV ablation, voltage map of the LA will be done to demon-strate the effect of PVAC ablation and confirm PV isolation.

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ELECTROPHYSIOLOGICAL FINDINGS AT RE-DOPROCEDURES IN PATIENTS WITH PREVIOUS PVABLATION WITH PHASED/DUTY CYCLEMULTIELECTRODE CATHETERS. BACCILLIERI1, P. Turrini1, A. Di Marco1, A. Stendardo1, P.G. Piovesana1,V. Scarabeo1, F. Campisi1, E. Mantovani1, R. Verlato1, E. Ceoldo2

1Interventional Electrophysiology Unit, Cardiovascular Department, ASL 15Veneto, Camposampiero (PD), ITALY, 2Medtronic Engineer, ITALY

A novel multi-electrode catheter has been recently developed tomap and isolate the pulmonary veins (PVs) (PVAC, Medtronic) bymeans of circumferential delivery of duty-cycled uni/bipolarradiofrequency (RF) energy. However little is known at yet aboutthe real extension, continuity and efficacy of this type of ablationlesions. Aim of this study was to evaluate the electrophysiologicalresults of previous duty-cycle circumferential PVs ablation inpatients undergoing to a second ablation procedure due to atrialfibrillation (AF) recurrence.Methods: Patients ablated for treatment of paroxysmal or persi-stent AF with the PVAC catheter showing AF recurrences aftermore than two months follow-up underwent a repeat ablation ses-sion using a standard circular mapping catheter and a 3.5 mm-tipopen-irrigation ablation catheter (Navistar, Biosense-Webster, orDuo, SJM) associated with a non-fluoroscopic mapping system(CARTO-Merge Biosense Webster, or NAvEx, St. Jude Medical. Results: 17 patients, age 61.8±7.5years, with paroxysmal (n=8) orpersistent (n=9) underwent to a first PVs ablation with the PVAC.Left atrial size was 42.1± 4.4 mm. Left ventricular ejection fractionwas 60±7.1. Twelve (70%) patients had a common left trunk, 6(35%) an early branching right superior pulmonary vein. After xxRF min PVAC ablation, disappearance of PVs potentials wasobserved in 90% of treated veins. Narrow double potentials(= 40msec) were recorded around the vein with the same ablationcatheter. Eight patients had arrhythmia recurrences after their firstablation, (47%). Four of them underwent to the second procedure.All showed recovery of conduction of one or more PVs.Interestingly, most of conduction recovery were related to locali-zed “gaps” easily ablated with the irrigated tip catheter. The twopatients with persistent AF showed conduction recovery of all theveins, the two with paroxysmal AF had conduction gaps aroundone and 3 veins respectively. After ablation, all this fiur patientshad no recurrence off-drugs during 6 month follow-up.Conclusions: The duty-cycle/PVAC PVs ablation has an an highacute success rate of PVs isolation. However in this series ofpatients almost half of them had AF recurrences related with con-duction recovery of the treated veins. Several localized gaps ofconduction along the first PVAC ablation line were observed at re-do ablation which were easily ablated with conventional irrigated-tip catheters.

A NOVEL TECHNIQUE OF PV ISOLATION APPROACHWITH PHASED RF/DUTY CYCLE TECHNOLOGY:ASSESSMENT OF THE RESULTS DURINGTHE LEARNING CURVER. Verlato1, S. BACCILLIERI1, P. Turrini1, A. Di Marco1, A. Stendardo1,P.G. Piovesana1, V. Scarabeo1, F. Campisi1, E. Mantovani1, E. Ceoldo2

1Interventional Electrophysiology Unit, Cardiovascular Department, ASL15Veneto, Camposampiero (PD), ITALY, 2Medtronic Engineer, ITALY

Catheter ablation of atrial fibrillation (AF) is an accepted treatmentto prevent recurrent AF after failure of antiarrhytmic drugs. Therecommended technique for AF ablation should include the isola-tion of pulmonary veins (PVs). New techniques for PVs isolationare subject of investigation, laser, cryo, and duty-cycle uni/bipolarRF energy circumferential ablation, aimed to reduce the procedu-re time and to increase its efficacy. Aim of the present study was toinvestigate the feasibility and the results of PVs ablation using themulti-electrode pulmonary vein ablation catheter (PVAC,Medtronic) combining the capability of circular mapping andduty-cycled circumferential simultaneous ablation around the PVsostium in our initial experience with this technique. Methods and Results: 17 patients, age 61.8±7.5years, with paroxy-smal (n=8) or persistent (n=9) drug refractory AF were ablatedwith the PVAC system. Echocardiographic recordings demonstra-ted an average left atrial size of 42.1+4.4 mm in the parasternallong-axis view. Left ventricular ejection fraction was 60.7+7.1. In 12(70%) patients we found a common left trunk, while in 6 (35%) anearly branching of the right superior pulmonary vein was obser-ved. The mean total procedure time, measured since patient entryin the EP lab to introducer removal was 141.47+33.72 min (range70-195). The mean fluoroscopy time required for PVAC ablationwas 24+7 min (range 16-41). The mean multi-electrode RF ablationtime required to achieve complete PV isolation was 10+6 min. Onesmall and hypoplastic right inferior PV could not be ablated withthe PVAC. Successful acute PVs isolation was obtained in 90% oftreated veins. There was one peri-procedural complication (rever-sible TIA) related with problems with introducer flushing. Duringfollow-up 8 patients (47%) had arrhythmia recurrences, left atrialflutter in one and AF in 7. Four patients underwent a re-do abla-tion with standard technique that was effective in abolish arrhy-thmia recurrences off-drug in all patients. The left atrial flutter wassuccessfully ablated at a critical isthmus close to the right PVs. Onemore patient (a 75 years-old highly symptomatic female with bothparoxysmal and persistent AF) underwent to ablate and pace. Conclusions: PVs isolation using the PVAC system was feasiblewith an acceptably low total procedure and fluoroscopy-times, alow complication rate, an high acute success rate, even during ourinitial experience. The long-term efficacy of PVAC ablation shouldbe improved and dedicated introducer sets should be designed forsafer and easier ablation with this technique.

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CRT: A NUMERICAL MODEL TO PERSONALIZE BIVPROGRAMMINGA. DI MOLFETTA1, L. Santini1, L Fresiello2, G.B. Forleo1, M. Sgueglia1,C. Tota1, M. Cesario1, D. Sergi1, G. Ferrari2, F. Romeo1

1Department of Cardiology- University of Tor Vergata, Rome, ITALY, 2Instituteof Clinical Physiology- CNR, Rome, ITALY

Purpose: actually BIV temporizations are set considering QRSduration (BIV programmer) or during ECO to minimize mechani-cal asynchrony of ventricular contraction. Non-response might beattributable to suboptimal programming. A numerical model(NM) could be useful to evaluate the effects of different AV and VVdelay on cardiovascular system (CS).Method: a lumped parameter model of CS was updated. Heart isdescribed by a variable elastance model reproducing electro-mechanical activity of heart chambers and septum. A NM of BIV,driving heart cycle was developed. 20 patients were analyzed byECO and ECG before BIV implant and during postoperative fol-low-up (24h, 1, 3 and every 3 months). NM was validated verify-ing that it reproduces pathological data and BIV effects in postop-erative follow-up. After that, starting from simulated pathologicalcondition, the effect of different AV and VV were evaluated by NMto optimize cardiac output. Temporizations calculated by BIV pro-grammer, differ from AV and VV calculated by NM for 18 patients.Also the improvements of systolic and diastolic performance wereevaluated comparing ECO data and ventricular systolic and dias-tolic elastances estimated by the software before and after theimplantation.Results: NM permits to study the effect of different AV and VV onCS and optimizing a selected variable. Moreover, it permits to esti-mate the trend of hardly measurable variables such as ventricularelastance.Conclusions: Different variables could be used to set AV and VV.By the NM, the BIV effect could be simulated and the best AV andVV for each patient and for a selected variable could be set insteadof empirically testing a different temporization on a patient.

CAN NON SUSTAINED VT’S PREDICT CARDIACRESYNCHRONIZATION THERAPY NON-RESPONDERS?L.P. PAPAVASILEIOU, F. Vecchio, A. Topa, G. Panattoni, D.G. Della Rocca,V. Minni, A. Di Molfetta, F. Paparoni, M. Cesario, C. Tota, L. Santini,G.B. Forleo, G. Magliano, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Cardiac resynchronization therapy (CRT) is considered to be oneof the most important innovations in the treatment of heart failure.Even if large clinical trials support the role of CRT as an importanttherapeutic option in HF, 30% of patients do not improve clinical-ly after CRT.Aim of our study was to determine the role of NSVT in CRT-Dpatients. Methods: Retrospective evaluation of 88 consecutive CRT-Dpatients. All pts underwent echocardiographic evaluation beforeCRT-D implantation and during follow-up. Electronic control ofdevice was performed at follow-up and all arrhythmic events wereevaluated. Ventricular arrhythmias not leading to ICD appropriatetreatment were classified as NSVT while events leading to appro-priate discharge were classified as VT. Patients were divided in twogroups based on the presence (responders) or absence (non respon-ders) of an improvement of clinical status and increase of LVEF.Results: Follow-up was concluded in 54 patients. Mean follow-upwas 4,52±2,84 months/pt. NSVT’s were observed in 24/54patients (44%). Responders were 43/54 pts (80%) with a meanincrease of LVEF of 13±9%. In this group 39,5% presented NSVTduring FU. Ischemic heart disease (IDCM) was present in 54%,while primary dilated cardiomyopathy (NIDCM) in 46%. Non-responders were 11/54 pts (20%) and 64% presented NSVT; in this

group. 36% were affected by IDCM while 64% by NIDCM. Groupsresulted to be homogeneous regarding medical treatment. Thepresence of NSVT during FU resulted to be non-statistically signif-icant; nevertheless there is a clear trend of presence of NSVT inCRT non-responders. Conclusions: Presence NSVT in CRT-D patients seems to correlatewith failure of resynchronization therapy. In addition, patientsaffected by primary dilated cardiomyopathy seems to be more fre-quently non-responders.

CLINICAL BENEFITS OF CARDIAC RESYNCHRONIZATIONTHERAPY IN OVER 75 YEARS OLD PATIENTSR. MEMEO, F. Quadrini, V.E. Santobuono, L. Nuzzi, P. Palmisano,G. Luzzi, M. Anaclerio, F. Nacci, S. Favale

Cardiology Unit, University of Bari, Bari, ITALY

Purpose: Cardiac Resynchronization Therapy (CRT) is today animportant additional therapy for heart failure patients (pts) whoare refractory to pharmacological therapy. Nevertheless 20-40% ofthese pts do not benefit from CRT, for unknown reasons. The aimof this study was value the CRT effects on a over 75 years old pop-ulation, comparing it with a youger population.Materials and Methods: Pts who underwent to CRT-D implanta-tion were consecutively valued. Each pts underwent to New YorkHeart Association (NYHA) functional class and 2D echocardiogra-phic valuation, just before device implantation and after 6 months,measuring left ventricular end-diastolic dimension (LVEDD) andleft ventricular ejection fraction (LVEF). Pts who at 6 months fol-low up presented a NYHA functional class improvement greaterthan or equal to 1 and a significant reverse remodeling (greaterthan or equal to 15% LVEDD reduction and/or greater than orequal to 15% LVEF improvement) were considered responders. Allpts than were divided in 2 groups: under 75 years old pts (Y) andover 75 years old pts (O). Results: Fourtynine pts were valued (66 males, 67±11 years),affected by dilated cardiomyopathy (47% of those with ischemicetiology). At 7±1 months follow up, 42 pts (52%) were consideredas responders. There was no statistical difference about clinicaland echocardiographic features between two groups. Thus per-centage of responders was not different in two groups (43% in Y vs53% in O; p=0.64).Conclusion: Our data show that CRT offers, in short-term, samebenefits in over 75 year old pts as compared to younger pts.

FRAGMENTED QRS IN CARDIAC RESYNCHRONIZATIONTHERAPY PATIENTSS. SACCHI, G. Mascia, M. Pennesi, L. Perrotta, A. Paoletti Perini,G. Ricciardi, P. Pieragnoli, M. Chiostri, M.C. Porciani, A. Michelucci,L. Padeletti

Istituto di Clinica Medica e Cardiologia, Università degli Studi, Florence, ITALY

Background: Fragmented QRS, also in the presence of a wide QRS(120 msec or wider) due to bundle branch block or paced rhythms,is a highly specific sign for myocardial scar and an independentpredictor of mortality. The aim of this study was to evaluate frag-mented QRS incidence in CRT patients.Methods and Results: We enrolled 91 CRT patients implantedaccording to current guidelines (LBBB, EF 35% or lower, NYHAclass III, IV). Mean follow-up was 30.2±20.3 months. All patientsunderwent baseline ECG before CRT implantation and 2 ECGs ormore during follow-up. Fragmented wide QRS (f-w QRS) wasdefined by the presence of more than 2 notches on the R or on theS waves in 2 or more contiguous leads, either inferior or lateral oranterior ones. Baseline ECG analysis revealed f-w QRS in 36 (40%)patients (f-w QRS basal group). After CRT implantation, f-w QRSwas documented in 59 (67%) patients (f-w QRS post-implantationOP

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group). Of this group, f-w QRS was persistent in 40 (67%) patientsand was intermittent in 19 (33%) patients.Arrhythmic events and cardiac death were higher, also if not signifi-cantly, in the f-w QRS basal group as compared with the non f-wQRS basal group (22% vs. 16% for arrhythmic events; 14% vs. 9% forcardiac death). The same occurred in f-w QRS post-implantationgroup when compared with non f-w QRS post-implantation group(22% vs. 10% for arrhythmic events; 12% vs. 3% for cardiac death).Conclusions: Fragmented wide-QRS (f-w QRS) is present in a sig-nificant number of patients candidates for CRT. Evolution of QRSafter CRT is highly variable: in few cases CRT seems to correct thefragmentation, in most, fragmentation appears after CRT. Thereare also forms of intermittent f-w QRS; furthermore, the site offragmentation (inferior, lateral or anterior) is highly variable.

CARDIAC MEMORY IN HUMANS:VECTOCARDIOGRAPHIC QUANTIFICATIONIN CARDIAC RESYNCHRONIZATION THERAPYL. PERROTTA1, C. Fantappie’1, G. Ricciardi1, P. Pieragnoli1, M. Chiostri1,S. Valsecchi2, Mc. Porciani1, A. Michelucci1, F. Fantini1, L. Padeletti1

1University of Florence, Florence, ITALY, 2Medtronic Italia, Rome, ITALY

Background: Cardiac memory (CM) refers to a change in repolar-ization induced by an altered pathway of activation. Effects ofbiventricular pacing on CM induction have not been investigated.Objective: To investigate the development of CM during cardiacresynchronization therapy (CRT) through vectorcardiography (VCG).Methods: Eleven patients undergoing CRT were enrolled. VCGwas acquired during spontaneous ventricular activation at base-line and during AAI and DDD pacing immediately after and 7, 14,21 and 60 days after the implantation.Results: At 1-week follow-up, during AAI pacing T vectors anglessignificantly changed (azimuth 23±19°; p=0.002; elevation 23±27°;p=0.019) and magnitude significantly increased (baseline 1.13±0.69mV; 7 days: 1.77±1.27 mV ; p=0.026). T angle changes remained sta-ble throughout the follow-up period while a further significantincrease in magnitude was observed at 60 days (2.21±1.50 mV;p=0.01 vs baseline and p= 0.04 vs 7 days). Paced T vector magni-tude at implant (2.24±1.25 mV) decreased significantly at 7 days(1.64±1.26 mV; p=0.030) with a further significant decrease at 60days (1.40±1.18 mV; p= 0.003 vs baseline; p= 0.02 vs 7 days).Conclusion: CRT induces a significant change in T vector magni-tude, azimuth and elevation after resumption of spontaneous ven-tricular activation after 7 days from implantation. While furtherchanges in T vector angle were not observed, after two months ofCRT a significant decrease of paced T vector magnitude and a sig-nificant increase of spontaneous T vector magnitude wereobserved.

CONCORDANCE IN TIME BETWEEN SONRAND HEART SOUNDA. TASSIN1, A. Kobeissi2, L. Vitali3, G. Gaggini3, F. Treguer1, P. Ritter4,A. Furber1, J.M. Dupuis1

1University Hospital, Angers, FRANCE, 2Sorin Group France, Clamart, FRANCE,3Sorin Biomedica CRM, Saluggia, ITALY, 4University Hospital, Bordeaux,FRANCE

Introduction: Heart Sound (HS) is mainly constituted of 2 compo-nents (S1 and S2) occurring respectively during the isovolumiccontraction and relaxation phases of the cardiac cycle and reflectcardiac contractility. The Endocardial Acceleration signal (SonR) ismainly constituted of 2 components, SonR1 and SonR2, respective-ly recorded during the isovolumetric contraction and relaxationphases of the cardiac cycle. Previous studies showed that the peakto peak amplitude of its first component (sonR1) is correlated toLVdP/dtmax. The objective of the study was to evaluate the con-

cordance in time between S1 and SonR1 and S2 and SonR2 in pace-maker implanted patients.Methods: Ten patients with complete atrioventricular (AV) blockwere implanted with a double chamber device (BEST-Living, SorinBiomedica, Saluggia, ITALY), connected to a right ventricular lead(BEST, Sorin Biomedica, Saluggia, ITALY) equipped with a SonRsensor. SonR, phonocardiographic and electrocardiographic sig-nals were recorded simultaneously on an external digital recorderduring AV delay scanning in VDD and DDD modesResults: A close correlation was observed between SonR1 - S1, andSonR2 - S2 timings. Mean cycle by cycle SonR1 to S1 delay was -4.3±22 ms and SonR2 to S2 delay was -7.7±15ms. A stable delay wasobserved between SonR1 and S1, and between SonR2 and S2, in allpatients, regardless of the AV delay, so the paced AV interval seemednot to influence the SonR1 to S1 neither the SonR2 to S2 delays.Conclusion: Good concordance in time was observed betweenSonR1 and S1 as well as SonR2 and S2. These results support thehypothesis that SonR signal and HS are the expression of the samecardiac phenomenon. SonR signal could be useful in clinical prac-tice to determine the timings of the different cardiac cycle phasesand by this way, be relevant for the hemodynamic monitoring andoptimization.

LEFT VENTRICULAR PACING WITH A NEWQUADRIPOLAR TRANSVENOUS LEAD FOR CRT:EARLY RESULTS OF A PROSPECTIVE COMPARISONWITH CONVENTIONAL IMPLANT OUTCOMESG.B. FORLEO, L. Santini, L.P. Papavasileiou, D.G. Della Rocca, G. Panattoni,G. Magliano, V. Romano, M. Sgueglia, A. Di Molfetta, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Background: Flexible left ventricular (LV) pacing configurationsare a useful component of cardiac resynchronization therapy(CRT) systems for preventing high LV pacing thresholds andphrenic nerve stimulation (PNS). A quadripolar LV lead hasrecently been designed with the purpose of allowing more choicesin lead placement location and programming capability.Objective. We investigated the potential benefit of quadripolar LVleads in comparison to that of bipolar leads in terms of safety, pro-cedural course of implantation procedures and left ventricularleads’ performance.Methods: Forty-five consecutive patients were implanted eitherwith the quadripolar (n=22; quadripolar group) or with a conven-tional bipolar LV lead (n=23; bipolar group). The primary outcomeof the study was LV lead failure, defined as the need for lead revi-sion or reprogramming during the first 3 months after implanta-tion. Additionally, operative and follow-up data were prospective-ly noted and checked for significance between groups. Results: The implantation success rate in both groups was 100%.Baseline characteristics, procedure duration and fluoroscopy timedid not differ significantly between groups. Biventricular ICDswere implanted in all cases.Two lead dislodgments (requiring re-operation) and 4 clinical PNSwere reported in the bipolar group; reprogramming of the devicewas sufficient to prevent PNS in 3 patients, the fourth is pendingsolution. One PNS successfully managed noninvasively occurredin the quadripolar group. By Kaplan Meier analysis, event free sur-vival for the combined primary outcome was significantly lowerin patients with quadripolar leads (p=0.037).Conclusions: This prospective, controlled study provides strongevidence that CRT with the quadripolar LV lead results in lowrates of dislocations, and phrenic nerve stimulation.

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IS IT POSSIBLE, WITH A REMOTE MONITORING SYSTEM,TO INCREASE THE RESPONSE TO THE BIVENTRICULARPACING THERAPY AND IMPROVE THE MENAGEMENT OFPATIENTS WITH ADVANCED HEART FAILURE?A. CURNIS, L. Bontempi, A. Lipari, F. Vassanelli, C. Pagnoni, N. Ashofair,M. Cerini, L. Dei Cas

EP Laboratory, Department and Chair of Cardiology, Spedali Civili andUniversity of Brescia, Brescia, ITALY

Background: The evidence of the importance of resynchroniza-tion therapy as treatment for patient with moderate to severe heartfaliure and ventricular dyssynchrony is now well supported byseveral clinical trials and observational evaluations. A 95% or morepacing, demonstrated significant improvement in quality of life,functional status, and exercise capacity in patients with New YorkHeart Association (NYHA) class III and IV heart failure. However,about 20%-35% of patients is not-responder to CRT. Severalparameters such as etiology (ischemic vs non ischemic), QRS dura-tion, non-optimized therapy, arrhythmic episodes and low per-centage of pacing are identified as possible causes of non-responseto CRT. Chronic atrial fibrillation (CAF) is present in 10-30% ofpatients with congestive heart failure. Actually, there are only lim-ited clinical data evaluating effects of biventricular pacing in apopulation of patients with CAF. Remote monitoring is demonstrated as an effective method inearly diagnosis of arrhythmias like AF, VT and VEBS, but also inevaluation of the pacing percentage.Aim: The aim of the study is to evaluate the efficiency of theremote monitoring to report the effective percentage of biventric-ular pacing and allow an earlier diagnosis of arrhythmic episodes. Methods and Results: We followed 67 patients, mean age 50,4 ±20.2 years, with CAD/CHF (43/24), implanted by a biventricularpacing with a remote monitoring system. With remote monitoring,360 transmissions were done: 44 without events; 24 AF episodes;30 SVT; 44 NSVT; 33 VT/VF; 12 effective ATPs; 3 ineffective ATPsand e DC-Shocks supplied; 7 malfunction; in 37 patients anOptiVol Alarm was found and a therapy adjustment was per-formed avoiding an Acute HF episode. In particular: in 9 (13,4%)patients was noted a low percentage of pacing (1 of these had apacing of 80-90%, 6 patients had a pacing of 70-80% and 2 patientsless than 70%). These patients underwent an ambutalory visit andfor 3 pts the therapy was optimized, in 2 the device programmingwas changed and 4 patients were admitted to hospital for an AV-node ablation. In all patients, the biventricular pacing after theactions performed is resulted more than 95% with a subjective andclinical improvement of functional status.Conclusions: In few patients CRT is not effective. An early identi-fication, by a remote monitoring system, of malfunction, arrhyth-mic episodes or a low percentage of biventricular pacing due tohigh ventricular AF response, can allow to modify the therapy andprevent acute heart failure episodes, reducing hospitalizations andimproving quality of life.

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NON-INFECTIVE INDICATIONS FOR LEADEXTRACTION - COMMON PRACTICEA. ANDRZEJ KUTARSKI1, B. Malecka2

1Dept. of Cardiology, Medical University of Lublin, Lublin, POLAND, 2Dept. ofElectrocardiology of Jagiellonian University of Cracow, Cracow, POLAND

Background: During the last HRS Congress on 2009 r HeartRhythm Society Expert Consensus on treatment of permanent pac-ing complications, including indications for lead extraction.Objective: We decided to search, what were rationales for suchprocedures in common practice in spotlights mentioned guidelines.Methods: analysis computer data-base of oldest and biggest onereferential centre of lead extraction in Poland.Results: During the last four years we have extracted 1032ingrown (PM >12, ICD >6 mths) leads in 590 pts. (61,3% M) aged5-91years (mean age 64.5),with PM and ICD systems.The mostcommon (51,0%) indication for lead extraction were non-infective:overmuch of non-functional leads 16,8%, recapture of venousaccess using extraction of functional or abandoned lead for newlead implantation in case of innominate / subclavian vein occlu-sion-8,5%, avoidance of 2 HV-ICD lead-4,6%, dropped-in leadwith ending in CVS which may pose an immediate threat to thepatient if left in place-4,1%, overmuch of leads functional, changeof pacing mode, upgrading-3,2%, non-functional exit block-2,9%,dislodgement-2,7%, child-1,9%, interference with active CIED sys-tem or with therapy of breast cancer-1,3%, permanent AF, atriallead 1,2%, chronic pain et device insertion side 0,7%, implantationwhich would require>4 leads in SV or>5 in VCS-0,5%, VCS syn-drome-0,3%, extracardiac pacing 0,1%, missed tip location 2,2%.Lead dependent endocarditis and pocket infection were less com-mon indication (18 and-31%). In 54,7% of pts.-class 1, 9,7% class 2a,in 33,4% class 2b indications were recognized retrospectively. Butknown anomalously placed leads (A or V perforating leads, LVplaced leads) had to be extracted with outstanding safety precau-tions (class 3)-2,2%.Conclusions: About 50% leads are extracted due to infective indi-cations, but avoidance of overmuch of abandoned leads consiststhe second lead extraction motive and are performed during CIEDprocedure.

ENDOVASCULAR LEADS EXTRACTION: DO EXISTPREDICTIVE PARAMETERS FOR ADVERSE EVENTS?L. BONTEMPI, A. Curnis, E. Vizzardi, M. Cerini, A. Lipari, C. Pagnoni,N. Ashofair, M. Mutti, F. Vassanelli, L. Dei Cas

Division and Chair of Cardiology, Spedali Civili - University of Study, Brescia,ITALY

Purpose: Malfunctions and infections of leads and devices requirethe extraction. Techniques and approaches developed for thetransvenous removal of the catheters, ensuring a success probabil-ity between 90 and 98%, with rare complications (1-3%), some-times fatal. The actual extraction techniques included manual trac-tion with or without locking stylets, mechanical extractors, electro-surgical dissection sheath and excimer laser using a femoral, jugu-lar, subclavian or hybrid approach. The aim was to investigate theexistence of predicting variables for lead extraction success usingtechniques now available, as: patient age, catheters age, devicetype, extraction indications (malfunction /infection)Materials and Methods: from 04/2003 to 09/2010, 443 pts weresubjected to lead extraction procedure (M 76% F 24%, mean age68.4±13 years). The number of extracted leads was 651 (mean leadage 120 months±124), 66% of patients had an extraction indicationfor infection, the remaining 34% were extracted due to malfunction.The analyzed population was divided into two subgroups: adverseevents group (AE 3.9% of pts) as failure/partial success of extrac-tion, tachyarrhythmias, pericardial effusion, early or delayed tam-ponade, and non adverse event group (NAE 96.1% of pts)

Results: Complete success achieved in 94%. A multivariate analy-sis was performed, taking into account all possible predictingparameters. No statistically significative difference was foundbetween two groups considering patient age, catheters mean ageand extraction indications (p>0.05). Considering the type ofdevice, in patients with an implanted PM the group AE was 16%of the population, instead in patients with ICD or CRT was respec-tively 5.5% and 2.2% (p<0002). Conclusion: The only independent and significant predictor forpredicting the risk of adverse events was the type of leads anddevice implanted. This result is likely to be related to increasedstructural fragility of the leads, resulting in a higher incidence offracture during the extraction.

FACTORS AFFECTING SURVIVAL FOLLOWING LEADEXTRACTION IN PATIENTS WITH CARDIAC DEVICEINFECTIONF. VIGANEGO, S. O’Donoghue, Z. Eldadah, M. Shah, M. Rastogi, J. Mazel,E.V. Platia

Cardiac Arrhythmia Center, Washington Hospital Center, Washington, DC, USA

Introduction: The rate of cardiac device infections (CDI) is rising,causing considerable morbidity and mortality. CDI rarely respondto antibiotic therapy alone and usually require complete hardwareremoval. Purpose: We sought to analyze the overall outcomes following suc-cessful lead and pacemaker/defibrillator extraction in patients withCDI referred to our center and factors affecting in-hospital mortality.Patients / Methods: Among all patients referred to our center for car-diac device extraction between January 2009 to August 2010, thosewith CDI were selected. Clinical outcomes of patients followingcomplete hardware removal were analyzed. Data was collected ret-rospectively by review of hospital medical records. Student’s t-testwas employed for comparison of continuous variables. Fisher’sexact test was used for comparison of categorical variables.Results: Of 32 patients with CDI, 20 had documented bacteremia,while 12 had localized pocket infection. Staphylococcus aureuswas isolated in 80% of the bacteremic patients. Lead vegetationswere observed on echocardiography in nine patients, and valvevegetations in five. Lead extraction was not performed in twopatients. Procedural success was achieved in 29 (97%) of theremaining patients, with laser in 58% of the patients. There was noprocedure-related mortality. Despite complete hardware removal,five patients (17%) died during the hospitalization. Low ejectionfraction and the presence of lead vegetation were statistically asso-ciated with in-hospital death (p=0.05), while a trend toward statis-tical significance was observed for the presence valve vegetationand Staphylococcus aureus bacteremia.Conclusions: CDI are associated with high in-hospital mortalitydespite antibiotic therapy and successful lead extraction. CDI mayoften be under-recognized and lead extraction performed too late.Echocardiography should be performed in all patients with sus-pected CDI to help identify patients at higher risk. It is possiblethat earlier hardware removal in these patients may have a posi-tive impact on mortality.

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LARGE SINGLE CENTER EXPERIENCE IN TRANSVENOUSCORONARY SINUS LEAD REMOVAL: PROCEDURALOUTCOMES, TECHNICAL IMPLICATIONS ANDPREDICTORS OF MECHANICAL DILATATIONA. DI CORI, E. Soldati, L. Segreti, G. Zucchelli, R. De Lucia, L. Paperini,S. Viani, A. Boem, D. Levorato, M.G. Bongiorni

Azienda Ospedaliero-Universitaria Pisana - U.O. Malattie Cardiovascolari 2, Pisa, ITALY

Aim of the study: We aimed to evaluate procedural outcomes andimplications of CS lead extraction.Methods: We analyzed 145 consecutive patients (69±10 years, 121male), with 147 CSL, who underwent TLE between January 2000and March 2010. Indications were local infection in 81 (56%), sep-sis in 35 (24%), and lead malfunction in 29 patients (20%). All butone (99%) CSL (time from implant 29±25 months) were successful-ly removed; manual traction was effective (MT group) in 106patients (72%) and ineffective in 41 patients (28%), for whommechanical dilation was necessary (MD group). In univariateanalyses, lead polarity (unipolar) [OR 2.85, 95% CI (1.13-5), P =0.005] and non infective (malfunction) indication [OR 2.6, 95% CI(1.12-6.08), P = 0.026] were risk factors for MD. In multivariateanalyses, prior cardiac surgery (OR 2.4, 95% CI 1.01-5.9, p=0.05),unipolar lead design (OR 3.7, 95% CI 1.56-8.33, p=0.003) and noninfective procedural indication (OR 5.3, 95%CI 1.9-14.7, p=0.001)remained independent predictors of MD (p<0.0001). 5 (3.4%) com-plex procedures occurred: 4 patients (2.7%) required a trans-femoral approach (TFA) and two patient (1.3%) required a repeat-ed procedure. Acute complications were observed in 5 patients(3.4%): four (2.7%) minor and one (0.7%) major (i.e. cardiac tam-ponade treated by pericardial drainage) after MT. No deathsoccurred. No predictors of complications were identified. Conclusions: Our large experience confirm that CSL, after medi-um-term pacing, can be safely and effectively removed almostwith MT alone. MD with or without TFA is required in about 30%of cases and preoperative predictors include a prior cardiac sur-gery, an unipolar lead design and a non infective indication.According to CS body fragility, complications, even if rare, areunpredictable and may be observed also during MT alone.

PERCUTANEOUS EXTRACTION OF OVER 1000PERMANENTLY IMPLANTED LEADS IN 590 PTS.USING MECHANICAL SYSTEMS - EFFECTIVENESSAND COMPLICATIONSA. ANDRZEJ KUTARSKI1, M. Czajkowski2, R. Pietura3, M. Grabowski4,B. Malecka5

1Department of Cardiology Medical University of Lublin, Lublin, POLAND,2Dept. of Cardiosurgery Medical University of Lublin, Lublin, POLAND, 3Dept.of Interventional Radiology and Neuroradiology Medical University of Lublin,Lublin, POLAND, 4I Dept. of Cardiology Medical University of Warsaw,Warsaw, POLAND, 5Dept. of Electrocardiology of Jagiellonian University ofCracow, Cracow, POLAND

Aim of the study: Analysis of effectiveness&safety of differentmechanical systems for extraction of old-time implanted intracardiacleads.Methods: We extracted 1032 ingrown (PM >12,ICD >6 mths) leadsin 590 pts (61,3%M) aged 5-91 y. (mean age 64.5). 876 extractedleads were functioning and 156 abandoned, 75,0% were PM-BP,10,6%-PM-UP and 11,8% ICD and 2,5% consisted VDD PM leads.71,0%-passive fixation, 38,2% were RA (RAA, BB), 8,1% LA (CS,CSO), 50,8%, RV (RVA, RVOT) 2,6%,LV vein and 03% LA or LV.Mean lead longevity was 82,3 +/-59,6 mths. Number of extractedleads: 44,2% - 2, 42,2%-1, 13,6% - 3(max. 6) leads. Indication forlead extraction were non-infective in 51,5%.Results: Aver. procedure time was 113,6 min. Mechanical systems(various stylets and Byrd-Cook dilators) were used for most(84,8%) of leads extracted by a superior approach (at the insertion

site through the subclavian vein); femoral approach (FWS withbasket, snare or lasso catheters and sometimes Byrd dilators) wereused for free floating PM and ICD leads with prox. ending inlumen of vein and combined approach (including jugularapproach) for extraction of teared (during extraction) leads wereused in 2,1% and 1,5% respectively. Technique of simple extorsionand gentle traction was utilised in 10,1% for active fixation (screw-in), straight, isodiametric leads removal.Conclusions: 1. Percutaneous lead extraction in experienced cen-tre is very effective 2. In experienced centre it is safe procedure 3.Procedure consist of combination complementary techniques; 4.Cardio-surgery stand-by is necessary

TRANSVENOUS REMOVAL OF PACING ANDDEFIBRILLATING LEADS: 13 YEARS OF EXPERIENCEIN A SINGLE CENTERM.G. BONGIORNI, E. Soldati, G. Zucchelli, L. Segreti, A. Di Cori,R. De Lucia, S. Viani, L. Paperini, D. Levorato, A Boem

Azienda Ospedaliero Universitaria Pisana - U.O. Malattie Cardiovascolari 2,Pisa, ITALY

Background: Transvenous extraction of Pacing (PL) andDefibrillating Leads (DL) is today a highly effective technique.Device related complications are currently rising the need ofTransvenous Lead Removal (TLR). Aim is to analyse the long-standing experience performed in a single center.Methods: since January 1997 to June 2010, we managed 1548 con-secutive patients (1176 men, mean age 65.6 years, range 3-95) with2761 leads (mean pacing period 69.5 months, range 1-420). PL were2363 (1247 ventricular, 959 atrial, 157 coronary sinus leads), DLwere 398 (378 ventricular, 6 atrial, 14 superior vena cava leads).Indications to TLR were class I in 33% and class II in 67% of theleads. We performed mechanical dilatation using the CookVascular (Leechburg PA, USA) polypropylene sheaths and, if nec-essary, other intravascular tools (Catchers and Lassos, Osypka,Grentzig-Whylen, G); a Internal Trans-Jugular Approach (JA)through the internal jugular vein was performed in case of free-floating leads or failure of standard approach.Results: Removal was attempted in 2753 leads because the tech-nique was not applicable in 8 PL. Among these, 2703 leads (2305PL, all the 398 DL) were completely removed (98.2%), 28 (1%) par-tially removed, 22 (0.8%) not removed. Among 2673 exposedleads, 424 were removed by manual traction (15.9%), 1995 bymechanical dilatation using the venous entry site (74.6%), 15 byfemoral approach (FA) (0.7%) and 191 by JA (7.4%). All the free-floating leads were completely removed, 23.7% by FA and 76.3%by JA. Major complications occurred in 10 cases (0.64%): cardiactamponade (9 cases, 2 deaths), hemotorax (1 death).Conclusions: our experience shows that in centers provided withwide experience, TLR using mechanical dilation has a high successrate and a low incidence of serious complications. The use of theJA allows very high effectiveness and safety in case of free-floatingor difficult exposed leads.

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FEASIBILITY AND MID-TERM OUTCOME OF CARDIACRESYNCHRONIZATION THERAPY AFTER CORONARYSINUS LEAD EXTRACTION: TERTIARY REFERRAL CENTREEXPERIENCEG. ZUCCHELLI, G. Solarino, I. Fabiani, E. Soldati, A. Di Cori, L. Segreti,G. Coluccia, R. De Lucia, S. Viani, L. Paperini, A. Boem, M.G. Bongiorni

Division of Cardiovascular Diseases, Azienda Ospedaliero-Universitaria Pisana,Pisa, ITALY

Purpose: We aimed to evaluate the feasibility and mid-term out-come of cardiac resynchronization therapy (CRT) after coronarysinus (CS) lead extraction in a tertiary referral centre. Methods: We enrolled all patients who were referred to our hospi-tal for CS lead removal from December 2000 through May 2009and were transvenously reimplanted with a CRT system beforeJune 2009. Results: We studied 113 consecutive patients undergoing CS leadextraction (120 CS leads); ninety patients (75 male, mean age 69.2,range 35-84) underwent CS lead reimplantation (success rate:95.6%; right side approach: 64.4%). Reimplantation was usuallyperformed in patients with previous diagnosis of infection (74.4%);in these patients the median time between extraction and reim-plantation has been 3 days. CS lead was usually positioned in LVpostero-lateral region (62.2%); in 2 cases (2.2%) more than 1 proce-dure was required. Balloon angioplasty was attempted in twopatients (failure in one), whereas in the others we used a conven-tional implant technique. At 1-year follow-up, we observed 4 cases(4.4%) of local infection and 6 cases (6.7%) of system malfunction,requiring reintervention (2 cases in the same hospitalization). One-year mortality was 5.5%.Conclusion: LV lead reimplantation is in our experience an effec-tive and safe procedure, even if a right side approach is oftenrequired. Although the mid-term mortality was particularly low,the overall incidence at follow-up of infection was more relevantthan first implant procedures.

TRANSVENOUS EXTRACTION OF IMPLANTABLECARDIOVERTER DEFIBRILLATOR LEADS: FEASIBILITY,SAFETY AND DETERMINANTS OF SUCCESS INA SINGLE CENTER EXPERIENCEL. SEGRETI, E. Soldati, G. Zucchelli, A. Di Cori, R. De Lucia, L. Paperini,S. Viani, D. Levorato, A. Boem, M.G. Bongiorni

Azienda Ospedaliero-Universitaria Pisana - U.O. Malattie Cardiovascolari 2,Pisa, ITALY

Introduction: Transvenous extraction of implantable device is awell known procedure, almost described and documented for pac-ing leads, with small series for implantable cardioverter defibrilla-tor (ICD) leads. Aim of our study was to describe a large singlecenter experience in implantable cardioverter defibrillator (ICD)leads extraction by transvenous mechanical technique. Methods: Since 1997, 352 consecutive patients (309 men, mean age62.1 years, range 8-92) with 378 ICD leads (mean implantationtime 42.2 months, range 1-204) underwent a transvenous removal.System features included almost left sided implanted systems(92%) with passive fixation (77%) and dual coil (74%) leads.Indications to remowal were: 105 (28%) systemic infection, 186(49%) local infection and 87 (23%) malfunctions.Results: Removal was feasible with complete success in all the 378approached leads (100%). 23 leads (6%) were removed by manualtraction, 355 (94%) by mechanical dilation, whose 321 (85%) usingthe venous entry site approach and 34 (9%) by the transvenousjugular approach crossover. Mean extraction time was 21±31.7 min(range 1-210). No major complications occurred.Dual coil compared with single coil leads showed an higher rate offibrous adherences at the innominate vein (69 vs 52%, respective-ly) and superior vena cava (70 vs 51%, respectively), without dif-ferences in the other sites. Comparing the easy (”traction” group)with the complex approach (”transjugular” group), all baselinepatient and leads features resulted comparable (p = ns), with theonly exception for the lead implantation time that resulted statisti-cally longer in the second group (10.4±10.3 vs 44.2±34.3 min,p<0.05, respectively).Conclusions: Our large experience shows that transvenous ICDleads removal is a feasible, safe procedure with a high success rate.However, even if the mean dwell time is usually lower than pac-ing leads, manual traction is rarely effective and often the jugularapproach (JA) may be required

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CUMULATIVE BURDEN OF RIGHT VENTRICULARPACING IN SINUS NODE DYSFUNCTION VSATRIOVENTRICULAR BLOCK PATIENTS: MID-TERMOUTCOMES FROM THE NATURE REGISTRYG. MOLON1, A. Vicentini2, D. Vaccari3, A. Pezzotta4, J.C. Deharo5

1Osp. Sacro Cuore - Don Calabria, Negrar (VR), ITALY, 2CdC Pederzoli,Peschiera del Garda (VR), ITALY, 3Osp. Civile, Montebelluna (TV), ITALY,4Group Italia, Milan, ITALY, 5Hôpital La Timone, Marseille, FRANCE

Introduction: The clinical benefits of preserving atrio-ventricularconduction (AVC) to avoid worsening of left ventricular functionare well-known. The aim of this sub-analysis of the “NATURE”observational study is to compare the% of ventricular pacing (VP)in dual-chamber pacemaker (PM) patients (pts), according to dif-ferent implant indications: Sinus Node Dysfunction (SND), or sus-pected (susp) / documented (doc) atrio-ventricular blocks (AVB).Methods: 843 pts (75.4±9.4 years, 44% male) from 124 centers wereincluded in the study. Devices were programmed with SafeR phys-iological pacing mode (AAI pacing + back-up Vp when AVBsoccur), specifically designed to reduce%VP.Results: Average follow up (FU) duration was 8.4±2.4 months (M).Mean AP% and VP% were 54.2±36.8% and 19.9±27.3%, respective-ly. Mean AP% and VP% per implant indication have been report-ed in table 1.Conclusions: in SND pts, AP% was higher than in susp/doc AVB;an unexpected high VP% was reported in SND pts as compared toAVB pts. This finding may suggest the presence of a moderateshort-term progression of AVC abnormalities, or an under-evalu-tion at implant of susp/doc AVB in SND pts. No significant differ-ence of Vp% between susp and doc AVB was observed.

DUAL-CHAMBER PACEMAKER REPROGRAMMINGIN CLINICAL PRACTICE: RESULTS FROM A LARGECOHORT OF THE NATURE REGISTRYA. VICENTINI1, D. Vaccari2, G. Molon3, E. Favero,4 J.C. Deharo5

1CdC Pederzoli, Peschiera del Garda (VR), ITALY, 2Osp. Civile, Montebelluna(TV), ITALY, 3Osp. Sacro Cuore - Don Calabria, Negrar (VR), ITALY, 4SORINGroup Italia, Milan, ITALY, 5Hôpital La Timone, Marseille, FRANCE

Introduction: The NATURE observational study is designed toevaluate dual chamber pacemakers (PM) patient’ (pts) outcomeand clinical practice over a 2-years follow-up (FU) period. The aimof this sub-analysis is to classify the observed device reprogram-mings through 1-year FU.Methods: The study population consists of 843 enrolled pts from11 countries, implanted with dual chamber PMs programmed inSafeR mode, meaning AAI+back-up V pacing when atrioventricu-lar blocks (AVBs) occur. Clinical informations were retrieved atimplant, and device programmings were assessed through memo-ries downloading during 1-year FU.Results: Data from 99 pts followed up to 1-year FU have been con-sidered (FU duration: 189.9±142.5 days; FU visits: n=647). Theywere 75±9 yrs old (56% female), and implant indications were: 76%sinus node dysfunction, 17% documented paroxysmal AVB, 7%suspected AVB. 63% of pts underwent at least 1 PM reprogram-ming (reprog): among them 9%/55%/36% had 1/2/3 reprog,respectively. The most frequent reprogramming actions were relat-ed to atrial (A) and ventricular (V) outputs adjustments, as shownin table 1.Conclusion: At 1-year FU, 2/3 of PM pts underwent device repro-gramming adjustment(s), mainly for A&V output regulation, andless frequently to tune AVD interval or basic rate values.

CRT OPTIMIZATION BY SONR OR STANDARDMETHODS: RESULTING CLINICAL RESPONSE RATEFROM THE RANDOMIZED CLEAR STUDYR.P. RICCI1, M. Lunati2, L. Padeletti3, S. Orazi4, A. Capucci5, S. Cerisano6,P. Ritter7

1Osp. S. Filippo Neri, Rome, ITALY, 2Ospedale Niguarda, Milan, ITALY,3Ospedale Careggi, Florence, ITALY, 4Osp. C. De Lellis, Rieti, ITALY,5Osp. Lancisi, Ancona, ITALY, 6Osp. S. Maria Nuova, Florence, ITALY,7CHU Bordeaux Haut Lévêque, Bordeaux, FRANCE

Introduction: An increased response rate to CardiacResynchronization Therapy (CRT) requires tailored CRT optimiza-tion. The SonR (Peak Endocardial Acceleration or SonR) sensorprovides an integrated device system that optimizes frequently AVand VV delays (AVD and VVD), resulting in the optimal heamo-dynamic performance. The CLEAR study aims to evaluate theclinical response rate of pts optimized by SonR (SonR group) vsstandard medical practice methods (STD group).Methods: A population of 186 heart failure pts in sinus rhythm(73±10 years, 63% male, NHYA class 3.1±0.3, LVEF 26.8±8.2%, QRSwidth 161.3±22.8 ms, ischemic/idiopathic/valvular cardiomyopa-thy 38%/48%/8% respectively) were implanted with a CRT pace-maker (PM). After implant (within 7 days), pts were assignedeither to SonR (n=87) or STD (n=99) group for 1-year follow-up(FU). Pts in SonR group were optimized (VV configuration, AVD,VVD) using SonR automatic methods at each FU (discharge, 3M,6M) and on a weekly basis for AVD. Pts in STD group were fol-lowed according to the routine practice of the participating cen-tres. The composite criterion (death, HF-related hospitalizations,NYHA class and Quality of life (QOL)) was applied to define animproved or worsened/stable pt status.Results: a significantly higher rate of improved pts was observedin the SonR group (78%), after 1-year FU, compared to STD group(62%) as shown in table 1.Conclusions: SonR optimized method significantly improves therate of clinical response to CRT vs STD practice methods.

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Parameter Reprog. Rate Value at inclusion Reprog. amplitude(% of FU visits) (Mean+/-SD)

V output (V) 22.7% 3.5 -0.74+/-0.82A output (V) 22.1% 3.5 -0.92+/-0.67Rest AVD (ms) 4.4% 155 -16.1+/-41.7Basic rate (ppm) 4% 60 +5+/-7.4Max rate (ppm) 1.2% 120 +7.5+/-17.3A width (ms) 1.1% 0.35 +0.25+/-0.33V width (ms) 0.9% 0.35 +0.33+/-0.27Exer AVD (ms) 0.8% 80 -27+/-24.7

Clinical status evolution* SonR arm,% (n) STD arm,% (n) p(n=87) (n=99)

Pts improved 78% (68) 62% (61)0.0146

Pts worsened/stable 22% (19) 38% (38)*composite criterion including deaths, HF-related hospitalisations, NYHA class and QOL.

FREQUENT VV AND AV DELAYS OPTIMIZATION IN CRTPATIENTS IMPROVES CLINICAL RESPONSE RATE:RESULTS FROM THE RANDOMIZED CLEAR STUDYD. VACCARI1, G.Q. Villani2, R.P. Ricci3, M. Lunati4, L. Padeletti5, P. Ritter6

1Osp. Civile, Montebelluna (TV), ITALY, 2Osp. G. da Saliceto, Piacenza, ITALY,3Osp. S. Filippo Neri, Rome, ITALY, 4Ospedale Niguarda, Milan, ITALY,5Ospedale Careggi, Florence, ITALY, 6CHU Bordeaux Haut Lévêque, Bordeaux,FRANCE

Introduction: Frequent and individual VV and AV delays opti-mization in CRT patients (pts) improves clinical response rate. TheCLEAR study aims to evaluate the clinical response of pts opti-mized by SonR (SonR group) vs standard medical practice meth-ods (STD group) over 1-year follow-up (FU). This sub-analysisassessed the benefit of a periodic CRT optimization towards ptsclinical response, whatever the optimization method implemented.Methods: Severe heart failure patients (n=186) in sinus rythm(73±10 years, 115 M, NYHA 3.1±0.3), were enrolled in the studyand randomized either in SonR group (providing automatic VVconfiguration, VV and AV delays optimization) or STD group(providing standard medical practice) for a 1 year FU. The com-posite criterion (death, HF-related hospitalizations, NYHA classand Quality of life), and the single criteria of HF related events,were applied to define an improved or worsened/stable pt sta-tus.The aim of this sub-analysis was to compare periodically (ateach FU, i.e. discharge, 3 and 6 months) optimized pts vs the others.Results: 1) clinical response rates reached 85% and 92% (compos-ite criterion and HF related events only, respectively) in periodical-ly optimized pts. 2) In non-periodically optimized pts, 61% and82% response rates were observed (p<0.05) (table 1).Conclusion: Periodic CRT optimization ensures a significantlyhigher response rate to CRT vs non periodic optimization (p<0.05).This finding highlights the need for an automatic, device-integrat-ed CRT optimization, which remains operator independent, flexi-ble and cost-effective.

COMPARISON BETWEEN OPTIMIZED CRT PATIENTSBY SONR OR CLINICAL PRACTICE:NYHA CLASS EVALUATIONS. ORAZI1, R.P. Ricci2, M. Lunati3, L. Padeletti4, A. Capucci5, S. Cerisano6,P. Ritter7

1Osp. C. De Lellis, Rieti, ITALY, 2Osp. S. Filippo Neri, Rome, ITALY, 3OspedaleNiguarda, Milan, ITALY, 4Ospedale Careggi, Florence, ITALY, 5Osp. Lancisi,Ancona, ITALY, 6Osp. S. Maria Nuova, Florence, ITALY 7CHU Bordeaux HautLévêque, Bordeaux, FRANCE

Introduction: NYHA class is a standard recognized method tomeasure clinical patients’ (pts) status in severe heart failure ptswith a CRT device. The CLEAR study aims to evaluate the clinicalresponse rate of pts optimized by SonR (SonR group) vs standardclinical practice methods (STD group). This sub analysis aimed tocompare NYHA class evolution in SonR group vs STD group in apopulation implanted with a SonR featured CRT-P device.Methods: Data from 156 HF pts in sinus rhythm (73.3±9.3 yrs, 65%

male, NYHA 3.0±0.2, QRS width 162±23ms, LVEF 26.7±8.1%,ischemic/idiopathic/valvular cardiomyopathy 37%/47%/7%respectively) were analysed. Pts were randomized to SonR group(n=57) or STD group (n=99) within seven days following thedevice implant. Pts in SonR group were manually optimized bySonR method (VV configuration and paced/sensed AV delays) ateach FU (pre-discharge, 3- and 6-months), and the AVD values(rest and exercise) were also automatically optimized on a weeklybasis by the same SonR method; pts in STD group were treated fol-lowing standard clinical practice of the Centre. The variations ofthe NYHA class from baseline to 1-year FU were considered as amain endpoint of this sub analysis.Results: A significant difference between SonR group and STDgroup was observed (p=0.0015) in terms of NYHA class evolution(see Table 1).Conclusion: The SonR optimization method is significantly supe-rior in terms of NYHA class improvement when compared to themethods used in STD clinical practice.

REMOTE FOLLOW-UP IN PATIENT WITHIMPLANTABLE DEVICE: A SINGLE EXPERIENCEG. GIUNTA1, L. La Rocca3, L. Marruncheddu1, P. Franciosa1, F. Fattorini2,E. Crisuolo1, C. Straccio1, A. Ciccaglioni1, F. Fedele1

1Dipartimento di Malattie Cardiovascolari Policlinico Umberto I, Rome, ITALY,2Dipartimento di Scienze Anestesiologiche Policlinico Umberto I, Rome, ITALY,3Medtronic Italia, ITALY

Introduction: The increasing number of patients with implantabledevice includes a growing commitment within clinics dedicated.The remote monitoring system CareLink NetworkÆ might help toimprove the clinical management of all the patients and to opti-mize medical and technical service.Methods: Using the secure CareLink website, medical staff is ableto set controls to each patient by checking the results from anyInternet or mobile. Each patient is equipped with a modem to con-nect to an analog telephone sets. At the scheduled day, the patientwith the CareLink monitor, (manually using a telemetry head forPMK or automatically for the ICD wireless) transmits data to thesecure server via phone line. All data will be checked first by anurse and then by a doctor on the website Medtronic Carelink.Results: From January to April 2010, we enrolled 47 patientsimplanted with Medtronic devices (4 reveal, 21 PMK, 22 ICD). Wereceived 33 transmissions, 16 scheduled (13 without events, 3 AT /AF), 17 non-scheduled, including 10 OptiVol alarms (algorithmmonitoring pulmonary congestion through measures transtho-racic impedance in patients with ICDs), 2 for symptoms reportedby the patient and 5 used for monitor the symptoms. We had 4 inhospital visit: one for an atrial lead repositioning, 1 for pneumonia,1 for AT / AF; for 11 times there were changes of drug therapy byphone.Conclusions: The analysis of all data from remote control allowsus to optimize the diagnostic-therapeutic path for each individualpatient. The strategy of remote management for patient with ICDand HF has allowed to optimize the path of the patient with HF bylimiting the consumption of resources.

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Periodically optimized pts (n=66 pts)Non-periodically optimized pts (n=120 pts)

p

% (n) % (n)Pts improved 85% (56) 61% (73)

0.0007Pts worsened/stable 15% (10) 39% (47)Pts free from HF

92% (61) 82% (97)related eventsPts with HF related 0.0344hospitalis./death 8% (5) 18% (23)

SonR group (n=57) STD group (n=99) p

NYHA at baseline3.04±-0.25 0.00153.01±-0.23

NYHA at 1-yr FU 1.95±-0.61 2.27±-0.78

DEGREE AND SEVERITY OF SLEEP BREATHINGDISORDERS CORRELATE WITH THE BURDEN OFVENTRICULAR TACHYARRHYTHMIAS IN ICD PATIENTSG. MANTOVANI1, E. Aime’2, C. Gentilini3, M. Lorini3, C. Storti4,M. Longobardi4, E. Moro5, F. Anselme6

1Ospedale Civile, Desio (MB), ITALY, 2IRCCS Pol. S. Donato, S. DONATO (MI),ITALY, 3Osp. Mellini, Chiari (BS), ITALY, 4CdC Città di Pavia, Pavia, ITALY,5Osp. Civile, Conegliano V.to (TV), ITALY, 6Hôpital C. Nicolle, Rouen, FRANCE

Introduction: Sleep breathing disorders (SBDs) are frequentlyobserved in cardiovascular patients (pts), and probably play a rel-evant role in the occurrence of ventricular tachyarrhythmias (VTA)in individual pts. This study aimed to investigate the relationshipbetween SBDs and the incidence of VTA in unselected ICD ptsover 1-year follow-up (FU).Methods: After implant, all ICDs were programmed with lowbasic rate =60bpm, slow-VT detection rate =120bpm, and the bestapplicable arrhythmia discrimination criteria. One-year afterimplant, pts underwent an overnight Holter-recording with NasalPressure signal recording. Degree and severity of SBDs were esti-mated based on Apnea-Hypopnea Index (AHI=number ofepisodes/sleep hour): Weak (W), Moderate (M) or Severe (S) SBDgroups presented AHI<15, 15=AHI<30, and AHI=30 respectively.The normalized incidence of VTA (number of VTA episodes/FUduration) was assessed through 1-year FU in the 3 AHI groups (W,M, S).Results: Data from 217 ICD recipient pts (16% CRT, 55% DR, 29%VR models) were considered (64.1±10.9 yrs; 90% males; LVEF35.5±13.7; NYHA class I 22% / II 60% / III 18%, secondary preven-tion in 64% of pts). Group W consisted of 110 pts (50.7%), group Mof 66 pts (30.4%), and group S of 41 pts (18.9%). During a mean FUof 341.5±69 days, the VTA incidence was significantly higher in thegroups M and S as compared to the group W (table 1).Conclusions: In this unselected cohort of ICD pts, the incidence ofVTA was significantly correlated with the presence and the degreeof severity of SBDs. Screening for SBDs should be proposed in ICDindicated pts in order to allow early treatment of SBDs and VTAincidence reduction.

ICD MODEL SELECTION ACCORDING TO PRIMARYOR SECONDARY PREVENTION INDICATIONS:PRELIMINARY OUTCOMES FROM THE FIRST REGISTRYM. PIACENTI1, P. Scipione2, E. Dovellini3, A. Proclemer4, S. Cerisano5,R. Manfredini6, O. Pensabene7, F. Frascarelli8, O. Piot9, L. Padeletti10

1Istituto Fisiologia Clinica, CNR, Pisa, ITALY, 2Ospedale Lancisi, Ancona, ITALY,3Ospedale Careggi, Florence, ITALY, 4Ospedale S. Maria della Misericordia,Udine, ITALY, 5Osp. S. Maria Nuova, Florence, ITALY, 6Osp. MaggiorePoliclinico, Milan, ITALY, 7Osp. Villa Sofia, Palermo, ITALY, 8OspedaleMisericordia e Dolce, Prato, ITALY, 9CCN, St Denis, France,10Ospedale Careggi,Florence, ITALY

Aims: The FIRST registry is designed to assess patient (pt) out-come and clinical practice in an unselected population of ptsimplanted with single- (SC), dual- (DC) or triple-chamber (CRT)defibrillators (ICD). This sub-analysis aims to identify the modelsof ICD routinely used in standard clinical practice in pts with pri-mary or secondary prevention implantation indications.Methods: To date data have been analyzed from 280 ICD pts (SC,DC, or CRT) from 42 European centers. Implant indications, accord-ing to the most recent ICD guidelines, were assessed for each pt.Results: pts were implanted for primary prevention in 57% ofcases, while 43% were implanted for secondary prevention.Primary prevention included 65% MADIT II, 17% SCD-HeFT, 9%MADIT I and 9% others; pts in secondary prevention wereimplanted due to Ventricular Tachycardia (VT) in 63%, VentricularFibrillation (VF) in 26%, and syncope + inducible VTs in 11% ofpts. Table 1 summarizes the differences in device prescriptionaccording to primary or secondary prevention indications.Conclusions: Primary prevention is a significantly more frequentICD implantion indication with respect to secondary prevention,in accordance with recent international reports. The rate ofimplant of DC ICD is higher in secondary prevention pts as com-pared to primary prevention pts, maybe due to superior perform-ances of pacing and detection algorithms in DC vs SC models. Onthe contrary CRT-D implants is used most as primary prevention,reflecting that the prevalent indication is the electrical treatment ofheart failure.

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SBD GroupPts (n)Normalized VTA incidence (Mean±SD) p* vs W

W 110 8.08±29.99 -

M 66 26.13±93.63 0.0111

S 41 62.27±215.39 0.0002

*p:prob>Chi-square (negative binomial distribution)

Primary Secondary pprevention indication prevention indication

SC 35% 41% 0.35 (ns)

DC 28% 47% 0.002

CRT 37% 13% <0.0001

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POSTERS SESSIONWednesday, December 1Thursday, December 2

1 - SIGNAL AVERAGED ELECTROCARDIOGRAPHY: A BETTERINDICATOR OF LEFT VENTRICULAR ENLARGEMENTM. ALASTI1, B. Omidvar1, M. Haghjoo2, A. Alizadeh2, M.H. Nikoo2,H.R. Bonajdar2

1Department of Cardiology, Imam Khomeini Hospital, Azadegan Avenue,Jundishapur University of Medical Sciences, Ahvaz, IRAN, 2Department ofPacemaker and Electrophysiology, Rajaie Cardiovascular Medical and ResearchCenter, Iran University of Medical Sciences, Tehran, IRAN

Purpose: Signal averaged electrocardiography is a noninvasivemethod to evaluate the presence of late potentials. The purpose ofthis study was to demonstrate the correlation of filtered QRS obtai-ned via signal averaged electrocardiography and left ventriculardimensions and volumes and comparing with standard 12-leadelectrocardiography. Materials and Methods: We included the patients with advancedsystolic left ventricular dysfunction (ejection fraction equal or lessthan 35%). We excluded patients with: (1) non-sinus rhythm; (2)previous pacemaker implantation; (3) a recent myocardial infar-ction (<3 months); (4) severe aortic disease. All patients underwentsurface 12-lead electrocardiography, signal averaged ECG, andechocardiography. Results: The study included 86 patients (M/F=57/19) with meanage of 54.66±13.23 years. The mean left ventricular ejection fraction(LVEF) was 18.31±5.49% and mean QRS duration was 0.14±0.02sec; 52% of patients had left bundle branch block. Mean filteredQRS duration was 145.87±24.89 ms. Our data showed a significantlinear relation between filtered QRS duration and left ventricularend-systolic volume (r=0.37, P:0.000), left ventricular end-diastolicvolume (r=0.31, P:0.004), left ventricular end-systolic diameter(r=0.24, P:0.031) and left ventricular end-diastolic diameter(r=0.23, P:0.039), although the correlation coefficient was not good.There was not any significant correlation between QRS durationand left ventricular diameters and volumes.Conclusion: Filtered QRS duration has a better correlation withleft ventricular dimensions and volumes than QRS duration instandard 12-lead electrocardiography.

2- PHRENIC STIMULATION THRESHOLD AND BODYPOSITION: IMPLICATIONS FOR LV PACING OUTPUTPROGRAMMINGM. BIFFI, B. Gardini, A. Mazzotti, V. Mantovani, G. Massaro, M. Ziacchi,M. Balbo, F. Bonfatti, M. Salomoni, G. Boriani

Institute of Cardiology, University of Bologna, Bologna, ITALY

Phrenic stimulation (PS) hinders CRT delivery. Pacing configura-tion programming is useful to overcome PS, nonetheless severalpatients may occasionally report PS symptoms at follow updepending on body position. We sought to understand the beha-viour of PS threshold on different body positions to assist LV out-put programming.Methods: 35 patients with occasional PS symptoms > 6 monthsafter implantation were evaluated. PS threshold and cardiac thre-shold were measured at the programmed pulse width in the con-figuration providing the greatest Phrenic-cardiac difference in 3different body positions: supine, left lateral, sitting.Results: PS threshold changed considerably depending on thebody position, whereas cardiac threshold had little change:Supine Left lateral SittingPhrenic threshold (V@0.4ms) 4.43±0.9 3.35±1.2 4.07±1.9Cardiac threshold (V@0.4ms) 1.07±0.6 1.09±0.5 1.11±0.6The difference between phrenic and cardiac threshold decreased inpositions other than supine.This may explain why PS symptomsdevelop in the positions where relevant periods of time are spent. Conclusion: This finding has several implications: LV outputshould be minimized to the lowest detected PS threshold; automa-tically adapted LV pacing can help to avoid PS provided that the

maximum adapted voltage is appropriately tuned; to avoid time-consuming ”customizing” of the LV output, automatic PS detec-tion coupled to LV output programming could be developed toimprove patients comfort. Blending automatic PS detection (orautomatic body position detection ) with automatic switch of thepacing configuration such as to avoid PS would prove a compre-hensive built-in solution that may allow effective CRT delivery,device longevity, and patients’ comfort.

3 - AUTOMATIC CAPTURE VERIFICATION IS SUPERIOR TOFIXED-OUTPUT STIMULATION: ENHANCED PACEMAKERLONGEVITY OVER A 10-YEARS FOLLOW UP

M. BIFFI, A. Mazzotti, B. Gardini, V. Mantovani, G. Massaro, M. Ziacchi,M. Balbo, F. Bonfatti, M. Salomoni, G. Boriani

Institute of Cardiology, University of Bologna, Bologna, ITALY

Aim of the study: The impact of an algorithm for automatic RVwas compared to fixed-output stimulation (shipment parameters)on actual pacemaker longevity over a 10-years follow up.Methods: Prospective observation of 300 patients implanted withVDDR/DDDR pacemakers in 1999-2000 up to March 31st 2010. 63patients were paced by AutocaptureTM (ACP), 237 were paced byfixed-output (FOP: 3.5V@0.4ms); they were seen twice yearly atthe pacemaker clinic. Atrial output was identical (3.5V@0.4ms) inthe 2 groups. Homogeneous device programming according topacing indications was achieved. Factors known to affect pacema-ker longevity were collected: median heart rate,%A&V paced acti-vity, pacing output and impedance, pacing indication. Patientsdead before pacemaker replacement, lost to follow up or develo-ping permanent AF were excluded from analysis.Results: 112/300 patients aged 75 (68-79) years at implantationcompleted the study for a median 105 (82-120) months follow up.Adverse clinical events due to an increased RV threshold occurredin 2 FOP patients compared to none among ACP. Pacemaker repla-cement occurred in 6/29 (21%) ACP patients vs 75/83 (90%) FOPpatients (p<0.001). ACP was the single independent predictor ofpacemaker longevity at multivariable analysis (HR=0.03, p<0.001)either in the overall population or in the specific patients sub-groups. In the FOP group, 12 patients had the same pacemakers asthe ACP group (algorithm not active): the replacement rate was9/12 (75%) at a median 96 (93-98) months service of life.Conclusions:. Automatic verification of stimulation is reliable atlong term, and warrants superior safety in the event of pacingthreshold changes. It allows a significant longevity increase com-pared to fixed-output stimulation, that may heavily impact thepatients’ quality of life and the cost of pacing therapy. Moreover, itis a fundamental technology in a strategy of remote monitoring,and may enable automatic device follow-up operated by trained,non-medical personnel.

4 - IMPLANTATION OF TWO-CHAMBER AND BIVENTRI-CULAR PACEMAKERS: VECTORCARDIOGRAPHIC DIA-GNOSTICS OF STIMULATION LEADS LOCALIZATIONV. ZALEVSKY, G. Knyshov, Y. Bilynskyi, V. Lazoryshynets, R. Vitovskyi,B. Kravchuk, K. Rudenko, O. Trembovetska, V. Beshliaga, M. Dyrda,M. Myroshnyk, L. Tokarska

M. Amosow National Institute of Cardio-Vascular Surgery, Kiyv, UKRAINE

Introduction: In order to optimize the clinical effect in the case oftwo-chamber pacing in HOCM patients, especially in the case ofbiventricular ES for resynchronization therapy in dilatation car-diomyopathy (DCM) patients, there is often a necessity to esta-blish whether it is captured ventricular lead stimulation, or whe-ther it is a left-ventricular lead shift from initial implantation loca-lization, and what is the contribution of right and left ventricularPO

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stimulation for fusion excitation. The 12-lead ECG analysis is hel-pful; however, until now certain variants of ECG have no uniqueinterpretation; therefore there is every reason to look for improvedof diagnostics.Objective: We intended to study the possibilities of vectorcardio-graphy (VCG) to improve the stimulating lead localization.Material and methods. The VCG of 78 HOCM and 43 DCMpatients was recorded. 10 of them were recorded directly duringbiventricular pacemaker implantation. All patients were examinedwith the help of complex echocardiography methods.Results: We have obtained VCG samples showing 3D sequence ofventricular excitation wave propagation from different localiza-tions of stimulating lead. We have also improved and simplifiedthe diagnostics of localization and possible dislocation of stimula-ting lead with the help of comparison of VCG loops registeredduring separate RV and LV stimulation with fusion stimulatingand spontanious excitation of both ventricles.Conclusion: 1. The registration of VCG loops in front, sagittal andtransverse planes superimposed with graded sectorial plots per-mits to instantaneously determine the dislocation of stimulatinglead during the pacemaker implantation.2. The VCG figures of 3D sequence of ventricular excitation wavepropagation during ventricular stimulation beat ECG in stimula-ting lead localization and improve understanding of ECG plotsformation.

5 - USEFULNESS OF QRS DURATION MEASUREDIMMEDIATELY AFTER IMPLANTATION TO PREDICTRESPONSE TO CARDIAC RESYNCHRONIZATION THERAPYF. QUADRINI, R. Memeo, V.E. Santobuono, P. Palmisano, L. Nuzzi, G. Luzzi,M. Anaclerio, F. Nacci, S. Favale

Cardiology Unit, University of Bari, Bari, ITALY

Purpose: Identification of responders (R) in patient (pts) selectionfor cardiac resynchronization therapy (CRT) remains a controver-sial topic. There is also interest in the clinical impact of wQRSchange after CRT. Aim of the study: to assess if wQRS prior andimmediately after device implantation is a predictor of response toCRT and to value if other predictors exist.Materials and Methods: wQRS was assessed before and immedia-tely after device implantation, by electrocardiographic evaluation,with a sliding velocity of 100 mm/s. After implantation wQRSanalysis was made after pacing parameters optimization. Each ptsunderwent to New York Heart Association (NYHA) functionalclass and 2D echocardiographic valuation, just before deviceimplantation and after 6 months. Pts who at follow up presented aNYHA functional class improvement greater than or equal to 1and a significant reverse remodeling were considered R. Results: We consecutively included 49 pts (82% males, 67±11years), affected by dilated cardiomiopathy (CMD) (55% of thosewith ischemic etiology), who underwent to successful CRTimplantation. At 7±1 months follow up, 28 pts (57%) were classi-fied as R. A wQRS statistically significant difference was showed,between before and after implantation, in both R and non respon-ders (NR) (152±23 vs 127±20 ms respectively in R; p<0.001. 155±27vs 131±17 ms respectively in NR; p:0.002). wQRS reduction(¶<delta>wQRS), by the CRT effect, was similar in two groups(25±25 vs 24±25 ms; p:0.92). Female gender and non ischemicCMD etiology were found as predictors of response to CRT (88.9%females vs 50.0% males R; p:0.033. 72.7% non ischemic vs 44.4%ischemic R; p:0.047). Conclusion: In our study wQRS prior and after device implanta-tion and their mutual difference were not predictors of response toCRT. Female gender and non ischemic CMD etiology were foundas a subgroup with higher probability of response to CRT.

6 - IDENTIFYING OPTIMAL LEFT VENTRICLE LEADPOSITION USING A NEW CORONARY GUIDEWIREWITH TEMPORARY PACING CAPABILITIES ANDNON-INVASIVE HEMODYNAMIC ACUTE MONITORINGA. D’ONOFRIO1, C. Cavallaro1, S. De Vivo1, A. Vecchione1, M. Cavallaro1,S. Comenale1, M. Iovino2, A. Gargaro2, P. Caso1

1Monaldi Hospital, Naples, ITALY, 2Biotronik Italia, Vimodrone, ITALY

Background: Despite effectiveness of Cardiac ResynchronizationTherapy (CRT) mainly relies on left ventricle (LV) lead positioningamong many other parameters, standard implanting proceduresmostly preclude LV lead site optimization. A new coronaryguidewire (Biotronik VisionWire [VW]) electrically isolated exceptfor the 15mm-long distal part, is specifically designed for tempo-rary pacing. In this study it was used to investigate whether the finalLV lead position always corresponded to the best accessible site.Methods and Results: 3 patients (2 male, mean age 73) with stan-dard indication for CRT-D were recruited. During implant, moni-toring of hemodynamic profile, including continuous pressure sig-nal and normalized stroke volume estimate (NSV), was non-inva-sively obtained with peripheral photoplethysmography andmodel flow (Finometer, Finapres Medical Systems BV, TheNetherlands). Pressure and NSV signals were recorded during ini-tial spontaneous rhythm, and VVI pacing 5bpm higher than theintrinsic rate, in the following configuration: spontaneous rhythm,right pacing, left pacing from two sites. At least, two different coro-nary branches were chosen basing on fluoroscopy imaging andreached (if accessible) with the VW guidewire. The final lead posi-tion was chosen considering normal parameters, including LVpacing threshold, phrenic nerve stimulation, lead stability,anatomic considerations. Pressure and NSV were post-processedto assess the best site, basing on pressure and NSV maximization.As compared with right pacing, systolic and diastolic pressuresincreased on average by 7%±4% and 3%±3% respectively, duringleft pacing; NSV by 9%±9%. In only 1/3 patients the final leadposition corresponded to the best accessed site assessed duringpost-processing analysis.Conclusions: VW guidewire and photoplethysmography mayrepresent effective tools for a rapid non-invasive assessment of dif-ferent LV lead positions. Final LV lead position may differ from theoptimal one. This study is still ongoing.

7 - CRT BY LV PACING SYNCHRONIZED WITH INTRINSICRV CONDUCTIONG. NERI1, S. Vittadello1, G. Masaro1, D. Vaccari1, A. Barbetta2, F. Di Gregorio2

1Cardiology Dept., General Hospital, Montebelluna (TV), ITALY, 2ClinicalResearch Unit, MEDICO Spa, Rubano (PD), ITALY

Background: Cardiac resynchronization therapy (CRT) is general-ly applied in patients affected by HF and LBBB, often featuringnormal or mildly slowed AV conduction in the right heart. In thesecases, the delayed LV activation usually treated with biventricular(biV) pacing could be corrected by LV pacing alone, properly syn-chronized with the intrinsic RV conduction. This approach wouldproduce the main benefit of reducing the total pacing energy whilepreserving the physiological RV contraction pattern. Methods: Four patients, undergoing elective replacement of biVpacemakers, were implanted with a 3-chamber stimulator allo-wing independent management of RV and LV pacing and sensing(Helios 300, Medico). The stimulator was programmed to pace theLV preceding the intrinsic R-wave detection in RV. The anticipa-tion was individually adapted in order to minimize the interven-tricular desynchronization (VVD), as assessed by echo-Doppler ofthe aortic and pulmonary flow. A full echocardiographic examina-tion was then performed to compare the main hemodynamic para-meters with early LV and synchronous biV pacing.Results: Intrinsic AV conduction with LBBB entailed 75±15 msPO

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VVD. LV pacing synchronous with RV sensing had a poor impacton VVD (70±14 ms). In contrast, LV pacing preceding RV sensingby 89±23 ms (range 60-110) reduced VVD to 22±9 ms. With respectto biV pacing in standard configuration (synchronous RV and LVstimulation with 152 ms AV delay), early LV pacing alone induceda remarkable acute increase in LVEF (+12±2%), in the velocity-timeintegral of the aortic flow (+15±14%), and in the systolic excursionof the tricuspid annulus (TAPSE: +33±18%).Conclusions: In patients endowed with intrinsic conduction, LVpacing alone could be a valuable alternative to biV pacing, provi-ded that the LV stimulation is delivered well before the R-wavedetection in RV. In our experience, this pacing modality abolishedthe VVD and improved the systolic function in both ventricles.

8 - LONG-TERM EVALUATION OF CARDIAC RESYNCHRO-NIZATION THERAPY: BENEFIT PREDICTORSC. PIGNALBERI, F. Saputo, B. Magris, S. Aquilani, V. Altamura, R.P. Ricci,M. Santini

Department of Cardiology, San Filippo Neri Hospital, Rome, ITALY

Background: Cardiac Resynchronization Therapy (CRT) is the lastfrontier of non-pharmacologic treatment of heart failure. However,in many experiences, almost a third of patients (pts) enrolled didnot experienced any benefit; the reasons are still not completelyunderstood. Aim of our study is to identify the features of respon-ders pts Vs non-responders in the entire population of pts implan-ted in S. Filippo Neri Hospital.Methods and population: From February 1999, 320 pts have beentreated with CRT according to International Guidelines. We per-formed a retrospective analysis, dividing our population inresponders and non-responders, according to the NYHAFunctional Class (at least Class II or improvement after theimplant) (Par. 1) and to the hospitalization number (< 1 in the yearafter the implant or in the year before the follow-up) (Par. 2a and2b, respectively), evaluating each criterion alone or in combina-tion. Then, we evaluated the differences between the two subpo-pulations in relation to the clinical and surgical variables. Results: The median follow-up was 25 months; 53 pts (17%) werelost at the follow-up and excluded from statistical analysis.According to Par. 1, 127 pts (50%) were classified as responders,while 103 (42%) and 98 pts (40%) according to par. 1 + 2a and Par.1 + 2b respectively.Conclusions: After a long-term follow-up, 87% of pts are stillalive. 50% and 40% of those can be classified as responders, accor-ding to NYHA class, and to the combination of NYHA class andhospitalizations in the last year, respectively. The only indepen-dent predictive factor of CRT success is diabetes mellitus.

9-THE PROBLEM OF NON-RESPONSE TO CARDIAC RESYN-CHRONIZATION THERAPY: A SINGLE CENTER EXPERIENCES. MAFFE’, A. Perucca, P. Paffoni, U. Parravicini, P. Dellavesa, A.M. Paino,M. Bielli, L. Cucchi, F. Zenone, N. Franchetti Pardo, F. Signorotti, M. Zanetta

Division of Cardiology, SS Trinita’ Hospital, ASL No, Borgomanero, ITALY

Cardiac resynchronization therapy (CRT) has been demonstratedto have significant favourable effects in patients with severe heartfailure and wide QRS complex. Several studies have shown positi-ve clinical and haemodynamic effects of CRT, with significantreduction in mortality and morbidity. However a consistent num-ber of patients fail to benefit from CRT, and the percentage ofresponders patients is 60-70% in different series in literature. Thedefinition of responder patient may also vary according to theparameter used to identify the clinical response. Aim of this paperis to highlight the extreme variability of the concept of responderto CRT in a population of patients implanted in a single center ofmedium size, using different indicators of response. Forty-seven

patients treated with CRT were included (35 men, mean age 71± 9years); the patients underwent clinical and echocardiographicassessments at baseline and at 1-6-12-24-36-48-60 months follow-up. To evaluate the response to CRT were used the criteria morecommonly reported in literature: a >5%, >15% and >25% increasein left ventricular ejection fraction (LVEF); a >15% decrease in leftventricular end-systolic volume; a > 1class increase in NYHA clas-sification. The mean follow up is 18±14 months. The responderpercentage is 96%, 87% and 79% with the >5%, >15%,>25% increa-se in LVEF criterion, respectevely. Ninety-one percent of patientspresent a > 1class increase in NYHA classification and 72% ofpatients have a >15% decrease in left ventricular end-systolic volu-me. In the presented population will show a good response to CRTwith each of the used methods for the evaluation. However, wedocumented a significant variability in the respondes percentage,depending on the criteria used. We believe it is to emphasize theimportance of standardizing the criteria for assessing response toCRT, in order to make better comparable series and results

10 -THE RELATIONSHIP OF NON-SUSTAINED VENTRICULARARRHYTHMIAS AND MAJOR EVENTS IN CRT-D PATIENTSF. VECCHIO, L.P. Papavasileiou, A. Topa, G. Panattoni, D.G. Della Rocca,A. Di Molfetta, V. Minni, M. Cesario, C. Tota, F. Paparoni, L. Santini,G.B. Forleo, G. Magliano, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

Background: Non-sustained ventricular tachycardia (NSVT) is afrequent phenomenon in patients with heart failure, but its asso-ciation with sustained ventricular arrhythmias is still not clear. Aim of our study: Whether NSVT’s has a cause-and-effect relation-ship with sustained ventricular arrhythmias in CRT-D patients. Methods: Retrospective data analysis was conducted in 88 conse-cutive CRT-D patients (69 male, 19 female, mean age 71±9 y.o)during a mean follow-up of 21±16 months. During every follow-up ventricular arrhythmias were registered and classified inNSVT: ventricular arrhythmias not leading to ICD appropriate tre-atment and VT: events leading to appropriate discharge. Patientswere divided in two group. Group NSVT +: presence of NSVTduring follow-up, Group NSVT -: absence of NSVT during follow-up. Results:. Group NSVT + consisted in 39 patients (44%).Appropriate ICD discharge in this group was 23% at a meanperiod of 10.6±7.6 months. Inappropriate discharge was 5%.Group NSVT- consisted in 49 patients (56%). Appropriate ICDdischarge was 6% at a mean period of 15.5±10.8 months.Inappropriate discharge was 2%. Statistical analysis between thetwo groups showed that the presence of NSVT during FU predictmajor arrhythmic events. (p=0,04).Conclusions: Patients with heart failure treated with CRT-D, expe-rience frequently major arrhythmic events. The presence of NSVTduring follow-up predicts future events.

11 - USE OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORAND CARDIAC RESYNCRONIZATION THERAPY IN HIGHRISK PATIENTS: AN ITALIAN SURVEY STUDY ON 220CARDIOLOGY DEPARTMENTSG. INAMA1, C. Pedrinazzi1, M. Landolina2, F. Oliva3, L. Inama1, M. Zoni Berisso4

1Dipartimento Cardiocerobrovascolare - Azienda Ospedaliera OspedaleMaggiore, Crema, ITALY, 2Dipartimento di Cardiologia, Fondazione PoliclinicoS. Matteo IRCCS, Pavia, ITALY, 3Cardiologia 2, Dipartimento Cardiologico “A. DeGasperis”, Milan, ITALY, 4Ospedale Padre Antero Micone ASL 3, Genoa, ITALY

Introduction: In this study we evaluated, by means of a nationalsurvey involving Italian Cardiology Departments, the criteria andthe decision-making process for the use of ICD/CRT. The additio-nal aim was to evaluate how the indications for the use of ICD andCRT, according to the current European Guidelines, are applied inPO

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a “real life” scenario and the level of adherence to Guidelines. Methods: Our clinical survey involved 220 Italian CardiologyDepartments (“Progetto Area Aritmie ed Area ScompensoANMCO”). A dedicated questionnaire Report Form for the appro-priate data collection was used for the required data. The surveywas performed in the period 2008-2009. Results: 68% of Centres performed ICD and CRT implantation.The average number of implants was 59 per year with a total num-ber of 12.980 of procedures per year. Arrhythmic risk stratificationwas commonly tested in 76.4% of the Centres. The most commoncontraindication for ICD/CRT implant was concomitant diseasesor old age. Regarding the level of adherence to the CurrentGuidelines, the questionnaire specifically asked which was thedecision approach for 3 different clinical scenarios. Regarding thelevel of adherence to the Current Guidelines, the questionnairespecifically asked which was the decision approach for 3 differentclinical scenarios. The first clinical scenario described a patientwith non-ischemic dilated cardiomyopathy and EF=35%. Thesecond clinical scenario regarded a patient with ischemic dilatedcardiomyopathy and EF=30%. The third clinical scenario descri-bed the case of a patient with ischemic dilated cardiomyopathyand EF between 30 and 40%. Discussion: The findings of our survey indicate that in Italy themajority of Centres routinely performs ICD and/or CRT implanta-tion. This survey has shown that the adherence to EuropeanGuidelines for the implantation of ICD and CRT in ItalianCardiology Departments could be considered generally good.

12 - ARE THE RESULTS OF THE SCD-HEFT TRIAL APPLICABLEIN OUR CLINICAL SETTING?J. MARTÍNEZ, P. Peñafiel, I. Garrido, F. Pastor, J.J. Sánchez,G. De La Morena, D. Pascual, A. García, M. Valdés

Hospital Universitario Virgen de la Arrixaca, Murcia, SPAIN

Introduction: current guidelines suggest the implant of an auto-matic implantable cardioverter defibrillator in patients with non-ischemic dilated cardiomyopathy, left ventricular ejection fraction(LVEF) 35% and NYHA class II-III. This recommendation is main-ly based on a study (SCD-HeFT) in which patients had a medianejection fraction of 25% [20-30%].Objective: to evaluate the characteristics of the population thatmeets these criteria in our clinical setting.Methods: retrospective and observational study of patients atten-ded in a specialized heart failure clinic between February 1999 andApril 2010. We included patients with non-ischemic dilated car-diomyopathy in stable clinical condition, on optimal medical treat-ment, II-III NYHA class and left ventricular ejection fraction °‹35%. Patients with a cardiac resynchronization therapy deviceindication were excluded.Results: 96 patients were included. Our data, compared to those ofSCD-HeFT study population, are similar in terms of age [60 (50-69)vs 60 (52-69)], gender (men 75% vs 76.7%) and NYHA class(NYHA II 73% vs 70%), but differ in median LVEF [30 (24-32) vs 25(20-30)] and in the number of patients with LVEF between 31 and35% (34.4% vs 17%).Conclusion: using the same inclusion criteria, our population dif-fers clearly from that of the SCD-HeFT trial in LVEF distribution.These data, together with the fact that patients who benefit mostfrom automatic implantable defibrillator therapy are those withlower LVEF, put into question that the results of SCD-HeFT trialshould be extrapolated to our population.

13 - COMPLICATIONS DEVICE LONGEVITY ANDPATIENT SURVIVAL IN THE SWEDISH PACEMAKER ANDICD REGISTRYF. GADLER, C. Linde

Dept. Cardiology, Karolinska Hospital, Stockholm, SWEDEN

Background: The Swedish National Pacemaker Registry was star-ted 1989 and now covers all pacemaker (PM) and implantable defi-brillator (ICD) implants in Sweden. Up to now 90 000 patientshave been entered. The registry is internet based with onlineaccess for the users with full search and statistical options availa-ble for the users.Methods: Data from 87380 PM and 5929 ICD implants were usedto calculate patient survival after first implant. Device longevitywas analyzed in all device models implanted in > 100 examples.Patient survival and complication rate was analyzed in both PMand ICD patient groups.Results: Device longevity differed among manufacturers as awhole, fig 1-4, but among models the differences were even morepronounced both as regards to PM and ICD’s. PM patients hadgenerally poorer survival rate than ICD patients and were older atfirst implant (76/77 years Male/Female vs. 63/60 years M/F).Complication rate in PM implantation was 5,6% and in ICDimplantation 6,1%.Conclusion: Device longevity is both manufacturer and modeldependant and differences are pronounced. Patient survival isgenerally poorer in PM patients compared to ICD patients.Complication rate in PM and ICD therapy is low.

14 - ICD PRICING IN THE REAL-LIFE SCENARIO:UP-FRONT COST OR DAILY COST?M. BIFFI, B. Gardini, A. Mazzotti, G. Massaro, M. Ziacchi, F. Bonfatti,M. Salomoni, M. Balbo, V. Mantovani, G. Boriani

Institute of Cardiology, University of Bologna, Bologna, ITALY

Background: We firstly reported that ICD longevity is significan-tly different among manufacturers. Health care systems are sensi-tive to ICD up-front cost, but this may prove unreliable, being notrelated to longevity. We calculated the daily cost of ICDs from dif-ferent manufacturers based on their actual longevity as measuredat device replacement.Methods: Longevity of single chamber (SC), double chamber(DC), and biventricular (BiV) ICDs from Medtronic (MDT),Guidant (GDT) and St. Jude Medical (SJM) was measured in all thepatients implanted in years 2000, 2001, 2002 who reached devicereplacement within December 31st 2009. The cost of each ICD(device + lead/s) was divided for its own longevity. Data areexpressed as median (25th-75th percentile).Results: 123/153 (80%) patients implanted in the abovementionedperiod survived until ICD replacement. Longevity of SC deviceswas 86 (80-101), 53 (45-63), and 56 (50-60) respectively for MDT,GDT, SJM (p<0.001), whereas it was 84 (79-86), 51 (45-55), and 41(37-56) months respectively for MDT, GDT, and SJM DC devices(p<0.001).CRT-Ds were respectively replaced after 81 (67-89)(MDT), 44 (43-45) (GDT), and 44 (43-45) (SJM) months (p<0.05).MDT devices had a significantly lower daily cost compared toother manufacturers (p<0.001)ICD cost/day (Ä)Single Chamber (n=63)Double chamber (n=50)CRT-D(n=10) PMedtronic (n=23) 4.8 (4.6-5.7) 6.9 (6.8-7.7) 8.5 (8.3-10.3) 0.004Guidant (n=43) 6.8 (6.2-9.2) 12.6 (11.8-13.3) 15.4 (15.1-15.8) <0.001St Jude Medical (n=57) 6.9 (6.2-7.6)13.4 (10.3-16.1) 14.6 (14.1-14.9) <0.001P <0.001 0.001 0.10PO

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Conclusions:. Cost effectiveness computations of ICD treatmentshould be based on ICD longevity and cost in the real-life scenario,whereas device upfront cost is of limited clinical meaning.Independent observations in the real-life scenario are needed toproperly value newer technologies against actual benchmark

15 - PRACTICE PATTERNS AND EFFICACY OF IMPLANTABLECARDIOVERTER DEFIBRILLATOR IMPLANTATIONS IN ATERTIARY CENTER OF NORTHERN GREECEV. Vassilikos, A. Vosnakidis, L. Mantziari, K. TSILONIS, S. Paraskevaidis,G. Dakos, G. Stavropoulos, G. Efthimiadis, S. Mochlas, G. Louridas,G. Parcharidis, I. Styliadis

Aristotle University of Thessaloniki, AHEPA Hospital, First CardiologyDepartment, Thessaloniki, GREECE

Purpose: To assess the routine clinical practice and the effective-ness of implantable cardioverter defibrillators (ICDs) in a tertiarycenter of Northern Greece.Methods: Data concerning indications for implantation and activa-tion of ICDs were analyzed, as well as the clinical course of patientswho received an ICD in our center during the years 2002-2007.Results: Two hundred and twenty ICDs were implanted (28% forprimary and 72% for secondary prevention) in patients aged 62±12years (199 males/21 females), according to indications suggestedby the European Guidelines and limitations dictated by the GreekNational Health Council. Most common etiologies were ischemiccardiomyopathy for both primary (38%) and secondary preven-tion (78%) and hypertrophic cardiomyopathy mainly for primaryprevention (35%). After a mean follow up of 38±17 months (5-73months) we observed appropriate activation of the ICD in 31%and 49% in primary and secondary prevention groups respective-ly (42% in total). Left ventricular ejection fraction <=30% was theonly factor that correlated with increased probability of appropria-te activation of the ICD in the secondary prevention group (51%versus 37%, p<0.07). Inappropriate activation of the ICD wasobserved in 11% and 9% in the primary and secondary preventiongroups respectively and was caused mainly by atrial fibrillation orother supraventricular tachyarrhythmias. Mean patient survivalwas 60 and 68 months (p=NS) respectively for the primary andsecondary prevention groups. Survival was better in patients withLVEF >30% (70 months versus 64 months in patients with LVEF<=30%, p=0.055).Conclusions: Routine clinical practice regarding ICD implantationin our center is characterized by high appropriate activation rateand increased survival of patients receiving ICDs.

16 - TRIGGERS AND OUTCOME OF ACCELERATEDVENTRICULAR TACHYARRHYTHMIA IN PATIENTS WITHIMPLANTABLE CARDIOVERTER DEFIBRILLATORC. SCHUKRO, L. Leitner, J. Siebermair, T. Pezawas, G. Stix, J. Kastner,M. Wolzt, H. Schmidinger

Medical University of Vienna, Vienna, AUSTRIA

Background: Anti-tachycardia pacing (ATP) and shock deliverymay induce or accelerate tachyarrhythmia in patients withimplantable cardioverter defibrillator (ICD).Methods: This analysis investigates the triggers and the outcome ofaccelerated ventricular tachyarrhythmia by ATP or shock in a collec-tive of patients with ischemic cardiomyopathy (37.2%), coronary arte-ry disease without heart failure (26.1%), non-ischemic cardiomyopa-thy (20.2%), and other indications for ICD implantation (16.5%). Results: Until December 2009, ICD was implanted in overall 1275patients (age at implantation 59.7±14.0 years; 81% male). Within amean follow-up period of 5.3±4.0 years, intracardiac electrogramswere available in 1170 patients (97.5%). Overall 157 episodes of acce-lerated ventricular tachyarrhythmia were found in 100 of 1170

patients (8.5%). Termination of tachyarrhythmia was achieved byshock delivery in 153 episodes (96.8%). Triggers of acceleratedtachyarrhythmia were appropriate ATP in 141 (89.8%) and inappro-priate ATP in 12 (7.6%), as well as appropriate and inappropriateshocks in 2 (1.3%) episodes, respectively; 7 out of 100 patients hadmore than one cause for acceleration. After re-programming of ATPparameters, 31 patients (31%) had recurrent episodes of acceleratedarrhythmia. Patients with accelerated ventricular tachyarrhythmiarevealed higher all-cause mortality (46% versus 29.9%; p=0.001), aswell as higher cardiac mortality (16% versus 6.5%; p<0.001).Conclusions: Accelerated ventricular tachyarrhythmia is a fre-quent and serious complication of ICD interventions, which pro-vokes avoidable shock delivery and is associated with a higher all-cause and cardiac mortality. Despite re-programming of ATP para-meters, recurrence of accelerated arrhythmia was still frequent inthese patients.

17 - OUTCOME IN ISCHEMIC CARDIOMYOPATHYPATIENTS RECIPIENTS OF IMPLANATBLE CARDIOVER-TER-DEFIBRILLATORK. POLYMEROPOULOS, P. Ioannidis, E. Keklikoglou, D. Papakonstantinou,J. Zarifis

G. Papanikolaou Hospital, 1st Cadriology Department, Thessaloniki, GREECE

Purpose: To assess the outcome of patients with ischemic cardio-myopathy (ICM) implanted with a cardioverter-defibrillator (ICD).Materials and Methods: From June 2007 to August 2010, 38patients suffered from ICM received an ICD in our Institution.Group A consisted of 19 patients (17 males, mean age 69±10 years)who received an ICD for primary prevention, while Group B con-sisted of 19 patients (19 males, mean age 71±11 years) who recei-ved an ICD for secondary prevention. The follow-up period wasmonths 11±9 months. There was no statistical difference betweenthe two groups concerning age (p=0.43), sex (p=0.48), left ventricu-lar ejection fraction (p=0.9), history of atrial fibrillation (p=0.31),pharmacologic treatment (ACE inhibitors or ARBs p=0.49, furose-mide p=0.48, eplerenone p=0.3 and statins p=0.48). All patientsreceived amiodarone and b-blocker. Results: No statistical significance was demonstrated betweengroups concerning appropriate interventions (4 patients in group Aand 6 in group B) and time to first appropriate intervention (p=0.54).Two patients in each group received inappropriate shock, mainlydue to atrial fibrillation (p=1) and there was not statistically signifi-cant difference about the time of the event (p=0.48). During the fol-low-up period, there were 3 deaths in group B (p=0.07). Conclusions: In our cohort of ICM patients with ICD, neither thefrequency nor the time to first event, either for appropriate or forinappropriate interventions seemed to be statistically significant,between primary or secondary prevention patients.

18 - SUBCUTANEOUS ICD IMPLANTATIONG. Zuccon1, V. Ardente2, M. BENCIVENNI2, E. Algeri2, S. Russo2, D. Baldazzi2,A. Montin1

1MedicoPace S.p.a., Rubano (PD), ITALY, 2Cardiology Unit, Carpi (MO), ITALY

Traditionally implantable cardiac ICDs require the insertion of atleast one lead into cardiac chambers. Conventional transvenousleads are responsible for detecting cardiac rhythm and for the tran-smission of lifesaving electric shocks after detection of malignantarrhythmias. The surgical implantation of these permanent transve-nous leads inside the cavity of the patient’s heart is associated with asignificant percentage of complications within widespread andhighly effective therapy. The S-ICD defibrillator developed byCameron Health Inc. (San Clemente - California), instead is implan-ted just under the skin, which potentially avoid many of the compli-cations associated with traditional implant procedure and electrodePO

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performance problems in the long term. The S-ICD defibrillator hasalso been designed to ease the implantation and explantation. Thismay lead to a more predictable time taken to perform the surgicalprocedure. The S-ICD defibrillator is the first completely subcutane-ous implantable cardioverter defibrillator to be used for the treat-ment of sudden cardiac arrest. For this new implant technique, thereis no requirement for the use of X-ray fluoroscopy. The S-ICD defi-brillator consists of the following components: SQ-RXô PulseGenerator, Q-TRAKô Subcutaneous Electrode, Q-GUIDEô ElectrodeInsertion Tool and Q-TECHô Programmer. The defibrillator isimplanted subcutaneously (just below the skin) with the electrodepositioned parallel to the sternum. An advanced integrated pro-gramming system developed specifically for the S-ICD defibrillator,allows wireless programming and telemetry.

19 - CLINICAL OUTCOME OF DUAL CHAMBER PACINGAND RECURRENCE OF SYNCOPE IN 14 CARDIOINHIBI-TORY SYNCOPE PATIENTSA. YAMINISHARIF1, R. Yaminisharif2, G. Davoodi1, A. Kazemisaeed1,A. Vasheghani-Farahani1, A. Shafiee3

1Tehran Heart Center, Depertment of Electrophysiology, Tehran, IRAN, 2IslamicAzad University, Faculty of Medicine, Tehran, IRAN, 3Tehran Heart Center,Depertment of Clinical Research, Tehran, IRAN

Objective: Since pacing therapy is considered as the last therapeu-tic option in cardioinhibitory syncope, we decided to investigatethe outcome of this method in these patients.Methods: 157 syncope patients [87 male and 70 female] wentunder tilt-table testing (TTT) in Tehran heart center from March2005 to March 2008; 14 patients [6 male and 8 female; 6<40 years]with cardioinhibitory response without responding to conservati-ve treatments met our clinical criteria and received a dual chamberpacemaker with rate-drop response ability. They were tilted againand followed-up. Results: After a mean follow-up of 390.33 ±193.74 days, 3 patientsremained symptomatic with a prominent vasodepressive compo-nent during TTT. They were treated pharmacologically. Two casesresponded well and one had presyncope. Complications includedatrial lead dislodgement and loss of ventricular capture so theirpacemaker mode was changed into VVI and AAI respectively andfollow-up was continued. No deaths or any other life-threateningevent happened during the study.Conclusion: We observed that permanent pacemaker is an effecti-ve treatment in highly symptomatic patients who do not respondto pharmacologic treatment even in those who are younger than40. Moreover, it can improve patients’ condition. Further control-led trials are needed to prove this fact.

20 - INTRAOPERATIVE DEFIBRILLATION EFFICACY OFTHE SINGLE COIL ICD-LEAD SPRINT QUATTRO SECURE S6935L. BINNER, G. Grossmann, D. Walcher, P. Stiller, W. Rottbauer, S. Stiller

University of Ulm, Medical Clinic II - Cardiology, Ulm, GERMANY

Purpose: To evaluate defibrillation properties of the single coilscrew-in ICD-lead Sprint Quattro Secure S 6935 (Medtronic Inc.,Minneapolis, MN, USA).Methods: A total of 123 patients (pts.) (82 male, mean age 60±15years) had been implanted with a Sprint Quattro Secure S lead.Primary implantation was performed in 97 pts. (46 single chamber,20 dual chamber 31 CRT-D), the others had lead replacement dueto different reasons. All of the implanted ICD devices had a capa-bility of delivering a 35 J energy shock. Intraoperatively, the ener-gy needed to effectively defibrillate induced ventricular fibrilla-tion was tested in 117 pts., contraindication for testing was ventri-cular thrombus formation in 5 pts.. Right pectoral device implan-tation had been performed in 5 pts., 12 pts. were on amiodaronetreatment. In all pts. at least two testings were performed duringimplantation procedure. Device programming for testing purpo-ses was as follows: 1.testing: 12Joule-18J-35J-external defibrillation2. testing: 9J-15J-35J-external, or, if necessary due to the firsttesting, the programmed starting energy was higher. In most of thepatients VF was induced delivering a 1J T-wave shock.Results: In mean, the lowest energy effectively terminating indu-ced VF was 12J±4,5J. In 65 pts. (56%) VF could be terminated witha 9 J shock, in another 24 pts. (20,5%) by means of a 12 J shock deli-very. However, in 3 pts. (2,6%) the implantation of an additionalsuperior vena cava lead (SVC-lead) was necessary to maintain a10J safety margin to maximum device output.Conclusion: Maintaining a 10J safety margin the single coil screw-in ICD-lead Sprint Quattro Secure S 6935 allows safe ICD-Implantation in 97,4% of the pts.. In 76,5% of the pts. the defibril-lation energy needed was < 12 J. In 2,6% of the pts. an additionalplacement of a SVC-lead was necessary. Intraoperative testing stillseems to be mandatory.

21-LONG-TERM CHANGES IN INTRACARDIAC IMPEDANCEIN CARDIAC RESYNCHRONIZATION THERAPY PATIENTSF. GADLER1, N. Holmstrom2, S-E Hedberg2, A Karlsson2, C Valzania3,M.J. Eriksson1

1Karolinska University Hospital, Stockholm, SWEDEN, 2St. Jude Medical AB,Jarfalla, SWEDEN, 3University of Bologna, Bologna, ITALY

Purpose: Cardiogenic impedance (CI) is derived from dynamicintracardiac impedance signals measured between implantedpacemaker lead electrodes. Continuous monitoring of these CIsignals may be used to monitor cardiac function in congestiveheart failure (CHF) patients (pts) treated with cardiac resynchroni-zation therapy (CRT). The objective of this pilot study was to inve-stigate the long-term stability of CI and the feasibility to monitorresponses to CRT during one year follow-up.Methods: Five CHF pts (NYHA class III-IV) with LBBB wereimplanted with a commercial CRT-D system. Using a research toolin the CRT-D, CI was acquired from pts in the supine position at 3follow-up intervals: 11, 12, and 69 weeks post-implant. P-wavetracked biventricular pacing with optimized AV- and VV-delayswas used. CI was measured between tip and ring electrodes inright ventricle (Z1) and between right atrial ring and left ventricu-lar ring electrodes (Z2) and analyzed with respect to changes in thesignal amplitude and morphology. At each follow-up echocardio-graphy (ECHO) was performed simultaneously with the CI mea-surements. The end-diastolic left ventricular volume (LVEDV) andejection fraction (LVEF) were compared with CI variables.Results: At 69 weeks post implant, reverse remodeling occurred in4 of 5 pts. LVEF improved 44±48% and LVEDV decreased -32±18%.PO

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The peak-to-peak (p2p) amplitude of Z1 increased 48±58% and theaverage amplitude of Z2 increased 5±8%. The impedance wave-form was relatively unchanged in 4 pts but differed in 1 (Pt 4).Conclusions: This pilot study shows that CI signals are associatedwith volumetric information of the heart corresponding to ECHOdata. The waveforms recorded from two CI vectors were relative-ly stable over time. The p2p amplitude of Z1 and average amplitu-de of Z2 correspond well with the ECHO derived LVEF andLVEDV, respectively.

22 - EIGHT PATIENTS UNDERGOING PERMANENTRIGHT BIFOCAL STIMULATIONM. MARINI1, P. Baraldi2, A. Montin3, G. Zuccon3, A. Andraghetti3

1I.N.R.C.A. Cardiology Unit, Ancona, ITALY, 2S. Agostino Estense HospitalCardiology Unit, Modena, ITALY, 3Medico S.p.a., Rubano (PD), ITALY

Traditionally right ventricular apex stimulation produces an ECGpattern similar to left bundle branch block with alterations indepolarization and contraction. In the literature, important clinicaltrials, that documented the negative effect of right apical pacingfrom a clinical point of view, have been published. Right bifocalstimulation performed with two endocavitary leads, one positio-ned in the interventricular septum and one in the apex, may be analternative proposal to biventricular stimulation in patients withwide QRS and low ejection fraction. This method has been appliedto solve failed attempts to place in stable position the lead in coro-nary sinus branches. We studied 8 patient in bifocal stimulation.They have already been implanted with DDD pacemaker and, atthe elective replacement, a third screw-in lead was positioned ininterventricular septum. The pacemaker used for ventricular rightbifocal stimulation is the model Helios 300, manufactured byMEDICO Spa. This pacemaker equipped by TVI sensor (trans-val-vular impedance), provides also a continuous monitoring of stro-ke volume. An echocardiographic exam was performed before PMreplacement, to evaluate the ejection fraction and the dimensionsof the hearth. At follow-up checks, every 9 months, the echocardio-graphic exam is performed once again and the ECG recorded inthree different configurations: right apex, right septum and rightbifocal. In this phase (9 months after implant date), an interestingissue is given from the enlargement of QRS: the average width ofQRS is 185±20 ms for apical stimulation, 165±10 ms for septal sti-mulation and 145±10 ms for bifocal one.Conclusions: this first initial experience confirms the idea that thistype of stimulation can be dedicated to patients with indication ofdefinite pacemaker implantation, which present a slight intraven-tricular conduction delay.

23 - COMPARISON OF METHODS IN REDUCING RIGHTVENTRICULAR PACING AND ITS CLINICAL IMPLICATIONS:IS THE DIFFERENCE WORTH IT?V. GOURINENI1, K Wong2, M Hyder2, E Tiffany-Ellis2, R Davoudi2

1Pennsylvania Hospital, University of Pennsylvania Health System,Dept ofInternal Medicine, Philadelphia, USA, 2Pennsylvania Cardiology Associates,Philadelphia, USA

Background: Right ventricular pacing (RV) has been associatedwith worsening heart failure, ventricular dyssynchrony and atrialfibrillation. Managed ventricular pacing (MVP) and search AVhysteresis (SAV) are two algorithms used to minimize unnecessa-ry RV pacing. The former algorithm has been shown to provide asmall but statistically significant reduction in RV pacing but at thecost of increased symptoms and expense to the healthcare system.No prior studies have assessed differences in incidences of atrialfibrillation between these algorithms.Methods: Retrospective dual chamber pacemaker data were ana-lyzed from patients (n=53) who presented for standard interroga-

tion. Patients were divided into MVP (n=24), search AV hysteresis(n=15) and standard AV delay programming (n=14). Percentageventricular pacing, percentage mode switch and hospitalizationsfor heart failure were analyzed. Results: Percentage ventricular pacing in the MVP, SAV and stan-dard groups were 22.0%, 30.8%, and 52.4% respectively. Right ven-tricular pacing was significantly less (p= 0.034) in the MVP groupas compared with the standard group. No difference was noted inthe percentage of ventricular pacing between the MVP group andthe SAV group (p = NS). The mean percent mode switch was0.52%, 5.0% and 9.5% in the SAV, MVP, and standard groupsrespectively (p =NS). Hospitalizations for heart failure in each ofthe three groups were not statistically different. Anti-arrhythmicand beta blocker therapy and history of atrial fibrillation prior toimplantation were similar in all three groups (p = NS).Conclusion: No significant difference in heart failure hospitaliza-tions or mode switch burden was noted between the SAV andMVP groups. Since the MVP algorithm is associated with a signi-ficant increase in cost, further large scale trials are needed to eluci-date the clinical impact of SAV versus MVP given minor differen-ces in ventricular pacing.

24-A VARIATION OF CARDIAC FUNCTION BY THE DIFFE-RENCE OF QRS DURATION IN THE VENTRICULAR PACINGM. SHIMA, Y. Deguchi, D. Fujibayashi, T. Hashida

Tokai University School of Medicine, Department of Cardiology, Isehara, JAPAN

Background: Although a pacemaker therapy is useful treatment inatrioventricular block (AVB) patients, ventricular pacing may havea bad influence in cardiac function. The purpose of this study isconsidering the impact of the difference of QRS duration in thetime of the sinus rhythm and ventricular pacing, and the differen-ce of ejection fraction (EF).Methods: The pacemaker operation was enforced to 314 patientsby AVB. In 61 cases which planted in 314 patients, the QRS dura-tion extended by ventricular pacing. In the case which QRS dura-tion extended by ventricular pacing, the difference of the BNPvalue in a cardiac dysfunction group (EF<50%) and a good fun-ction group (EF>50%) was compared.Results: The cardiac dysfunction group is consist of 17 patients(28%). After ventricular pacing in this group, the BNP valueincreased in 14 patients (83%). The elevation of the BNP value wasseen in all the patients whose QRS duration prolonged more than20 ms, and the value of BNP does not change in the group whichdoes not have a prolongation in QRS duration after ventricularpacing. In the group of good cardiac function (EF>50%), the varia-tion was not looked at by the BNP value. As for this, the sameresult was obtained also in the group for which QRS duration doesnot change.Conclusion: With the case in which cardiac dysfunction, it wassuggested that a prolongation of the QRS complex by ventricularpacing causes further worsening of cardiac function.

25 - PERMANENT PACING VIA A LEFT VENTRICULAR LEADIN A PATIENT WITH AN ARTIFICIAL TRICUSPID VALVEL. BINNER, J. Homann, S. Stiller, D. Walcher

University of Ulm, Medical Clinic II - Cardiology, Ulm, GERMANY

A 69 years old female patient with mitral valve replacement in1996 and tricuspid valve replacement 2008 (bioprothesis) andchronic atrial fibrillation developed bradycardia with a heart rateof less than 40 bpm. A bipolar left heart lead (Attain 4194,Medtronic Inc., Minneapolis, MN, USA) was transvenously placedin left lateral position via the coronary sinus approach.Intraoperative measurements demonstrated appropriate results.The lead was connected to a rate adaptive VVIR-pacemakerPO

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(Symphony SR 2250, Sorin Group, Saluggia, Italy). Three monthsfollow-up also exhibited stable electrical parameters in unipolar(uni) and bipolar (bi) mode. Thresholds (V) @ 0,35 msec: Implantation 0,4 (bi), PHD 0,5 uni/0,75 bi, 3-M FU 0,5 uni/0,75 biR-wave amplitude (mV):Implantation >30 mV (bi), PHD >16,2mV uni / >16,2 mV bi, 3-MFU >16,2mV uni / >16,2 mV bi,Pacing impedance (Ohm):Implantation 1151 Ohm (bi), PHD 651 Ohm uni / 957 Ohm bi,3-M FU 636 Ohm uni / 1060 Ohm bi,Conclusion: In patients with artificial tricuspid valves left ventri-cular pacing via the coronary sinus is an appropriate alternative toepicardial pacing using the transthoracic approach. Electricalparameters obtained were appropriate and long-term stable.

26 - CAR DRIVING IS SAFE FOR PATIENTS IMPLANTEDWITH AN ICDC. PIGNALBERI, C. Lavalle, L. Morichelli, A. Porfili, L. Quarta, A. Sassi,A. Aquilani, B. Magris, V. Altamura, R.P. Ricci, M. Santini

Cardiovascular Department, San Filippo Neri Hospital, Rome, ITALY

Patients implanted with pacemakers are usually allowed to drivecars. However, the safety of car driving for patients implantedwith an ICD has not conclusively been demonstrated.The aim of the study was to evaluate the incidence of symptomsduring driving and the rate of car accidents in a wide populationof patients with ICD.We extrapolated the occurrence of arrhythmias and the electricaltherapy administrated from each patient’s personal file. POPULATIONPts 292Age 65+13 yrsCar driver 100%Secondary Prevention 27.4%Primary prevention 72.6%Ischemic 54.8%Idiopathic 9.6%Channelopaties 8.2%A questionnaire, with items related to driving style, symptomsduring driving or car accidents before and after ICD implant hasbeen administrated to each patient.Conclusions: The very low incidence of symptoms during drivingand of car crushes demonstrates that driving license can be allo-wed or maintained after the implant of an ICD.

27 - DOES CURRENT CLINICAL PRACTICE MATCHCLASS I INDICATIONS FOR ICD IMPLANTATION? DATAFROM THE SAFE-ICD STUDYV. GIUDICI1, A. Locatelli1, E. Occhetta2, G. Comerci3, R. Sangiuolo4,M. Sassara5, G.P. Gelmini6, S. Orazi7, A. Talarico8, F. Accardi9, M. Gasparini10

1Ospedale Bolognini, Seriate, ITALY, 2A.O. Ospedale Maggiore della Carità,Novara, ITALY, 3Complesso Integrato Columbus, Rome, ITALY, 4Osp. S. Giovannidi Dio Fatebenefrateli, Naples, ITALY, 5Osp. Belcolle, Viterbo, ITALY,6A. Ospedaliera Desenzano del Garda, Desenzano del Garda, ITALY, 7OspedaleCivile Generale Provinciale G.De Lellis, Rieti, ITALY, 8Presidio Ospedalierodell’Annunziata, Cosenza, ITALY, 9Boston Scientific, Milan, ITALY, 10 Ist. ClinicoHumanitas, Rozzano, ITALY

Introduction: MADIT-II and SCD-HeFT trials have driven the mostrecent guidelines for ICD implantation. However, application of cli-nical practice may differ from guidelines indications. Aim: to analyze characteristics of primary prevention implantsamong a set of consecutive patients enrolled in the SAFE-ICDstudy, and match them with trials and guidelines’ inclusion criteria.Methods and Results: Among 2130 consecutive first ICD implantsin 41 Italian centers, 1475 (69%) were prophylactic. Among these,758 (35%) matched MADIT II criteria (ischemic; LVEF<=30%;

NYHA class I-III); 1502 (71%) the SCD-HeFT criteria (LVEF<=35;NYHA class II-III) and 1593 (75%) principal class I guidelines(LVEF<=35 and NYHA class II-III or LVEF<=30% and NYHA classI). 141 (7%) patients had LVEF between 35% and 40%. 191 patients,13% of those in primary prevention did not match the guidelinescriteria and included LVEF>40% patients, NYHA class IV, andNYHA I with a 30-35% LVEF.Conclusion: In SAFE-ICD study, primary prevention accounts fortwo third of ICD implants, with the majority of implants matchingSCD-HeFT criteria. At least 13% of patients are implanted accor-ding to center’s practice with characteristics that do not fall intoClass I indications.

28 - VALUE OF REMOTE MONITORING IN IMPROVINGEFFICIENCY OF SCHEDULED IN-OFFICE ICD FOLLOW-UPSG. De Meyer, Y. DE GREEF, B. Schwagten, E. Schepers, D. Stockman

ZNA Middelheim, Antwerp, BELGIUM

Introduction: Remote scheduled ICD follow-ups (FUs) have pro-ven to be feasible and time-saving. However, current limitations(lack of direct patient contact, no remote reprogramming possibi-lity, no automated threshold testing in older devices) prohibit theirwidespread use. We aimed to investigate if remote monitoringdata can make in-office scheduled ICD FUs more efficient.Methods: During the 6-monthly in-office ICD FU, 75 patients wereconsecutively included in the conventional (C) group (N=41) orthe remote (R) group (N=34). In the C group, ICD FU was perfor-med routinely (device interrogation during office visit). In the Rgroup, the physician reviewed the data from the HomeMonitoring system (Biotronik, Berlin, Germany) the day before theICD FU (pre-visit review) and interrogated the device for lackinginformation during the office visit. The time burden for the physi-cian in the C group equalled the duration of the visit, in the Rgroup it was defined by the duration of the pre-visit review andthe visit. Results: Mean age (67+/-10 versus 67+/-11 years), number ofinterrogated leads (60 versus 60% VVI, 28 versus 24% DDD, 12versus 15% CRT) and change in medication and/or device pro-grammation during the visit (40 versus 42%) were similar in de Rand the C group.Mean duration of device interrogation and visit were shorter in theR group than in the C group (3+/-2 versus 8+/-4 min, p<0,001 and13±6 versus 19±7 min, p=0,004). The time burden for the physicianwas shorter in the R group (15±7 versus 19±7 min, p=0,041).Conclusion: Reviewing remote monitoring data the day before in-office scheduled ICD FUs reduces the duration of device interro-gation and the visit by 62% and 32% respectively. These findingsare paralleled by a reduction in the time burden for the physicianby 21%.

29 - CRT-D MALFUNCTION DUE TO SCATTEREDRADIATION DETECTED BY HOME MONITORINGE. Marras1, F. CHIUSSO2, G. Allocca1, N. Sitta1, P. Delise1

1Santa Maria dei Battuti Hospital, Conegliano, ITALY, 2Biotronik Italia,, ITALY

Background: Radiotherapy is dangerous for implantable cardiacdevices recipients, as it can damage the electrical components ornegatively affect the random access memory (RAM) of the devices.Effects of direct radiotherapy are well known, however there arefew reports about the effects of scattered radiation, especially withregard to implantable cardioverter defibrillators (ICDs).Case report: We report the case of a 61 year old man implantedwith an ICD for cardiac resynchronization therapy (BiotronikLumax 540 HF-T) in a left pre-pectoral pocket due to dilated car-diomyopathy. The patient also received a GSM transmission unit(Cardiomessenger) for Home Monitoring (HM) remote controlPO

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after discharge. Twenty months later the attending cardiologistreceived a HM alert report notifying that the implanted device hadswitched into the backup mode: a temporary unexpected status inwhich antiarrhythmic therapies are disabled and the use of theRAM memory is excluded as was detected corrupted. The patient,recalled for an unscheduled follow-up, reported he underwentradiotherapy in the pelvis for prostate cancer, exactly the samedate when HM alert was received. Despite the zone of expositionto radiation was fairly far from the device and the dose of scatterradiation was relatively low, the unexpected backup status of thedevice was most likely due to the radiotherapy radiation absor-ption. The dysfunction was completely solved by performing thedevice firmware reinitialization. Without a remote monitoringthere were no chances, unless fortuitous, to detect the devicedysfunction earlier than the next scheduled follow-up 5 monthslater.

30 - HOME MONITORING EFFECTIVENESS TO PREVENTINAPPROPRIATE SHOCKS IN PATIENTS WITH IMPLANTA-BLE CARDIOVERTER DEFIBRILLATORS (ICDS)C. PUNTRELLO1, V. Lettica2, G. Pizzimenti3, G. Deblasi4, E. Pizzimenti4

1Paolo Borsellino Hospital, Marsala, ITALY, 2Guzzardi Hospital, Vittoria, ITALY,3Fogliani Hospital, Milazzo, ITALY, 4Biotronik Italy Spa, ITALY

Remote control of implanted devices allows an early detection ofinappropriate or bad functioning of implanted device, in advancecompared to standard in-hospital follow up, and an early thera-peutic reaction to optimize medical treatment. From Spencker stu-dy's data (Europace 2008) in a group of 54 patients with a bad fun-ctioning of shocks electrode, the incidence of inappropriate shockswas 27,3% in patients with remote control vs 53,4% in case ofpatients checked in standard hospital follow up (p<0,05). TheMADIT II (J P Daubert JACC 2008) demonstrated that on 590shocks the 31,2% percentage was inappropriate. The main causesof inappropriate shocks were the atrial fibrillation (40%) and theover/under sensing (20%); furthermore it was observed thepatients with inappropriate shocks had in follow up a mortalityincrease for all causes (HR=2.29, p=0.025). We wanted value withthis study,including 3 sicilian hospital centers (Marsala hospital,Vittoria hospital and Milazzo hospital), FV detections (due to seve-ral causes) to better understand the utility of Home Monitoring foran early detection of defects of ICD's system (through defibrilla-tion shocks) in primary and secondary prevention.

31 - INTEGRATION OF LATITUDE REMOTELY TRANSMIT-TED DATA INTO AN EMR SYSTEM USING FILEMAKERPRO SOFTWARE: PROCEDURE AND ALGORHYTMSG. PUPITA1, S. Molini1, S. Borio2, J. Ellis3, M. Brambatti1, S. Guardiani2,A. Capucci1

1Clinica di Cardiologia, Ospedali Riuniti di Ancona, Ancona, ITALY, 2BostonScientific, Milan, ITALY, 3Boston Scientific, Boston, USA

The LATITUDEÆ Patient Management system allows to remotelyfollow Boston Scientific ICD and CRT-D device patients, accessinga website where the device interrogation info is displayed. BostonScientific has developed a software to transmit the recorded datain a digital manner, downloading available transimissions into alocal directory. The software create HL7 files that are structuredaccording to the HL7 2.3.1 Observation Result Unsolicited messa-ge type, which provides for the transmission of new observationinformation about patients in the form of a lab report document:each file contains a Message Header, a Patient Identification seg-ment, and four Observation Reports sections (last interrogation,implant, lead test, lead information), each one having severalObservation Results segments containing the parameters, thatinclude lead status, device set up, arrhytmic events and stimula-

tion statistics details. We developed a procedure to retrieve datafrom the HL7 files to put them into our EMR system; both are builtin FileMaker Pro. The integration procedure is fully automated: itimports each files’ segments in an ad hoc table, reconstructs theoriginal message and grabs each parameter by parsing the recon-structed text, using specifically built custom functions developedin Filemaker Pro; finally the parameters are sent into the EMRsystem. We’ve tested the above mentioned procedure with ourcenter’s data, processing a total of 15 transmission files. We’veencountered 3 minor issues: data import must be set to Unicode,else special characters like accented letters or apostrophes are notpassed correctly; date fields calculations need to be adjusted forthe presence of the datum, else an error is returned; the thresholdmeasure units are always passed even if no measurement has beenrecorded. A trial version of the software can be obtained throughBoston Scientific representatives

32 - CLINICAL AND COST-SAVING BENEFITS OF DAILYREMOTE MONITORING IN PACEMAKER PATIENTS WITHAMBULATING INABILITYM. MARINI, C. Capparuccia

U.O.S. Aritmologia INRCA, Ancona, ITALY

Background and Objectives: Remote Monitoring (RM) of pace-maker recipient patients may become a powerful tool to reducefollow-up burden, physician workload and cost management if itwill be proved to safely replace in-hospital visits. This is particu-larly appealing in patients with Ambulating Inability (AI), whichrepresents a standard characteristic of patients in our Instituteexpressly devoted to Health and Science on Aging (INRCA). Ourobjective is to present an ongoing study aimed to directly compa-re clinical benefits and social costs between a follow-up strategyexclusively based on RM and a conventional program of in-hospi-tal visits in pacemaker patients with AI.Methods and Results: We have designed an ongoing protocolenrolling patients with AI indicated to a dual-chamber pacemaker.Patients are being randomized to a follow strategy based on RMonly (RM group) or standard in-hospital visits (SV group) everysix months. For this study RM is accomplished with the BiotronikHome Monitoring based on GSM daily transmissions fromBiotronik Evia DRT pacemakers. For each patient the number ofin-hospital visits, transfer time, distance, costs, and clinical ordevice related adverse events will be recorded and compared bet-ween groups. At present 8 patients have been enrolled (5 female,mean age 78). During a mean follow-up of 60 days, the number ofin-hospital visits was 1 in the RM group and 4 in the SV group. Themean time and distance for home-hospital transfers was 31 minu-tes whereas the mean distance was 34 km. Overall transfer cost forthe National Health Service was of 194.72Ä in the SV group whileit was of 48.00Ä for the RM group.Conclusions: social and clinical management of pacemakerpatients with AI may particularly benefit from daily RM systems.Our study is aimed to assess whether such benefit does exist andits extent.

33 - AUTONOMIC DYSFUNCTION IN AIDS PATIENTSRECEIVING ANTIRETROVIRAL THERAPYW. WONGCHAROEN1, K. Keanprasit1, A. Phrommintikul1, N. Chattipakorn2

1Department of Internal Medicine, Faculty of Medicine, Chiang Mai University,Chiang Mai, THAILAND, 2Department of Physiology, Faculty of Medicine,Chiang Mai University, Chiang Mai, THAILAND

Background: Previous small studies have demonstrated the presen-ce of autonomic dysfunction in HIV-infected patients. However, thedata in those receiving highly active antiretroviral therapy (HAART)is conflicting. The aim of this study was to assess the autonomic fun-PO

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ction using heart rate variability (HRV) and heart rate turbulence(HRT) analysis in AIDS patients receiving HAART.Methods: Sixty HAART-treated AIDS patients (male = 38, meanage = 44±8 years) and 20 HIV-seronegative subjects (age, sex-mat-ched) were enrolled in the study. The time-domain and frequency-domain HRV and HRT parameters were assessed on 24-hour digi-tal Holter recordings. The patients with diabetes mellitus or signi-ficant structural heart diseases were excluded. Results: All the time-domain HRV parameters were significantlylower in the AIDS patients, as compared to the control group. Thenormalized power of the low-frequency (LF) component and thehigh-frequency (HF) component was also significantly decreasedin the AIDS groups. However, there were no differences in HRTparameters between the two groups. Among the AIDS patients,those who had low CD4 T cell count (< 400 cells/mm3) tended tohave higher LF/HF ratio (1.6±0.4 vs. 1.4±0.3, p=0.05) than thosewho had higher CD4 T cell count (>400 cells/mm3).Conclusions: The autonomic dysfunction was demonstrated in AIDSpatients receiving HAART. The AIDS patients with lower CD4 T cellcount tended to have greater degree of impaired autonomic function.

34 - ATRIOVENTRICULAR BLOCK AND VENTRICULARFIBRILLATION IN PATIENT WITH NONCOMPACTIONOF THE VENTRICULAR MYOCARDIUMA. PLACCI, C. Tomasi, F. Giannotti, G. Bellanti, M. Margheri

Department of Cardiology - Ravenna Hospital, Ravenna, ITALY

Isolated noncompaction of the ventricular myocardium (INVM) isa sporadic or familial heart muscle disorder characterized byexcessively prominent trabecular meshwork and deep intertrabe-cular recesses. The chronic microvascular ischemia, progressivemyocyte necrosis and fibrosis and excessive trabeculations canlead to cardiovascular complications such as left ventricular failu-re, systemic arterial embolism, and dysrhythmia. We describe thecase of an adult patient with INVM not previously detected, thatexperienced resuscitated extra hospital sudden cardiac death(SCD). ECG pattern showed a ventricular fibrillation cardiovertedby automatic external defibrillator. After cardioversion patientwas in atrioventricular complete block. Echocardiography showedmild left ventricle dilatation, normal wall thickening, left ventricleejection fraction of 50%, heavy trabeculation of the left ventricle’sapical and lateral wall (the ratio of non compacted-to-compactedmyocardium was 1.8:1). All routine blood tests were normal, andthe ECG monitoring performed during the patient’s stay in inten-sive care unit before implantable cardioverter defibrillators (ICD)implantation showed persistent atrioventricular block requiringtemporary ventricular pacing. All the three main mechanisms ofarrhythmogenesis, reentry, trigger activity, and automatism, havebeen implicated in the genesis of ventricular arrhythmias (VA) inpatients with INVM. Moreover, these arrhythmogenic substratesin this case could be magnificated by bradycardia. Implantation ofICD in these cases is a treatment option, but data on long-term fol-low-up are limited. In fact, literature data reporting a presence ofsupraventricular arrhythmias and an incidence of malignant VA inas many as 47% of the patients and SCD in almost 50% of thepatients with INMV. The presence of complete AV block is repor-ted in few cases of INMV. Interstitial fibrosis and subendocardialfibroelastosis, which are frequently found on endomyocardialbiopsies in these patients, may be the underlying pathoanatomiccorrelate. The post implant test was ineffective to induce a ventri-cular sustained arrhythmias, as well described in the papers ofSteffel J that found a inducibility on EP study of VA only in 38% ofINMV patients. Since no guidelines or recommendations regar-ding ICD implantation in patients with IVNC exist, this decisionwas left to the discretion of the treating physician. Additional stu-dies and a long-term follow-up are required to stratifies the risk ofSCA in this patient, considering the low sensibility of EP testingIVNC for arrhythmic risk stratification.

35 - ATRIAL FIBRILLATION INCIDENCE IN PACEMAKERPATIENTS WITHOUT TACHYARRHYTHMIA HISTORYK. POLYMEROPOULOS, E. Keklikoglou, P. Ioannidis, D. Papakonstantinou,G. Tsinopoulos, E. Delvizi, J. Zarifis

G. Papanikolaou Hospital, 1st Cardiology Department, Thessaloniki, GREECE

Purpose: To evaluate atrial fibrillation (AF) episodes in patients withdual chamber (DDDR) pacemaker, without atrial arrhythmia history.Materials and Methods: One hundred thirteen patients (62 men),mean age 69±12 years, were enrolled and followed up for 7 monthsafter the implantation of a DDDR pacemaker. We considered ¡trialHigh Rate Episodes (AHRE), according to the Stored Electrograms(EGMs), any atrial event with rate > 175 bpm and duration > 1minute. The indication for implantation was atrioventricular blockin 77 patients (68%), sick sinus syndrome in 32 (28%) and carotidsinus syndrome in 4 patients (4%).Results: There were recorded 271 AHRE (mean 11.78±14.34) lon-ger than 1 min in 23 patients (20%). AHRE longer than one hourwere demonstrated in 6 patients (5%) and longer than 24 hours in3 patients (3%). Symptomatic AHRE (palpitations, dyspnea or fati-gue) were reported by 4 patients (17%), Ône of them with clinicaldocumented episode of persistent AF. The other 19 patients (83%)did not report any symptoms during the recorded episodes. Conclusions: The occurrence of atrial fibrillation in patients withDDDR pacemaker, without any previous history, is significant.The demonstration of such episodes is valuable for guiding appro-priate anticoagulation or antiarrhythmic treatment.

36 - RELATION BETWEEN FIRST HEART SOUND ANDFIRST SONR SIGNAL AMPLITUDEA. TASSIN1, A. Kobeissi2, L. Vitali3, G. Gaggini3, F. Treguer1, P. Ritter4,A. Furber1, J.M. Dupuis1

1University Hospital, Angers, FRANCE, 2Sorin Group France, Clamart, FRANCE,3Sorin Biomedica CRM, Saluggia, ITALY, 4University Hospital, Bordeaux, FRANCE

Introduction: First Heart Sound (S1) amplitude is known to behighly correlated to cardiac contractility index (LVdP/dt max) anddepends on atrioventricular delay (AVD). Previous studies sho-wed that the amplitude of the first component of the EndocardialAcceleration signal (PEA1 or sonR1), recorded during the isovolu-mic contraction phase of the cardiac cycle, is highly correlated toLVdP/dt Max too. The purpose of this study was to determine thecorrelation between S1 and SonR1 amplitudes by modulation ofpaced atrioventricular (AV) delay in patients implanted with dualchamber pacemakers (PM).Methods: A double chamber PM was implanted in 10 pts withcomplete AV block, connected to a right ventricular lead (BEST-Living and BEST, Sorin Biomedica, Saluggia, Italy) equipped witha SonR sensor. During performance of an AVD scan in VDD andDDD mode, SonR, phonocardiographic and electrocardiographicsignals were recorded on an external digital recorder and subse-quently analyzed with an automatic software routine.Results: The correlation between SonR1 and S1 amplitudes wasobserved in all cases (p<0.0001). SonR1 and S1 amplitudes chan-ged similarly with the AV delay. Inter-pt normalized SonR1 to S1amplitudes correlation was r=0.89 (p<0.0001) in DDD mode andr=0.81 (p<0.0001) in VDD mode.Conclusion: A good correlation between SonR1 and S1 amplitudeswas observed regardless of the pacing mode and the AVD. SonR1and S1 would seem to be therefore the demonstration of the samephenomenon. SonR1 might reflect cardiac function status and mightthus play a potential role in cardiac contractility optimization.

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37 - THE IMPACT OF STORED ELECTROGRAMS ONPACEMAKER LONGEVITYC. PERRI, S. Turner, A. Costa-Vitali, C. Lau, B. Goldman, E. Crystal

Sunntbrook Health Sciences Center, Toronto, CANADA

Electrophysiology Services, Schulich Heart Center, SunnybrookHealth Sciences Centre, Toronto, Canada.Hypothesis: Advanced diagnostic feature such as StoredElectrograms (SEGMs) cause premature pacemaker depletion.Background: Modern pacemakers have capacity to provide realtime record of the EGM. However, programming SEGM parame-ters ON may lead to premature battery depletion. Method: 100randomly selected patients (74 mean age; 53 M) with DDDimplants between 2002 and 2009 were studied. The models inclu-ded were St Jude Medical Identity DR 5386 (n=23) and 5376 (9);Victory DR 5816 (28) and 5810 (27); and Zephyr DR 5826 (13). Atone follow up visit, patients’ devices were interrogated usingProgrammer Model 3650, with SEGM programmed ON and OFF.The estimated remaining battery longevity was calculated. Otherparameters that may affect device longevity (impedance, thre-sholds, pulse amplitude, etc) were also collected.Results: There is a significantly different calculated battery longe-vity in all the models studied with SEGMs programmed ON(p=<0001) with an average reduction of 34% battery longevity.Conclusion: Activating Advanced Diagnostic features such asSEGM ON resulted in significant reduction in calculated longevi-ty in our selected population with DDD devices.

38 - LEAD POSITIONING IN DEFINITIVE SEPTALINTER-VENTRICULAR PACINGB. DERIOUICH, M. Hero

Centre Hospitalier Général, Evreux, FRANCE

Introduction: The target of stimulation is the septo-basal segmentof the inter-ventricular septum. The process to identify the proxi-mal inter-ventricular septum is anatomic by fluoroscopy and elec-tric by ECG interpretation.Methods: This type of stimulation was performed in 128 patients(aged 78 +/- 9 years) implanted for conduction disorders or sinusdysfunction. A postoperative echocardiogram was performed ran-domly in 20 patients, with 4 systemic incidences, parasternal, longaxis and short axis, apex 4 cavities and under xiphisternal, the leadposition should be located upstream of ventricular pillar.Results: In septo-basal position, during electrical stimulation, it isnoted a thickening at the base of the QRS like a real aspect of pre-excitation. The fluoroscopic tracking is done from the front, withthe systematic establishment of ventricular lead in the pulmonaryartery trunk. The second phase is the withdrawal in the ventricu-lar chamber with a slight upward movement with guide slightlywithdrawn up to supraventricular crest. The final shape of thelead is antero-posterior and LAO 45° where the thoracic spine isface up the distal extremity of the lead. Conclusion: Anatomic criteria, fluoroscopy ECG criteria contribu-te to a better positioning of proximal septum for right ventricularpacing. Echocardiography confirmed in 20 patients the lead posi-tioning

39 - COMPARISON PER-OPERATIVE AND INTRA-INDIVI-DUAL VENTRICULAR PACING BETWEEN APEX ANDSEPTO-BASAL POSITIONNINGB. DERIOUICH, M. Hero

Centre Hopitalier Général, Evreux, FRANCE

Apex pacing of the right ventricle (RV) disrupts the left ventricu-lar contractility sequence. It can therefore generate an intra-ventri-cular and/or inter-ventricular dyssynchrony. Proximal septalpacing of the RV can be considered as an alternative to apex stimu-lation. The aim of this study is to compare the intra-operative fea-sibility of both methods, safety and stability of septal stimulationparameters before leaving the hospital, at one month and at 6months follow-ups.Methods: 128 patients were implanted with single or dual cham-ber pacemaker for conduction disorders or sinus dysfunction. Thebipolar active lead was initially positioned at the apex of the RVand permanently at the proximal septum of the RV. Septal positionwas confirmed by scopy (AP and LAO 45°). The positioning timeand the scopy duration were notified. Electrical lead parameters,including lead impedance (LI), pacing threshold (PT), slew-rateand R wave sensing (RWS) were monitored at both sites duringimplantation. During follow-ups LI, PT and RWS were monitored. Results: 1 - There was no difference between electrical parametersduring the implantation between the apex and the septo-basalpositioning. 2 - During follow-ups the electrical parameters werestable without significant statistic difference. The median leadpositioning time was about 3 minutes and median fluoroscopytime near 60 seconds. RV septal lead could be replaced in twocases due to lead dislodgement (2%). A case of left superior venacava had shown an easy septal positioning.Conclusion: Long term reliable RV septal pacing can be achieve inroutine (98%) patients with standard indications for cardiacpacing. RV septal positioning is easy and electrical parameters arestable during long term follow-up and compared to the apex con-ventional positioning with short procedure duration and exposu-re time to X-rays.

40 - COMPARISON PER-OPERATIVE AND INTRA-INDIVI-DUAL WIDTHS OF VENTRICULAR PACING COMPLEX,BETWEEN APEX AND SEPTO-BASAL POSITIONNINGB. DERIOUICH, M. Hero

Centre Hospitalier General, Evreux, FRANCE

Introduction: The recommendations in Europe and NorthAmerica consider the width of the QRS is the only accepted crite-ria of cardiac desynchronization (> ou = 120 ms). The echocardio-graphic criteria have not been previously scientific validation.More the QRS is wide, more desynchronization is serious. In ourstudy, we compared the QRS pacing at conventional apex positionand at the proximal septum position. This is a comparison per-operative and intra-individual. Method: 128 patients (78 +/- 9 years old) were implanted with asingle or dual chamber pacemaker for conduction disorder (75%)or sinus dysfunction (41%). The ventricular active bipolar lead(dipole < ou = 10 mm) is initially tested at the apex and secondari-ly at the proximal septum. The width of the QRS pacing is avera-ged over 2 complex measured at the beginning of the spike to theend of QRS for derivations D2, AVR and V1, with a scrolling speedof 50 mm/s.Results: We observe a significant QRS width reduction in duringseptal stimulation (153 +/- 23 ms) versus apex stimulation (162+/- 22 ms). The comparison of values was performed by Mood°Øsmedian test (p <0.01), completed by a Student test (p <0.005).Conclusion: The septo-basal stimulation produces a wide QRSdecreased significantly compared to apex stimulation. It is therefo-PO

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re less harmful to hemodynamic. It can be seen as a method ofchoice for patients potentially pacemaker-dependent. Dyspneaduring effort and/or at rest has not been found during one monthafter implant in all patients.

41 - CHANGES OF PACING AND DEFIBRILLATIONPARAMETERS IN RIGHT VENTRICULAR SEPTAL PACINGSITE - ONE YEAR FOLLOW-UPT. MINARIK1,2, D. Brecka1,2, K. Grussmannova1, M. Taborsky2

1University Hospital, Ostrava, CZECH REPUBLIC, 2University Hospital, Olomouc,CZECH REPUBLIC

Introduction: Chronic RV apical pacing has been associated withasynchrony of ventricular activation and might result in impair-ment of systolic and diastolic LV function. Some of long-term stu-dies suggest that RV septal pacing may reduce these adverse chan-ges. Aim of this study was to dertermine long-term pacing anddefibrillation parametrs in RV septal pacing site.Methods: Thirty-one patients (25 males, age: 65,9±7,7 years, LVEF29,7±12,1%, LVEDD 64,3±7,4 mm, 25 ischemic, 6 dilated cardio-myopathy) undergoing ICD implantation (18 Atlas + HF and AtlasII+HF, 13 Atlas + DR and Atlas II+DR, SJM) with RV lead (RIATA7000, SJM) active positioning on septal site were studied. Atimplant and after 10-12 months we evaluated pacing threshold(V), R wave amplitude (mV), lead impedance (ohm), defibrillationimpedance (ohm) and defibrillation threshold (<22,5 J; >22,5 J).Results: The leads were successfully placed at high- and midsep-tal sites in RV. At implant and 10-12 months parameters were asfollows: pacing threshold 0,52 ±0,21 vs. 0,85±0,37 V (p<0,05), Rwave amplitude 9,2±2,7 vs.8,5±0,4 mV (ns), lead impedance519,3±53,4 vs. 431,5±57,2 ohms (p<0,01), defibrillation impedance43,2±4,6 vs. 42,1 ±4,9 ohms (ns). Defibrillation threshold wasunchanged in 30 pts, with the value of <22,5 J. Defibrillation thre-shold was changed in one patient (3,3%), was higher than 36 J andsolved by change of CD polarity.Conclusions: Septally positioned defibrillation leads were stabili-zed in all pts. We observed only low increase in chronic pacingthreshold and no change in R wave amplitude. Long-term defibril-lation thresholds were unchanged in 96,7% of pts. These datademonstrate that RV septal pacing in ICD pts is a save methodwith a very low risk of lead complications.

42 - LONG-TERM EVALUATION OF DIRECT HIS-BUNDLEPACINGC. PIGNALBERI, R.P. Ricci, S. Aquilani, B. Magris, V. Altamura, M. Santini

Department of Cardiology S. Filippo Neri Hospital, Rome, ITALY

Background: Right ventricular apex pacing has been recognizedas the main iatrogenic cause of desynchronisation of left ventricle,with relevant negative consequences at short and long term.Among the alternative pacing sites, direct His bundle pacing con-stitutes the most promising and the earliest technique. Nevertheless, its long-term evaluation is still not available.Aim of our study is to evaluate the feasibility ad safety of directHis bundle pacing after a long-term follow-up.Methods and population: Between March 2004 and February2005, 9 patients (pts) with normal A- V conduction have beenimplanted with a dual-chamber pacemaker, according toInternational Guidelines.Pacing threshold, sensing and impedancehave been tested in all the pts every 6 months; the mean durationof follow-up was 27±13 months. Results Among the 9 pts enrolled(5 males; mean age 59±6 years), the ventricular lead was placed inpara-hisian zone in 5 cases and directly on His bundle in theremaining 4. The mean duration of the procedure was 106±15 min.,the X-ray time 18±3 min. and the lead position time was 20±6 min.After the implant and at the last follow-up, spontaneous QRS axisdid not show any significant difference respect to that one obser-

ved during stimulation. The mean duration of paced QRS was103±20 msec. at the first follow-up and 106±23 msec. at the lastone, without any significant difference; the mean duration of spon-taneous QRS was 78±12 msec. Adevrse Event: -2 pts have died fornon-cardiac reasons after 22 and 27 months; 2 pts resulted lost atthe follow-up after 2 and 27 months; 1 pts has been explanted after11 months from implant as a consequence of device infection.Direct permanent His bundle pacing is a feasible and safe techni-que even at a long-term follow-up. His bundle constitutes a validand physiologic alternative pacing site.

43 - ROUTINE USE OF ICE (INTRACARDIACECHOCARDIOGRAPHY) DURING LEAD EXTRACTIONJ. PETRU, L. Sediva, J. Skoda, J. Kupec, P. Neuzil, F. Holy, J. Brada,K. Holdova, L. Plevkova, S. Kralovec

Na Homolce Hospital, Prague, CZECH REPUBLIC

Introduction: Amount of lead extraction procedures has beenincreasing recently. These procedures are very often difficult, chal-lenging and potentially life threatening. Except “typical” peripro-cedural monitoring (ECG, O2 saturation, invasive blood pressu-re…) we routinely use ICE (intracardiac echocardiography), whichis the aim of this study.Method and Results: We performed 81 lead extraction proceduresin 2009. In 54 cases was indicated laser sheath technique(Spectranetics). In our institution all these procedures are normallyheld in electrophysiology lab, with general anesthesia and cardio-surgery backup. Except this typical setting we always use ICE. Wehave multiple reasons for this. First of all ICE is very helpful formonitoring of pericardial space. In case of cardiac tamponade thediagnosis is assessed very quickly and the time to effective treat-ment (pericardial puncture, open heart surgery) could be significan-tly shortened. Also early knowledge of incipient pericardial effusioncan stop the extraction in time and prevent developement of tampo-nade. Another advantage of ICE is identification of the place of leadinsertion and monitoring of manoeuvring with extraction sheaths inrelation to myocardial wall. Thanks to ICE you can also clearly seebehaviour of intracardiac strutures (vegetations, thrombi) duringprocedure. One time we discontinued extraction because of identifi-cation of new large trombus (diameter >2cm) on tricuspid valve,which was invisible day before on TEE (transoesophageal echocar-diography). We had totally 3 serious complications - cardiac tampo-nades - in this group of patiens. In all three cases pericardial punctu-re was done as first aid, followed by cardiosurgical revision.Fortunately nobody has died.Conclusion: In our opinion routine use of ICE monitoring duringlead extractions is very helpful and has several advantages. Itbrings more safety into this challenging procedures.

44 - INITIAL RESULTS FROM THE LEAD EXTRACTIONDEVICE EVALUATION AND RESULTS DATABASE(LEADER DATABASE)R.H.M. Schaerf1, E.K. Bowser2, B.E. NORLANDER2

1Providence / Saint Joseph Medical Center, Burbank CA, USA, 2Cook VascularIncorporated for the LEADER database, Vandergrift PA, USA

Background: The successful development of the percutaneoustechniques and tools used in the extraction of problematic chroniccardiac leads was initially supported by a robust collection of cli-nical data, lead parameter information, complication rates andtypes, and procedural success rates across a large number ofextractors and extraction centers. Since the late 1990s, there hasbeen a dearth of clinical lead extraction data derived from multi-ple extraction centers representing both low and high volumeextractors using a myriad of extraction devices. The LEADERdatabase was established to provide an accurate and thoroughPO

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electronic vehicle for the verifiable, on-site, field based collectionof lead extraction procedural parameters and outcomes from awide, as-come cohort, of extraction centers and procedures acrossNorth America and Europe. All procedures attended by CookMedical Lead Management representatives are reported to theLEADER database. This is the first published report from the LEA-DER database and the cohort includes only those procedures inwhich one or more Cook Medical Incorporated (Bloomington, IN)lead extraction devices were utilized. It encompasses 601 consecu-tive patient procedures involving 1224 targeted cardiac leads.Methods: Prior to the initiation of the LEADER database, eachCook Medical Lead Management Representative based in NorthAmerica and in Europe was thoroughly trained in the documenta-tion methods for the database and was required to sign and agreeto a Role and Responsibility Agreement which defined individualresponsibilities, required timelines, and probable actions resultingfrom failure to comply. Using a lead extraction data collection spe-cific Portable Document Format (.pdf) hosted by a commerciallyavailable, server-side and client-based software applications firm,each representative was responsible for completing and submit-ting a LEADER data collection PDF form within two days of eachprocedure for each one that he/she attended. A database admini-strator was assigned to oversee the proper submission and recor-ding of data and to audit submitted forms. If an update or correc-tion to a submitted database form was required, a documented,auditable procedural protocol was strictly followed. CookMedical/Cook Vascular has verified that the form layout, formcompletion and form submission processes have been configuredto permit the capture, storage, and retrieval of procedural parame-ters and outcomes.Results: 601 consecutive patient (75% male / 25% female) leadextraction procedures involving 1224 targeted cardiac leads werereported to the LEADER database from the initiation of the data-base on October 12, 2009 through August 20, 2010. Reported phy-sician disciplines of the extractors were: electrophysiologists(n=405, 67%), cardiac surgeons (n=165, 27%), interventional car-diologists (n=30, 5%), and other (n=1, <1%). Based on an experien-ce scale that defines low volume extractors as those performing onaverage 2 extractions or less per month, medium volume extrac-tors as performing 3-5 extractions per month and high volumeextractors performing 6 or greater extractions per month, 62.5% ofthe reported procedures were performed by low volume extrac-tors, 29.0% by medium volume extractors and 8.5% by high volu-me extractors. Lead parameters of the reported cardiac leads wereas follows: average lead implant duration, (79.6 months or 6.6years); implant location, ventricle (56.9%), atrium (36.6%), corona-ry sinus / cardiac vein (6.3%) and superior vena cava (0.2%); tipfixation, active (60.7%), passive (39.3%), lead placement, left side(65.3%), right side (34.7%); reason for extraction, infected (64.3%),damaged lead (16.5%), replacement (7.3%), lead failure (5.9%),occluded vein (0.7%), other (5.1%); extraction outcome, 100% ofthe lead removed (91.9%), partial extraction, defined as leaving thetip or < 4cm (4.2%), unsuccessful/capped (1.6%) and patient refer-red (2.3%); major adverse events / complications, (1.0%, nodeaths).Conclusion: While lead extraction continues to be a challengingprocedure that requires a thorough physician understanding ofextraction and monitoring techniques, as well as, knowledge of thecompendium of available extraction devices, in this cohort of con-secutive patient procedures derived from what is believe to be thelargest multi-continent representation of knowledgeable physi-cians with low, medium, and high volume experience, lead extrac-tion procedures in which Cook Medical devices were used havebeen shown, with a 96% clinical success rate, to have performedwell when compared to current clinical benchmarks.

45 - APOTENTIALLY DANGEROUS HAVING CLASS 3INDICATIONS LEAD EXTRACTION. NOT ALL PATIENTNEEDS OPEN-HEART CARDIAC SURGERYA. ANDRZEJ KUTARSKI1, M. Czajkowski2, R. Pietura3, A. Tomaszewski4

1Dept of Cardiology Medical University of Lublin, Lublin, POLAND, 2Dept ofCardiosurgery of Medical University of Lublin, Lublin, POLAND, 3Dept ofInterventional Radiology and Neuroradiology Medical University of Lublin,Lublin, POLAND

Introduction: The 2009 International HRS Expert Consensus showedthe leads with class 3 recommendation for lead extraction (LE) andpointed that an ”additional techniques including surgical backupmay be used if clinical scenario is compelling”. The goal: Presentationof the single refferentional center experience in transvenous extrac-tion of permanently implanted ”potentially risky for extraction” leadswhich had to been removed but having class 3 (HRS) indications.Source of information: computer database containing informationabout performed procedures of LE (using mechanical systems only)since March 2006. Patients. Among 559 patients/procedures we selec-ted 18 patients meeting full or borderline class III indications (55,6%M, aver. 68,0 y, infective indications 44%).Results: Maintaining especial organization of procedures withmaximal safety regime we extracted transvenusly 1 lead perfora-ting right atrium wall, 7 leads perforating of right ventricle, 2 leadswith deep penetration into RV wall / septum, 3 leads from the leftventricle cave, one from left atrial appendage and 3 leads fromarterialised venous system (A-V shunt for hemodialysis). Fullradiological success was 100,0%, no leads were left for cardiac sur-geon. Age of oldest extracted lead in the patient aver 56,5 mths.,mean longevity saying in of extracted leads in the patient 49,0months. All extractions were performed without complicationsand enabled open-heart surgery avoidance. Major complicationsoccurred in 1 pt (5,6%) but it was not connected with lead extrac-tion, there were no minor complications (0,0%).Conclusion: permanently implanted leads recognized as poten-tially dangerous for routine extraction (leads perforating heartwall, erroneously located in left ventricle cave, active fixation car-diac vein leads and implanted ipsilaterally with dialysis shunt)may to be extracted percutsaneously providing all individuallywell-chosen safety precautions.

46 - EXTRACTED LEADS’ BREAKAGE. ONE MOREOPTION OF MANAGEMENTA. ANDRZEJ KUTARSKI1, R. Pietura2, M. Czajkowski3

1Department of Cardiology Medical University of Lublin, Lublin, POLAND,2Department of Interventional Radiology and Neuroradiology MedicalUniversity of Lublin, Lublin, POLAND, 3Department of Cardiosurgery MedicalUniversity of Lublin, Lublin, POLAND

Extracted leads’ breakage (LEB) is known of lead extraction.Utility of recaptured venous access by even incomplete leadextraction (guidewire introduced by empty lead liberating cathe-ter) were not described yet.Purpose: Description of alternative approach and technique inmanagement of lead breakage caused by extraction procedure.Source of information: computer database of reference centre, contai-ning information about performed procedures of lead extraction (LE) Patients: 574pts/procedures of LE. Full radiological success: 93,5%,longevity of oldest extracted lead in the patient: 86,2mths. Majorcomplications-1,39%, minor-2,09%. Patients with ELB-44.Methods: The procedures of LE were performed transvenouslywith the use of cutting-rotation forces of telescopic polypropyleneByrd dilators using subclavian approach usually. Laser energy orradiofrequency waves were not used. A screw-in leads, were triedto be removed by simple extortion only. For extraction of brokenleads and lead’ fragments femoral, right jugular and large spec-trum of snares lasso-and basket catheters were utilized.PO

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Results: In two patients we utilized lead venous entry approachwhich may to consist interesting alternative option for ELB manage-ment.After recognizing ELB,the proximal part of lead was removedand via empty Byrd dilator two guide-wires were inserted (thesecond one consisted only back-up for venous approach). As the firststep Attain system designed for LV lead implantation was inserted.In the second stage-the basket catheter was inserted. After the brokenlead remnant was grasped-the proximal part of Attain sheath wascut-off continuing gentle traction for basket catheter. We utilised leadblockade in its distal part and introduced internal green Byrd cathe-ter over the Attain sheath,containing basket catheter and lead endinginside. The lead remnant was extracted unbroken using typical rota-tional forces of following Byrd dilators.Conclusion:For extraction of longer than 3-4 cm lead’s fragmentjugular and femoral approach can be utilised. Utility of recapturedvenous approach may be interesting alternative.

47 - SYSTEMATIC BACTERIOLOGICAL LAB EXAMINATIONSFOLLOWING INFECTED ENDOCARDIAL LEAD EXTRACTIONUSING STANDARD OR MODIFIED MECHANICAL SINGLE-SHEATH DILATATION TECHNIQUEG.M. CALVAGNA1, R. Evola1, A. Gargaro2, N. Rovai2

1Divisione di Cardiologia Ospedale San Vincenzo, Taormina, ITALY, 2BiotronikItalia S.p.A., Vimodrone, ITALY

Background: The dramatic increase of cardiac rhythm manage-ment (CRM) device implantations (including pacemakers andimplantable defibrillator) in the last decades has been paralleledby the rate of late complications: basically, lead failure or infec-tions, the latter being the most frequent indication for lead removal.Methods and Results: Due to its efficacy and relatively low com-plication rate, the mechanical single-sheath dilatation technique isthe preferred method for lead removal in our centre, based onstandard or modified (Bongiorni approach) dilators of increasingdiameter (Byrd, Cook Vascular Inc.). Our population consisted of300 consecutive CRM patients (218 male, mean age 67) indicatedfor complete removal of 516 lead. Removal was complete for 502leads (97%) and partial for 10 (2%). There were no procedure-rela-ted deaths, one major and 7 minor complications, 27 observations.In 222 patients (74%) lead extraction was due to infection requiringremoval of 373 leads. Distal segments of the removed leads syste-matically underwent bacteriological examination in our microbio-logic lab. In 116 (31%) no pathogenic organisms were isolated pro-bably due to the concomitant antibiotic oral therapy. For the remai-ning leads, the following infections were isolated: Staphylococcus(S.) epidermidis in 81 leads (22%), S. aureus in 62 (17%), other S. in58 (16%), Enterococcus fecali and cloacae in 19 (5%), Klebsiellaspp. in 13 (4%), Pseudomonas aeruginosa in 12 (3%), Alcaligenesspp. in 9 (2%), Candida albicans 3 (0%).Conclusions: Systematic infection examination of removed leadsample is useful to get precious information for concerning infec-tion source and to obtain detail antibiogram to exactly tailor anti-biotic strategy individually optimized.

48 - EPIDEMIOLOGICAL PROFILE OF INFECTIVE ENDOCAR-DITIS: REGARDING 158 CASESS. FADILI, N. Baady, A. Assaidi, Z. Elhonsali, A. Bennis

University Hospital - IBN ROCHD, Casablanca, Morocco

The infective endocarditis is the location and proliferation at thelevel of the endocarde of germs transported by blood.It is a serious disease, mortality rate, any merged forms of which,remains neighbouring from 15% to 20%. His complications are fre-quent, particularly dominated by the risk of cardiac insufficiencyand embolisms of cardiac origin. The purpose of our study is tostudy epidemiological contour, diagnosis and private hospital of

the infective endocarditis hospitalized in the cardiology ward.Equipment and methods: We led a retrospective study concerning158 cases of infective endocarditis colligés to service cardiology ofthe university HOSPITAL IBN ROCHD of Casablanca betweenJanuary, 2006 and September 2010Results: The medium age of the patients is of 42 years (16 years old70 years) with a masculine predominance (61%), the infectiveendocarditis has come along on top of mechanical prosthesis in18% of cases, rheumatic valvulopathies in 82% of cases.with a predominance for staphylococci coagulase negative in 34%of cases. L’attained mitrale or mitroaortique predominates distin-ctly. The front-door of the infection was found at 25% of thepatients. It was dental in 38% of cases. Hémocultures was posi-tive in 49% of cases. The echocardiography transthoracique cou-pled with transoesophagienne ultrasound scan allowed to put inan obvious place specific lesions of the infective endocarditis andof abscesses périaortiques and ring in 21% of cases Evolution wasmarked by the happening of renal infarction and splénique in 2cases, break of mitral cordage in 4 cases, renal insufficiency in 7cases, a right anévrysme mycotique pariétal in a case and a fistulaaorta right ventricle in 3 cases. One operated on 21% of thepatients with simple surgical suitesConclusion: The evolution of illness imposes appeal on the preco-cious valvular surgery, the respect for the rules of prophylaxis anda better diagnostic and therapeutic taking care of ill dices the firstsymptoms of the infective endocarditis, it will allow to reduce fre-quency and seriousness of illness.

49 - A NOVEL BENEFICIAL METHOD TO INSERT A PACINGLEADD. FUJIBAYASHI, Y. Deguchi, M. Ishi, M. Shima, T. Hashida, M. Amino,K. Yoshioka, T. Tanabe

Tokai University School of Medicine, Isehara, JAPAN

Background: There are some methods to insert a pacing leads toan axillary vein such as venography-guided puncture, ultrasono-graphy-guided puncture, and cut-down technique from a cephalicvein. In recent years, the number of the cases to implant a pacingdevice is increasing. Therefore, we designed a new technique,eelectrode catheter guided puncturef to insert pacing leads moresafely and more simply than conventional techniques. Method: From January 1st 2008 to March 31 2010, consecutive 174cases who underwent an electrophysiological study prior to thepacing device implantation were selected. In those cases, we insertan electrode catheter to the axillary vein and detain the electrodeas a mark to suitable site for puncture and advance a needle slo-wly by biplane guided. Results: All but 2 cases were successfully treated by this methodalone without venography. (98.8%) Among those, “Buddy cathetertechnique”, inserting 2 catheters mutually to straighten the tor-tuous vein or to remove the obstacle valves, was required toadvance the electrode catheter in some cases. We had no complica-tions by using these techniques. Conclusion: To implant pacing devices, our eelectrode catheterguided puncture method is simple and safe compared with con-ventional techniques. This technique could be helpful to avoid theadministration of contrast medium, could find out the PersistentLeft Superior Vena Cava before making the generator pocket. Italso could be helpful to determine the insertion point of the leadswithin a small range. “Buddy catheter technique” was helpful toadvance the electrode catheter in some particular cases.

50 - RISK FACTORS OF SUBCLAVIAN VENOUSOCCLUSION AFTER PACEMAKER IMPLANTATIONT. HASHIDA, Y. Deguchi, M. Shima, D. Fujibayashi, M. Amino, K. Yoshioka,Y. Ikari

Tokai Univ. School of Medicine, Isehara, JAPANPOSTERS - CARDIAC PACING

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Background: Subclavian venous occlusion after pacemaker leadinsertion is a complication of pacemaker implantation. There arefew long-term reports on subclavian venous occlusion. Objective: The aim of this study was to identify the long-term riskfactors and incidence of angiographic subclavian venous occlusionafter implantation of permanent pacemakers.Methods: Contrast venography was obtained in 42 patients under-going repeat pacemaker procedures from 2007 to 2010. Venogramswere graded as complete venous obstruction, or patent. We assessedclinical symptoms, sex, age, cardiac ejection fraction (EF), years afterimplantation, number of implanted leads, lead diameter, material oflead, insertion site and drugs (antiplatelets and anticoagulants). Results: After median interval of pacemacker implantation isabout 10 years. 42 patients (male:female=25:17) had done venogra-phy. Complete obstruction was seen in 9 of 42 patients (21%). 9patients with venous occlusion did not show clinical symptoms.Sex, age, EF, years after implantation, number of implanted leads,lead diameter, insertion site and drugs of anticoagulants and anti-platelets did not correlate with subclavian venous occlusion. Conclusion: Sex, age, EF, years after implantation, number ofimplanted leads, lead diameter, insertion site and drugs do not cle-arly predict subclavian venous occlusion after implantation of per-manent pacemakers.

51 - STRAIGHT SCREW-IN ATRIAL LEADS “J POST-SHAPED”IN RIGHT APPENDAGE VERSUS J-SHAPED PASSIVEFIXATION: A PROCEDURAL SAFETY COMPARISONF. ZOPPO, F. Zerbo, A. Lupo, E. Bacchiega, G. Brandolino, E. Bertaglia

Dipartimento di Cardiologia, Mirano (Venice), ITALY

Background and objectives: In recent years, the use of activescrew-in atrial pacing leads has rapidly developed. The reliabilityand performance of active-fixation atrial leads have been reportedand compared with those of passive-fixation leads. This retrospec-tive study compared the performance and safety of non-pre-sha-ped screw-in leads with those of passive-fixation J-shaped leads.Patients and Methods: From January 2004 to January 2010, 1464consecutive patients underwent implantation of a new pacemakeror cardiac defibrillator. Of these, 855 patients received a passivepre-J-shaped or a straight screw-in atrial lead, and constituted thestudy population. The remaining 609 patients, who received onlya ventricular lead (535 patients) or a pre-J-shaped screw-in atriallead (Medtronic Capsure fix 5568, 74 patients), were excludedfrom the analysis. The study group consisted of 165 patients(19.3%, Group FIX) who received a straight screw-in atrial lead,and 690 patients (80.7%, Group PASS) who received a passive-fixa-tion J-shaped one. Procedural and short-term complication rateswere analyzed up to 3 months post-implantation. Results: Group FIX patients were slightly younger than GroupPASS patients (74.8+/-10.8 versus 77.3 +/-9.9 years, p=0.004). Theimplanted devices were equally distributed between the 2 Groups. On implantation, pacing threshold (1.2+/-07 vs 0.6+/-0.5 V,p=0.000) and impedance (628.4+/-176.4 vs 564.2+/-128.2 Ohm;p=0.000) were significantly higher and P wave sensing (3.1+/-1.6vs 4.2+/-1.9 mV; p=0.000) was significantly lower in Group FIXpatients than in Group PASS patients.The rates of atrial lead-related complications were similar in bothgroups: 2 complications in each study group (1.2% vs 0.3%, p=0.1).The rate of atrial lead dislodgement was higher in Group PASSpatients (0 vs 16 dislodgements; p=0.048).Conclusion: Straight screw-in atrial leads, ”J post-shaped” in theright appendage, displayed the same performance and safety pro-file as J pre-shaped passive-fixation leads and had better lead sta-bility.

52 - PERMANENT EPICARDIAL PACING IN PEDIATRICAND CONGENITAL HEART DISEASE’S PATIENTSM. CABRERA ORTEGA1, E. Selman-Houssein Sosa2, A. Naranjo Ugalde2

1Cardiocentro Pediatrico William Soler. Department of Arrhytmia and CardiacPacing, Ciudad de la Habana, CUBA, 2Cardiocentro Pediatrico William Soler,Department of Cardiovascular Surgery, Ciudad de la Habana, CUBA

Background: Permanent epicardial pacing is often required inchildren and patients with congenital heart defects because of thesmall size of patients or lack of access to the chamber requiringpacing.Objective: Evaluate the outcome of patients with epicardialpacing leads implantation and identify possible predictors of lead-related complications.Methods: A retrospective and prospective analysis of patients thatrequired the implantation of definitive pacemakers with epicardialstimulation between January 1, 2000, and December 31, 2009 wasmade. Pacing and sensing thresholds were reviewed at implant, at1 month, at 3 months and at subsequent 6 months intervals. Leadfailure was defined as the need for replacement or abandonmentdue to pacing or sensing problems, lead fracture orphrenic/muscle stimulation.Results: A total of 48 patients underwent 65 unipolar, nonsteroidepicardial lead implantations (7 atrial/ 58 ventricular), median agewas 5,8 years; postoperative atrioventricular block (23 cases,47.9%) and congenital complete heart block (16 cases, 33.3%) werethe main indications for pacemaker. Mean follow-up period was32 months; epicardial lead failure occurred in 14 of 65 implanta-tions (21,5%) and increasing pacing thresholds was the most com-mon cause of lead failure (8 cases,12,3%). Neither age or weight atimplantations, congenital heart disease, lead implantation with aconcomitant cardiac operation nor the chamber paced was predic-tive of lead failure.Conclusion: The implantation of a definitive pacemaker with epi-cardial stimulation is a safe option in pediatric and congenitalheart disease’s patients although the increased pacing thresholdsreduce lead longevity.

53 - HIGH SENSING INTEGRITY COUNTER MIMICKINGLEAD FAILURE IN AN ICD / CCM OPTIMIZER PATIENTJ. MICHAELSEN1, J. Wilcox2, W. Große-Heitmeyer1

1Dept. of Cardiology, St. Bonifatius Hospital, Lingen, GERMANY, 2MedtronicInc., Minneapolis, USA

Purpose: High sensing integrity counter (SIC) in ICDs are oftenautomatically followed by lead replacement due to suspected leadfailure. There is little data on false positive SIC counts and possi-ble underlying mechanisms.Methods: We investigated a patient with dilated cardiomyopathywith an ICD (Medtronic 7230, Medtronic Sprint Quattro 6943) andan implanted cardiac contractility modulation system CCM(Impulse Dynamics Optimizer III) who had SIC counts between10-30/day. Multiple device interrogations (ICD and CCM), HolterECGs with marker chain telemetry (Medtronic DR220) and ECG-correlated radiography were performed. Results: Retrospective analysis of device f-up showed that theabsolute number of SIC counts was stable with 10 - 30 counts perday. This remained stable during the next 8 weeks. ProlongingCCM delay from 45 to 110 ms provoked oversensing and SICcounts, but non were detected at the initial programmed delay. Nodifference of SIC counts was seen with CCM on or off, electricalinterference of CCM/SIC was ruled out. Holter telemetry showedall SIC counts being triggered by ventricular oversensing 120-130ms before QRS complex without relation to the p-wave. No appa-rent noise was seen in the IEGM during these episodes. ECG-cor-related radiography revealed interaction of the atrial CCM lead(with a large atrial loop) and the atrial part of the ICD lead havingPO

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contact shortly before the QRS complex. High SIC counts were inthis case considered as mechanical interference between 2 leadswith no signs of lead failure. At f-up up to 9 months later the num-ber of SIC counts remained stable.Conclusion: High SIC counts are not necessarily due to lead failu-re but can also appear due to electrical interference or mechanicalinteraction despite a true bipolar lead. Therefore careful evalua-tion of every case is mandatory with Holter telemetry (+markerchains and IEGM-telemetry) as a helpful and necessary tool.

54 - LEAD’S LIGATURE FAILURE AND OVERMUCH OF LEA-D’S LENGTH IN RIGHT HEART - CAN WE OBSERVE IT ONLY?A. ANDRZEJ KUTARSKI1, B. Malecka2

1Dept. of Cardiology, Medical University of Lublin, Lublin, POLAND, 2Dept. ofElectrocardiology of Jagiellonian University of Cracov Poland, Cracow, POLAND

Background: There is controversy regarding dealing overmuch oflead’s length (long lead’s loops) in right atrium or in right ventricle.Methods: transvenous lead extraction in 590 pts. In 102 significantovermuch of lead’s length in right heart were noted. Leads wereextracted using mechanical tools only. We compared patient’sdate, effectiveness of extraction procedure and intracardiac tubelead’s abrasion in subgroup of pts. with normal lead route and inpts. with abnormally long intracardiac lead’s loops.Results: Phenomenon of to long loop of lead in right atrium,tricu-spid valve or in right ventricle,causing continuous dynamic colli-sion of two leads is observed in 17% of pts. referred due to diffe-rent reasons for lead extraction.Its reason consist ligature failure offunctional or abandoned lead (78%), lead fracture(13%), accidental(5%) or advisable (3%) abandonment to long loop of lead in rightatrium. Lead slide into CV system is observed more often in pts.with multiple leads, oldest system and in pts send for lead extrac-tion due to lead dependent infective endocarditis. Presence of tolong lead lops in right heart does not influence for effectivenesslead extraction but significantly increases risk of technical pro-blems occurred during extraction procedure. On the other hand itdoes not increase minor&major complications of procedure.Interesting is observed frequent coexistence of lead loping andexternal tube lead abrasion with spiral metal conductor exposure.It seems, that too long lead lops in right heart should be recogni-zed as “lead which may pose a potential future threat to thepatient if left in place” so leads, which extraction may be conside-red during another procedure (class 2b HRS guidelines).Conclusions: Long-tem staying abnormally long lead’s loops inright heart made lead extraction more difficult and terrible (morestrong adherent tissue), and seems to have connection with morefrequent phenomenon of external tube lead abrasion with spiralmetal conductor exposure andwith infective endocarditis, but notwith pocket infection.

55 - A DIFFICULT CARDIOVERTER-DEFIBRILLATOR IMPLAN-TATION IN A PATIENT WITH PERSISTENT LEFT SUPERIORVENA AND RIGHT SUPERIOR VENA CAVA ATRESIA:A CASE REPORTM. Viscusi1, M. Brignoli1, D. Di Maggio1, I. DE CRESCENZO2, C. Sardu3, P. Golino2

1AORN, Caserta, ITALY, 2SUN, Naples, ITALY, 3AOU, Federico II, Naples, ITALY

Persistent superior vena cava is not uncommon thoracic venousanomaly because occurs in 0,3-0,5% of general population and in3-10% of patient with congenital heart disease, rarely is associatedwith absent right superior vena cava. We report a difficult but suc-cessful cardioverter-defibrillator implatation case.A 71 years old male patient with ischemic dilatative cardiomiopa-ty,underwent to our observation for some substained, haemody-namically unstable ventricular tachychardia events with acute pul-monary edema episodies. Ecocardiografic exame showed dilata-

ted and hypocynetic left ventricule In 2004 patient had undergonecoronary by-pass surgery and he pratices optimizated therapy Wedecided to implant cardioverter defibrillator. In the first time weused approach through right subclavian vein that was unsuccefullafter a few trials because the guiding wire takes a left downwardcourse. So we decided to pratice a periferical phlebografy througha minimal injection of 10 cc of contrast material in both subclaviancompatible to several renal failure condition of our patient thatshowed RSCV absence and PLSVC. Once again, only PLVC couldbe catheterized with difficulty because PLVC has a anomalouscourse coming out in right atrium through coronary sinus (CS)and making a acute angle between right atrium and right ventri-cle. Defibrillator lead ended into right atrium through enlargedcoronary sinus (CS) via. The implantation at right ventricle apexwas difficult and realized only with preformed and different stiff-ness styled.The lead placed was at active fixation single coil gore-tex covered.Normal sensing and pacing parameters was obtained.Then we implanted an active fixation lead in right atrium lateralwall without particular difficulties. The first follow-up after onemonth and the second one after three months revealed normal sen-sing and pacing parameters. Periferical phebography is a simpleand rapid imaging diagnostic technique to delineate preciselyvenous system anatomy in operating room.

56 - PERMANENT PACING IN PATIENTS WITHPROLONGED ASYSTOLE AT THE HEAD UP TILT TESTF. SMURRA, I. Scarfò, L. Santini, A. Viele, V. Romano, G.B. Forleo,L.P. Papavasileiou, G. Magliano, A. Capria, F. Romeo

Policlinico Tor Vergata, Rome, ITALY

A prolonged asystole during HUTT usually leads to permanentpacemaker implantation. The aim of our study was to evaluate theactual efficacy of electrostimulation in patients with positive tilttest for cardioinhibitory syncope. Materials and Methods: We selected 22 patients who underwentHUTT from July 2007 to February 2010. Major cardiovasculardiseases was excluded. The duration of the tilt test-induced synco-pe, the degree and the duration of asystole were evaluated. GroupA consisted in 11 patients (50%) who presented cardioinhibitorysyncope with asystole >4 seconds; addressed to the pacemakerimplantation; group B consisted in 11 pts with milder cardioinhi-bitory response, in this group conservative treatment was prefer-red. Clinical follow-up was performed after two years.Results: Group A: 9 patients (82%) underwent bicameral pacema-ker implantation; while for 2 patients; conservative treatment waspreferred. Mean atrial pacing was found to be greater than ventri-cular pacing (AP 40.28% vs 3.5% VP). Atrial pacing is significantlyhigher when compared to ventricular pacing. (P=0.06). In addi-tion, in devices with rate drop response algorhytms, numerousepisodes were adequately recognized and treated. Two years fol-low-up was concluded in 67% of pacemaker patients. None ofthem presented new episodes and all patients reported improve-ment our quality of life. Regarding the 13 patients left to conserva-tive treatment, follow-up was concluded in 11 patients (50%).Recurrence of syncope occurred in 3/11 patients (27%) while theremaining 55% did not report new events.Conclusions: Given the higher percentage of atrial pacing,patients are more likely to suffer from sick-sinus syndrome ratherthan atrio-ventricular blocks. Permanent pacing is a valid and effi-cace option in patients that present prolonged asystole duringHUTT. Nevertheless, most patients without permanent pacing donot present recurrence of syncope probably due to educationalmeasures.

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57 - PACEMAKER IMPLANTATION IN PATIENTS ONVITAMINE K ANTAGONIST: THE ELECTRA 2008 SURVEYJ. TAÏEB1, M. Guenoun2, M. Hero3, R. Morice1, C. Barnay1

1Pole Cardiologie HG, Aix-en-Provence, FRANCE, 2Clinique Bouchard, Marseille,FRANCE

Management of patients on vitamin K antagonists undergoingpacemaker implantation or replacement is challenging. No guide-lines are currently available on this problem.Methods: A questionnaire was sent to French implanters including33 questions concerning pre, per and post implantation periods.The most frequent attitude was asked through single choice que-stions. 6 of which concerned anticoagulation strategy in 2 clinicalsituations i.e. atrial fibrillation (AF) and mechanical mitralvalve(MMV). Results: 98 questionnaires (25%) were obtained. In case of AF: Theinterval required between hospital admission and operation(AID), AID was 1-day in 77% for primo-implantation (PI) and 75%for replacement (R). In case of MMV, AID for PI and R was respec-tively 1-day (48%), 2-days (24%). Interruption of VKA and heparinprescription: In AF, 30% performed PI or R after VKA interruptionwithout heparin bridge therapy, 30% after VKA interruption swit-ched to low molecular weight heparin (LMWH), 10% after VKAinterruption switched to unfractionated subcutaneous heparin(USH), 13% continued VKA and 7% of implanters had no uniformstrategy(NUS). In case of MMV, 33% performed implantation afterVKA interruption with heparin bridge, 16% after VKA interrup-tion switched to LMWH, 18% to USH, 18% continued VKAwithout interruption. 5% of implanters had NUS. VKA was restarted: In case of AF, 43% restarted the day of opera-tion(D), 30% on D+1. In case of MMV, 55% restarted on day ofintervention (D), 25% on D+1. Conclusion: Interval between admission and implantation wasconcordant if VKA was indicated for AF (D-1) but not in patientswith MMV. The therapeutic attitudes regarding VKA discontinua-tion and a bridge with heparin were not similar in patients withAF as compared to patients with MMV. The time of resumption ofVKA was concordant for patients with MMV but not for AFpatients These disparities underline the need for guidelines on thispractical clinical situation.

58 - INFORMED CONSENT OF PATIENTS BEFOREPACEMAKER IMPLANTATION IN FRANCE: THE ELECTRA2008 SURVEYM. GUENOUN, J. Taïeb, M. Hero1Clinique Bouchard, Marseille, FRANCE, 2Pole Cardiologie HG, Aix-en -Provence,FRANCE

Informed consent of patients is required in France before pacema-ker implantation. However the way it is implemented may varyfrom centre to centre. The aim of the ELECTRA survey was to findout how informed consent is applied in clinical practice in France.Methods: A questionnaire on patient informed consent containing32 items including 8 single choice answer questions was sent toimplanting centers in 2008.Results: 103 completed questionnaires (27% of centres) were recei-ved. The operators (98% males) had an experience in pacemakerimplantation for <2-years (10%), 2 to 10-years (27%) and >10-years(63%). The volume of implantation was in 2007 <50 devices (18%),50 to 100 (37%) and >100 (45%). Implanting centers belonged to thepublic sector (63%) or private hospitals (37%) 1 - 1/3 of patients were examined before hospital admission by theoperator as documented by a written report (29%). In 39%, a writ-ten informed consent is delivered while only oral information in29%. 2/3 of patients were evaluated on admission and a signedinformed consent obtained 83%, while in 17% only oral informa-tion was given.

2 - The informed consent form was given to 90% of patients. It waseither the form of the French Cardiac Society (74%), or a modifiedversion (9%) or a document written by the implanting centre(17%).The document was signed (84%) or returned without signature(16%). The document was delivered by the implanter (23%) or bya nurse (67%).3 - After operation, an information brochure was given to 69% ofpatients. This consisted of a document put together by the devicecompany (62%) or by the implanting centre (38%). In 25% only oralinformation was given.Conclusion: This survey underlines differences in the informationgiven to the patients undergoing a pacemaker implantation and inthe obtained informed consent in various centres in France.Recommendations and guidelines may be useful to satisfy therequirements of the French Law.

59 - MODALITIES OF PACEMAKER IMPLANTATION INCLINICAL PRACTICE: THE ELECTRA 2008 SURVEYM. GUENOUN, J. Taïeb, M. Hero1Clinique Bouchard, Marseille, FRANCE, 2Pole Cardiologie HG, Aix-en-Provence,FRANCE

Background: There are various techniques, protocols and implan-ter experience in France in pacemaker (PM) implantation. A sur-vey was undertaken to compare current French practice, to theguidelines. Methods: A questionnaire was sent to PM implanters in 2007. Itincluded 33 questions concerning pre, per and post implantationperiods. It included patient admission, preparation for the procedu-re, operating technique, post- operative management and antithrom-botic strategy. The most common attitude used by the implanter wasasked using a single choice among 5 to 7 proposed choices. Results: 97 questionnaires (25%) were completed and analyzed.Implanters profile was: First line implanter since < 2-years (3%); 2-10 years (22%); >10-years: 75%. Number of devices implanted in2006 <50-(16%); 50-100 (34%); >100-(50%).1 - Admission time did not depend of the type of intervention i.e.primo-implantation or device replacement in the non vitamin Kantagonist (VKA) patients (p=0.18) and in the VKA patients(p=0.95). There was a significant difference in the admission timebetween non VKA patients and VKA patients for AF (p=0.014) orVKA patients for mechanical valve (p<0.001). 2 - The antibioprophylaxis was common while the shaving timeand fast duration differed widely. 3 - The first line cephalic approach was preferred to the subclavianapproach, 68% vs 30% (1 puncture 6%, 2 punctures 24%), (percuta-neous 29%, ”open air” 61%). The pectoral pocket was deep 67% orsuperficial 27%, to the right 31%, to the left 32% or according to rightor left handed patients (25%). The use of diathermy knife was syste-matic 49%, only in case of an haemorrhagic procedure or never 22%.Suture and haemostasis techniques, postoperative transfer, immobi-lization and monitoring differed according to the centres. Conclusion: In France, PM implantation in real life practice, mana-gement and operative techniques were quite variable from centreto centre underlining the need of a task force on this subject.

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60 - FOLLOW-UP OF PATIENTS IMPLANTED BYPACEMAKER IN FRANCE: THE ELECTRA 2008 SURVEYJ. TAÏEB, M. Guenoun, M. Hero1Pole Cardiologie, Aix-en Provence, FRANCE, 2Cinique Bouchard, Marseille,FRANCE

Consultation of pacemakers is the subject of best practice recom-mendations. However, there is no evaluation of this activity. TheELECTRA survey aims to know the monitoring practices of Frenchimplanters.Method: A single-choice questionnaire was sent by e-mail toFrench implanters during 2008.Results: 103 questionnaires were completed and returned (27%response rate). The implanters (98% of men) have an experience <2years (10%), between 2 and 10 years (27%) and> 10 years (63%) In2007 <50 implants (18%), 50 to 100 (37%) and > 100 (45%) were per-formed. 37% of the centers are private and 63% public.1-Support during follow-up: 47% without any consulting, (22%public-78% private) and 53% receive aid (76% public-24% private).Type of support: nurse-(73%), orderly-(12%), manufacturing engi-neer-(15%).2 - Multitrack ECG is made by physician+support-(77%) vsEGM+/-ECG-(23%) programmer. Physician alone (61%) vsEGM+/-ECG programmer-(39%).3 - Control timing: 1st control: 1 month(52%) 3 months(44%) or 6months(3%) after implant. After, for single and dual chamber PM,the control is every 3 months(1%), 6months(36%) or 12months(63%). For triple chamber PM every 3 months(9%),6months(75%) or 12 months(16%). There is a significant differencebetween types of PM (p<0.0001).4 - Measured parameters: stimulation thresholds: systematicmanual control(84%), automatic threshold check(11%) and in onlyevent of clinical problem(5%). Sensing: systematic manual control(77%), automatic thresholdcheck(12%). Memory check: Stimulo-dependance is systematicallysearched by 76% of physicians and only 25% in cases of clinicalrelevance. It is communicated to the patient in 54% of cases and tothe generalist in 75%.Conclusion: Only half of physicians are assisted. The role of thisaid is not codified and could be subject to recommendations.Follow-ups are made 2 times per years for CR-PM, but only onetime per year for single and dual chamber PM. Physicians are inte-rested in memory but don’t accept the automatic thresholds andsensing.

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1 - COMPARISON OF LEFT ATRIUM RADIUS VALUESAGAINST ENERGY LEVELS NEEDED FOR A SUCCESSFULELECTRICAL CARDIOVERSION AT PATIENTS WITH NON-VALVULAR ATRIAL FIBRILLATIONB. AKDEMIR1, A.R. Gulcan1, S. Karakas1, S. Koc1, M. Ucar1, I. Nizam2,R.E. Altekin1, H. Yilmaz1, N. Deger1, C. Ermis1

1Cardiology Department of Mediterranean University Hospital, Antalya,TURKEY, 2Internal Medicine Department of Mediterranean University Hospital,Antalya, TURKEY

Method: 40 outpatients from our policlinics, between the ages of30 and 80,who were planned to undergo electrical cardioversionfor nonvalvular atrial fibrillation were enrolled to the study.Respectively, all patients were first given 200 joules, then 300 jou-les if unsuccessful and finally 360 joules if the procedure failsagain. 200 and 300-joules were accepted as low energy level and360-joules was accepted as high energy level. Findings: Mean age of patients enrolled was 60,95 years. Mean LA(leftatrium) radius of the patients was 45.25 mm. During electricalcardioversion, 30 patients returned to SR (sinusrythym) (%75),where 10 still had AF (atrialfibrillation) (%25). Electrical cardiover-sion was applied with low energy level to 17 (42.5%) of thepatients and with high energy level to 23 (57.5%) of them. Allpatients who underwent electrical cardioversion with low energyhad SR (100%). Thirteen patients of high energy group had SR(56.5%). Mean LA radius of patients of low energy group wasdetected as 42 mm. Mean LA radius of patients of high energygroup was detected as 47.65 mm. LA radius values were comparedagainst energy levels needed for a successful electrical cardiover-sion at patients with nonvalvular atrial fibrillation. As LA radiusincreases, higher levels of energy are needed for successful electri-cal cardioversion. (p:0,001) Mean LA radius of patients who hadsuccessful electrical cardioversion with high energy level wasdetected as 46.8 mm, where mean LA radius of patients who hadunsuccessful electrical cardioversion with high energy level wasdetected as 48,7 mm. As left atrium radius increases, success rateof electrical cardioverison decreases (p:0.032).Conclusion: It was detected that as LA radiues value increases,higher levels of energy are needed for successful electrical cardio-version. At patients with AF who were planned to undergo electri-cal cardioversion, LA radius is important both for the success anddetermination of energy levels needed for procedure.

2 - DETECTION OF SUPRAVENTRICULAR ARRHYTHMIASIN PATIENTS WITH RECENT CRYPTOGENETIC STROKEWITH AN IMPLANTABLE LOOP-RECORDERV. GIUDICI1, A. Locatelli1, B. Casiraghi1, R. Grandi2, G.B. Antongiovanni1,P. Scopelliti1, M. Tespili1, A. Brambilla2

1Azienda Ospedaliera Bolognini - Department of Cardiology, Seriate, ITALY,2Azienda Ospedaliera Bolognini - Department of Neurology, Seriate, ITALY

To assess the incidence of supraventricular arrhythmias in a groupof Patients (Pts) with cryptogenic stroke by recording ECG with animplantable loop-recorder (ILR) with automatic arrhythmia detec-tion function. From 1/6/2009 to 30/8/2010 we studied all the Ptsadmitted to the Neurology Department of our Hospital. All the Ptsunderwent: cerebral CT scan or MRI, carotid doppler ultrasono-graphy, transthoracic and transesophageal echocardiography eva-luation, prothrombotic state.The Pts performed an ECG at admis-sion and during the second day; if in sinus rhythm, a 24 hourHolter monitoring was recorded in the 7th day. If negative for AFand without demonstration of the cause of cerebral ischemic eventwere proposed for an ILR. All the Pts had a CareLink Monitor toweekly transmit the information recorded by the ILR (Medtronic,Reveal XT). A follow up of 3 years with quarterly outpatient fol-low-ups is estimated. We evaluated 59 Pts affected by CryptogenicIschemic Stroke (36 Male, 59.3 + 9.7 years); 23 were excluded from

this analysis due to presence of Patent Foramen Ovale; 13 out ofremaining 36 pts (57.9 + 10.2 years) underwent a ILR implant (8male; median age 65.1± 8.2). All of them had preserved ejectionfraction ;atrial dimensions were normal. No patients had significa-tive valve disfunction. The median FU was 9.3±4.6 months. Duringthis period 352 transmissions were performed. We found anabnormal ECG in 2 cases: one pt experienced short (3-4 minutes)episodes of AF and oral anticoagulation therapy was started; ano-ther pt experienced symptomatic supraventricular paroxysmaltachycardia and underwent an EP study (slow A-V nodal patway). Prolonged monitoring with an ILR is a feasible approach to help tofind out the nature of Cryptogenic Stroke. A longer follow-up andrandomized trial is needed to determine an evidence based strate-gy with the use of ILR in the diagnosis of this pts.

3 - FIBRILLATORY WAVE AMPLITUDE ON SURFACE ECGAS A PREDICTOR OF SINUS RHYTHM MAINTENANCEAFTER ELECTRICAL CARDIOVERSIONG. MARCHETTI, A. Zaniboni, V. Castaldini, D. Franzè, V. Volzone, S. Urbinati

Cardiologia Ospedale Bellaria, Bologna, ITALY

Our study was performed to provide if F wave measurement onsurface electrocardiogram is an useful information in predictingthe evolution of atrial fibrillation after a rhythm control strategywith electrical cardioversion. 80 consecutive patients (pts) with persistent atrial fibrillation (AF)lasting more than 4 weeks, undergoing Electrical Cardioversion(ECV) in our Day Hospital between January 2008 and May 2010were included and pre-treated with antiarrhythmic drugs: amio-darone or flecainide or propafenone at least 1 month before ECV,than continued for at least 12 months. Fibrillatory wave (F- wave)amplitude measurements were done manually from peak tothrough using callipers in V1 lead on the surface electrocardio-gram (ECG). The surface ECGs of 80 consecutive patients under-going ECV for persistent AF were prospectively analysed. High voltage was defined as F wave amplitude >0.10 mV -groupA to differentiate this pattern from low voltage atrial activity-group B. High voltage F wave >0.10 was present in 48 pts (group A) andlow voltage in 32 pts (group B).Sex, weight, AF duration, left atrialsize, left ventricular ejection fraction, left ventricular hypertrophy,were not different between the two groups.Sinus Rhythm (SR) restoration was obtained with ECV in 74/80pts (all the 48 pts of group A plus 26 in group B) so the success ratewas 100% in group A versus 81.2% in group B. 6 pts with permanent AF had an F wave voltage in a range of 0.07-0.04 mV (all in group B).Pts with SR restoration had F wave maximal voltage in a range of0.08 - 0.16 mV (mean 0.12).At follow up AF relapses were: at six months 4 in group A versus11 in group B and at one year: 8 pts in group A versus 30 pts ingroup B.

4 - PREDICTION OF ATRIAL FIBRILLATION DEVELOPMENTIN HYPERTENSIVE PATIENTS WITH NORMAL LEFT ATRIALDIMENSION USING P WAVE WAVELET ANALYSISG. DAKOS1, V. Vassilikos1, I. Chatzizisis1, I. Chouvarda2, H. Karvounis1,S. Paraskevaidis1, L. Mantziari1, G. Stavropoulos1, N. Maglaveras2, I. Styliadis1

11st Cardiology Dept Aristotle University of Thessaloniki, Thessaloniki, GREECE,2Laboratory of Medical Informatics Aristotle University of Thessaloniki,Thessaloniki, GREECE

The purpose of our study was to evaluate P wave wavelet analy-sis for the prediction of atrial fibrillation (AF) development inhypertensive patients with normal left atrial dimension (LAd).Methods: We studied 20 hypertensives with normal LAd (<4cm)PO

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(Group A: 7 males, mean age 59.3±5.7 years) presented with thefirst episode of AF. A second Group of 20 hypertensives with nor-mal LAd without history of AF was used as control (Group B: 7males, mean age 57.9±8 years). The P wave was analyzed at base-line and at the end of 12.2±0.3 months follow-up, using the Morletwavelet and the wavelet parameters expressing the mean and maxenergy were calculated in the three orthogonal leads (X, Y, Z) andin the vector magnitude (VM), in three frequency bands (1st: 200-160 Hz, 2nd: 150-100 Hz and 3rd:90-50 Hz). Results: Group A patients showed longer P wave duration at Zaxis and VM (PdurZ:90.1±15 vs 73.8±15, p=0.002 andPdurVM:93.5±13 vs 79.9±13, p=0.002 respectively) along withhigher Mean and Max in all frequency bands at Y, Z axes and VMcompared to Group B controls. Multivariate analysis showed that higher mean in the 2nd frequen-cy band at Z axis (mean2Z), along with longer PdurVM, weresignificant and independent predictors of AF development withnormal LAd at both baseline (p<0.001 and p=0.002, respectively)and follow-up (p=0.005 and p=0.004, respectively) recordings.Mean2Z and PdurVM at cut-off values of 5.43ÏV and 85.8msecrespectively held sensitivity (Sn), specificity (Sp) and total predic-tive values (TPV) of 84%, 81% and 82.5% at baseline, whereas atcut-off 5.46ÏV and 87msec respectively held 83%Sn, 77%Sp and80%TPV at the end of follow-up.Conclusions: The development of AF in hypertensive patientswith normal LAd associated with fixed and specific atrial conduc-tion defects that can be reveiled using P wave wavelet analysis.

5 - STRATEGIES IN TRANS-THORACIC ELECTRICAL CAR-DIOVERSION OF ATRIAL FIBRILLATION IN CAMPANIA:THE SCARICA REGISTERA. CAMPANA1, F. Franculli2, L. Santangelo3, F. Candelmo4, R. Sangiuolo5,A. Catalano6, S.L. D’Ascia7, M. De Michele8

1Heart Department AOU San Giovanni di Dio e Ruggi D’Aragona, Salerno,ITALY, 2Division of Cardiology Ospedale G. Fucito, M.S. Severino, ITALY, 3Divisionof Cardiology SUN Monaldi Hospital, Naples, ITALY, 4Division of Cardiology S.Giuseppe Moscati Hospital, Avellino, ITALY, 5Division of CardiologyFatebenefratelli Hospital, Naples, ITALY, 6Division of Cardiology Maria SSAddolorata Hospital, Eboli, ITALY, 7Electrophysiology Unit Federico II University,Naples, ITALY, 8Division of Cardiology, Aversa, ITALY

Purpose: To present data about transthoracic electrical cardiover-sion (CVE) of atrial fibrillation (AF) collected on the AIACCampania section initiative.Methods: 137 patients underwent CVE for AF between octoberand december 2008 in 10 centers of Campania region; mean agewas 64±13 with 57% of males. Heart disease was present in 87% ofpatients and there was a left atrial enlargement in 81%. AF onsetwas classified as < 1 month, between and 6 months and >6months.Results: Responders (R) were 129 and non-responders (NR) were8; the efficacy of procedure was 94%. CVEs were performed inelectrophysiology laboratory (75%) or in intensive care unit (25%);an anaesthesiologist was present in the 39% of cases; the shock wasbiphasic in 86% and the position of paddles was antero-posteriorin 55%. A single shock was sufficient to obtain sinus rhythm in the76% of patients. A lesser quantity of energy was needed employingbiphasic waveform shocks. There were no significant differencesin the left ventricle ejection fraction and in the short axis left atrialdiameter between R and NR patients, whereas a significant diffe-rence in the time of AF onset was present (>1th in 46% of R and in75% on NR). Bipolar waveform was used in almost all cases of Rpatients.Conclusions: Only time from onset of AF seems to correlate withthe lack of response to CVE in the patients of the register. The datafrom the register show that a better standardization about sedationof patients, shock waveforms and position of paddles is needed.

6 - EFFECT OF “MPV” (MEAN PLATELET VOLUME)VALUE ON SUCCESS OF CARDIOVERSION AT PATIENTSWITH NONVALVULAR ATRIAL FIBRILLATIONB. AKDEMIR1, A. Yanikoglu1, B. Çaglar1, E. Kaya1, I. Nizam2, I. Basarici1,A. Belgi Yildirim1, I. Demir1, M. Kabukcu1, S. Yalçinkaya1, C. Ermis1

1Cardiology Department of Mediterranean University Hospital, Antalya, TUR-KEY, 2Internal Medicine Department of Mediterranean University Hospital,Antalya, TURKEY

Aim: To determine whether ”MPV” (mean platelet volume) valuehas an effect on success of cardioversion at patients with nonval-vular atrial fibrillation or not. Method: A total of 40 outpatients from our policlinics, between theages of 30 and 80, who were planned to undergo electrical cardio-version for nonvalvular atrial fibrillation were enrolled to thestudy. Following sedation with midazolam, defibrillator spoonswere placed on chest at sternum and apical area and cardioversionwas performed. Respectively, all patients were first given 200 jou-les, then 300 joules if unsuccessful and finally 360 joules if the pro-cedure fails again. Mann-Whitney U Test and Chi-square test wereused as statistical methods at our study. Findings: Demographical data of the patients were given at table1 and 2. Mean age of patients enrolled was 60,95 years. Of allpatients, 24 (60%) were male and 16 (40%) were female. MeanMPV of patients was 8,590 fL. Mean LA radius of the patients was45.25 mm. During electrical cardioversion, 30 patients returned tosinus rythym, where 10 still had atrial fibrillation. Patients withatrial fibrillation had an average MPV of 8,640 fL, where patientswith sinus rhythm had an average MPV of 8,573 fL. Althoughpatient with sinus rhythm had a lower mean MPV, there was nostatistically significant difference (p:0,870) (Table 3).Conclusion: No effect of MPV (mean platelet volume) on successof cardioversion at patients with nonvalvular atrial fibrillation wasobserved.

7 - ELECTROVIEW 3D MAPPING SYSTEM: A NEWLYAVAILABLE THREEDIMENSIONAL MAPPING SYSTEM TOPERFORME ATRIAL ARRHYTHMIASM. REBECCHI, L. Sciarra, E. De Ruvo, L. De Luca, L.M. Zuccaro, R. Iulianella,C. Commisso, M. Minati, A. Fagagnini, F. Guarracini, S. Matera, M. Porfirio,G. Pendenza, E. Lioy, L. Calo’

Policlinico Casilino, Rome, ITALY

Introduction: Electroviewô 3D Mapping System (BardElectrophysiology, CA, USA) represents a newly available 3D map-ping method to guide transcatheter ablation of arrhythmias.Electroanatomical mapping is performed by the capture of a fluoroimage that shows the catheter tip position during a point-to pointmapping in manually display on a standard 3D cardiac geometry. Methods and Results: We describe two case reports, respectivelyregarding one typical atrial flutter and one focal ectopic tachycar-dia, performed with this new 3D mapping method. In the first casereport, Electroview showed a particularly efficacy and fast in veri-fying the cavo-tricuspid isthmus block, through a single-beat iso-chronal activation time map obtained by using a multi-pole cathe-ter. In the second case report, a patient affected by focal atrialtachycardia underwent electroanatomical mapping of right andleft atrium performed with Electroview system. This new map-ping system, also proved particularly efficacy in guiding the focalatrial tachycardia ablation, through the correct identification ofoptimal site at level of the left atrium roof. Conclusions:. These two case reports showed that Electroviewô isa simple 3D mapping system without additional cost and extraset-up time. However, further studies with different types ofarrhythmias and greater number of patients are necessary to a bet-ter awareness of the real diagnostic capacities of this new 3D map-ping system.PO

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8 - AUTONOMIC DENERVATION IN RIGHT ATRIUM FORPATIENTS AFFECTED BY VAGAL-PAROXYSMAL ATRIALFIBRILLATIONM. REBECCHI1, L. Sciarra1, E. De Ruvo1, L. De Luca1, L.M. Zuccaro1, M. Porfirio1,M. Minati1, A. Fagagnini1, G. Pendenza1, F. Guarricini1, F. Pigozzi2, E. Lioy1, L. Calo’1

1Division of Policlinico Casilino ASL RMB, Rome, ITALY, 2Foro Italico University,Rome, ITALY

Background: Catheter ablation of ganglionated plexi (GP) in theleft atrium has been proposed in different subgroup of patientsaffected by vagal paroxysmal atrial fibrillation (AF). Anatomicalstudies found a high prevalence of GP in the posterior surface ofthe right atrium (RA). Experimental data suggested the potentialrole of right atrial GP in the AF initiation and maintenance.Objective: The aim of our study was to assess the efficacy of GPablation in RA in patients with vagal paroxysmal AF. Methods: Thirty-four patients (mean age 48.6±4.6 years, 22 men)without structural heart diseases were randomized to a selectiveablation procedure targeted on the elimination of vagal reflex evo-ked by high frequency stimulation (HFS) or an extensive approachat anatomical sites of GP. All patients underwent Holter ECG andheart rate variability (HRV) evaluation at baseline and at 3, 6 and12 months follow-up.Results: After a mean follow up of 11.7±6.3 months, AF recurred in5 (29.4%) of 17 patients with anatomic ablation and in 12 (70.6%)of 17 patients with selective approach (P=0.04). No patients hadmajor complications. Complex fractionated atrial electrograms(CFAEs) were mainly found in the posterior and septal wall in pro-ximity of vagal sites evoked at HFS or during ablation. GP ablationdetermined in 12 patients the disappearance and in 21 a significantreduction of CFAEs. After ablation, HRV parameters showed asignificant parasympathetic and sympathetic denervation, thatwas more prominent in patients with anatomic GP ablation and inthose without AF recurrence.Conclusion: This study demonstrates that, in a selected popula-tion of vagal paroxysmal AF, the anatomic ablation of GPs in theRA is effective in about 70% of patients. These results confirm thatatrial vagal denervation can abolish AF, as suggested by experi-mental and clinical data.

9 - THROMBOGENICITY AFTER CLOPIDOGREL AND ASPIRINADMINISTRATION DURING RADIOFREQUENCY ABLATIONK. POLYMEROPOULOS1, V. Vassilikos2, S. Paraskevaidis2, T. Karamitsos2,J. Styliadis2

1G. Papanikolaou Hospital, 1st Cardiology Department, Thessaloniki, GREECE,2AHEPA Hospital, Cardiology Department, Aristotle University, Thessaloniki, GREECE

Purpose: To assess the thrombogenic system activation in relationto aspirin and clopidogrel pretreatment, during RadiofrequencyAblation (RFA) procedures.Materials and Methods: We studied 40 patients (24 men) submit-ted for RFA due to right heart supraventricular tachycardias (atrio-ventricular nodal re-entry tachycardia n=24, atrioventricular re-entry tachycardia due to right-sided accessory pathways n=12,and typical atrial flutter n=4). Twenty patients (Group A) wererandomised to receive clopidogrel (300 mg the day before RFA, fol-lowed by 75 mg for one month) and twenty (Group B) were ran-domised to receive clopidogrel plus aspirin (325 mg the day befo-re RFA, followed by 325 mg for one month). Platelet aggregation(PA) induced by collagen (2 Ïg/ml) and thrombin-antithrombincomplex (TAT) levels, as marker of coagulation, were determined.Blood samples were evaluated at baseline, before sheath insertion(T1), after completion of the procedure (T2), 24 hours later (T3) andafter 1 month (T4).Results: A significant inhibition of PA by collagen (p<0.001) andnon-significant TAT levels (p=0.945) were documented betweengroups over time.

Conclusions: Dual antiplatelet treatment with clopidogrel andaspirin significantly inhibited platelet aggregation, though throm-bin generation was not affected in such cohort of patients, duringRFA procedures.

10 - PRKAG3 POLYMORPHISMS ASSOCIATED WITHSPORADIC WOLFF-PARKINSON-WHITE SYNDROME INTAIWANESE PEOPLEK. WENG, K. Hsieh, L. Ger

Kaohsiung Veterans Gneral Hospital, Kaohsiung, TAIWAN

Introduction: Mutations in AMP-activated protein kinase maylead to Wolff-Parkinson-White (WPW) syndrome associated withabnormal glycogen storage in human heart. PRKAG3 plays a rolein gene control in muscle glycogen content. We investigated whe-ther genetic variance in PRKAG3 is associated with sporadic WPWsyndrome in Taiwanese people.Methods: A total of 87 patients with sporadic WPW syndrome and94 sex-matched healthy controls were recruited. WPW syndromewas diagnosed by electrophysiologic study. Echocardiographyexcluded hypertrophic cardiomyopathy. PCR assays were used forthe genotyping of PRKAG3 polymorphisms.Results: A total of 87 patients (M/F 53/34, mean age 12.4°±5.9years) and 94 sex-matched healthy controls (M/F 58/36, mean age13.6°±1.8 years) were recruited for polymorphism analysis. Thegenotype and allelic type frequencies of PRKAG3 in both groupswere shown in Table 1. The genotype distributions of healthy con-trols were in Hardy-Weinberg equilibrium (p=0.926). A significantincrease in WPW syndrome risk was observed for PRKAG3 CGand CG+CC genotypes (AOR=1.99, 95% CI: 1.01-3.89, p=0.046;AOR=1.95, 95% CI: 1.03-3.71, p=0.042, separately). CC genotypeand allelic types were not correlated with risk of WPW syndrome.Conclusions: PRKAG3 polymorphisms might be associated withsporadic WPW syndrome in Taiwanese people.

11 - A STRANGE CASE OF LEFT POSTEROMEDIALATRIOVENTRICULAR ACCESSORY PATHWAY: APPARENTABSENCE OF PREEXICITATION DUE TO MARKED ATRIALCONDUCTION DELAYD. MALASPINA1, R. De Ponti2, M. Pala1, G. Guenzati1, M. Bernasconi1,M. Marzegalli1

1U.O. Cardiologia Azienda Ospedaliera S. Carlo Borromeo, Milan, ITALY,2Dipartimento Cardiocerebrovascolare Ospedale di Circolo Fondazione MacchiUniversità della Insubria, Varese, ITALY

We present the case of a 45ys woman with paroxysmal-persistentatrial fibrillation episodes and a very peculiar 12-leads ECG aspectof ventricular preexcitation associated with bifascicular block(RBBB+LAHB). For symptoms of palpitations and an ECG aspectsuggestive for ventricular preexicitation with short PQ interval,the patient had already undergone an EP study in a high volumecenter. This, performed with two quadripolar catheters and onlyhigh right atrial stimulation, excluded the presence of accessorypathway (AP) and of inducible arrhythmias. Subsequently, thepatient presented at the emergency room of our hospital for a veryrapid preexcited (minimum R-R interval 200 ms) atrial fibrillation.The arrhythmia was cardioverted by IV flecainide. Coronaryangiography and cardiac MRI resulted normal. We repeated EPstudy and, at baseline, high right atrial (HRA) stimulation docu-mented a marked (111 ms) atrial conduction delay from HRA toproximal coronary sinus (PCS). Therefore, incremental pacingfrom HRA did not render the accessory pathway (AP) manifest,whereas PCS pacing clearly uncovered preexcitation due to poste-romedial left-sided AP, capable also of retrograde conduction.Conduction over the AP was easily interrupted by radiofrequencyenergy delivery by using the transseptal approach, after AP locali-PO

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zation during PCS pacing. Very peculiarly, the surface ECG beforeand after ablation were completely identical. Afterwards, for theoccurrence of infrahisian paroxysmal 2:1 AV block a permanentcardiac pacemaker was implanted. After 15 months of follow-upthe patient is asymptomatic.Conclusions: 1) The presence of marked atrial conduction delaymay render difficult the diagnosis and localization of AP; 2) accu-rate electrophysiology study is necessary in these cases; 3) thecombination of a trifascicular conduction disease with a markedatrial conduction delay without an overt heart disease is unusualand the underlying cause remains to be determined.

12 - RADIOFREQUENCY CATHETER ABLATION OF ATRIO-VENTRICULAR REENTRANT TACHYCARDIA FROM A LEFTANTEROSEPTAL ACCESSORY PATHWAY IN DEXTROCAR-DIA WITH COMPLETE SITUS INVERSUSS. IACOPINO1, I. Lo Cane1, G. Colangelo1, V. Aspromonte1, G. Fabiano1,A. Talerico1, P. Sorrenti1, G. Campagna1, S. Pellicano2, M. Salierno3

1Electrophysiology Unit, S. Anna Hospital, Catanzaro, ITALY, 2University ofMessina, Messina, ITALY, 3Boston Scientific Italia, Milan, ITALY

The inversus situs in dextrocardia is a relativery rare anomaly, espe-cially in patients with a WPW syndrome. There are few cases docu-mented of ablation with dextrocardia. Here is related the case of a 21-year-old woman with situs inversus and dextrocardia with recurrentepisodes of paroxysmal tachycardia. The basal ECG, obtained bypositioning the electrodes in the right precordials (V1R-V6R) docu-mented the typical ECG of dextrocardia, but there were no signs ofventricular pre-excitation. An electrophysiological study was perfor-med. With a high right atrium stimulation with burst (cycle of 280msec), a tachyarrhythmia with a narrow QRS was induced, with aPR>70 msec (110 msec) (cycle of 280 msec), (orthodromic atrioventri-cular re-entry tachycardia) (AVRT) and with an activation sequenceearlier on the proximal-medium coronary synus. Through a retro-grad transaortical approach an ablation catheter with a 4 mm tip(Boston Scientific - TL1) was threaded into the left ventriculum.Standard radioscopic projections were used (RAO 30°, LAO 45°).During the tachycardia the mitral ring mapping was carries out andfused signals were located in correspondence with the left anterosep-tal region. The presence of the accessory pathway was confirmed bythe mapping of the left anteroseptal region during a stimulation fromthe right ventriculum. Here RF energy was delivered and tachyar-rhythmia was blocked with a single erogation. After a 30-minuteobservation, in basal conditions and after isoproterenol infusion, thetachyarrhythmia was no more inducible. The overall time of the pro-cedure was of 45 minutes; 12 minutes was the overall time of fluoro-scopy. With a 12-month follow-up no arrhythmia recurrence hasbeen documented. In conclusion, the AVRT from a left accessorypathway turned out to be possible and safe also in patients with dex-trocardia. In particular the first case of accessory pathway with a leftanteroseptal localization in dextrocardia has been documented.

13 - LATE PAROXYSMAL ATRIOVENTRICULAR BLOCK 2:1IN PATIENT WITH PREVIOUS EFFECTIVE ABLATION OF ARIGHT POSTEROSEPTAL ACCESSORY PATHWAYS. IACOPINO1, G. Colangelo1, V. Aspromonte1, I. Lo Cane1, G. Fabiano1,A. Talerico1, P. Sorrenti1, G. Campagna1, S. Pellicano2

1Electrophysiology Unit, S. Anna Hospital, Catanzaro, ITALY, 2University ofMessina, Messina, ITALY

The co-existence of atrioventricular block (AVB) and pre-excitationfrom Kent bundle is a rare condition. The appearance of AVB inpatients with Wolff-Parkinson-Whyte syndrome (WPW) whounderwent a ablation is not frequent, it is relatively early anddependent on the localization point.Here is the case of a 62-year-old man with a WPW syndrome who

underwent an effective ablation of a right posteroseptal accessorypathway done with only one radiofrequency erogation (55°C,45W, 60 seconds), whose ventricular pre-excitation signs disappea-red. ECG Holter done after 1, 3, 6 months from ablation documen-ted the presence of a stable synusal rhythm without any signs ofventricular pre-excitation. ECG Holter done after one year fromthe ablation, with an asymptomatic patient for tachycardia inabsence of drugs, showed the recurrence of intermittent ventricu-lar pre-excitation signs, with phases of asymptomatic AVB 2:1.A strain test was carried out which showed an AVB 2:1 duringstrain and intermittent pre-excitation in basal conditions andexclusive anterograd conduction through the accessory pathwayup to a load of 75 watts with the appearance of an AVB 2:1 duringthe strain. Therefore the patient underwent the implantation of adefinitive bicameral pacemaker. The 6-month follow-up did notshow any arrhythmic recurrence.As a conclusion the appearance of the AVB 2:1 in this patient aftera year from the ablation does not really appear to be connected tothe ablation itself. It is likely the coexistence of an AV bundle con-duction disease and of ventricular pre-excitation, as it has beenrecently documented in literature in a patient with asymptomaticintermittent apparent pre-excitation from an accessory pathway toa postero-septal localization and symptomatic AVB 2:1, later trea-ted with a VVIR PM implantation. These evidences suggest tostudy the conduction characteristics of the AV node, if possible,before and after the accessory pathway ablation.

14 - IS THERE ANY DIFFERENCES BETWEEN CAVOTRICU-SPID CONDUCTION IN PATIENTS WITH AND WITHOUTTYPICAL ATRIAL FLUTTER?S. MISIKOVA, B. Stancak, E. Komanova, P. Spurny, O. Olexa

Eastern Slovakia Institute of Cardiac and Vascular Diseases, Kosice, SLOVAKREPUBLIC

Introduction: Atrial flutter (AFL) is one of the most frequentlyoccurring atrial macroreentry tachycardias. Cavotricuspid isthmus(CTI) is the critical area of the atrial flutter reentry circle. Aims: The aim was to study the differences between the electro-physiology (EP) parameters reflecting the transisthmic conductionthrough CTI in patients with AFL and the reference group.Patients and methods: The study included 84 patients (64 men and20 women) aged 64,3±12,3 years. Patients were divided to twogroups depending on occurrence of the AFL. The AFL group con-sisted 60 patients with paroxysmal or persistent form of typicalAFL, the reference group consisted 24 patients who underwent EPstudy from another reasons. The EP study included the measuringof effective refractory periods of atrium and atrioventricular node(ERPs) and transisthmus conduction by CTI in the clockwise (CW)direction (stimulation of the ostium of coronary sinus) and coun-terclockwise (CCW) direction (stimulation of the low lateral partof the right atrium) during four different pacing rates (80, 100, 120and 140/minute). Results: Patients with AFL had slower CW transisthmus conduc-tion time through CTI during all frequencies of the stimulationthan reference group: 80/min. 89±22 ms vs 71±16 ms, p < 0,021100/min. 93±23 ms vs 75±15 ms, p < 0,020120/min. 93±24 ms vs 75±16 ms, p < 0,003140/min. 94±25 ms vs 75±14 ms, p < 0,012 The CCW transisthmus conduction time between the groups didnot differ. We could not find the differences between the groups inthe ERPs. Conclusion: Slower CW transisthmus conduction time throughCTI predispose to the induction of the typical AFL. This findingcan be helpfull when consider CTI ablation after pulmonary veinisolation.Key words: atrial flutter, ablation, cavotricuspid isthmus.PO

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15 - A NOVEL MULTIELECTRODE CATHETER FORABLATION OF RIGHT ATRIAL FLUTTERG. De Meyer, Y. DE GREEF, D. Stockman, B. Schwagten

ZNA Middelheim, Antwerp, BELGIUM

Background: Cavo-tricuspid isthmus ablation in right atrial flutteris traditionally performed by sequential single tip ablation usingradiofrequency (RF) energy. The T-VAC (Tip-Versatile AblationCatheter, Medtronic) is a linear hexapolar ablation catheter, delive-ring phased bipolar and unipolar RF energy in a temperature con-trolled mode. This could result in more homogeneous lesions. Weexamined the safety, feasibility and efficacy of the T-VAC and com-pared procedural data to a conventional approach.Methods: Twenty pts (12 males, mean age 67±10 year) with atrialflutter were studied. Ten pts were assigned to the ‘conventional’(C) group using a cooled-tip catheter (Alcath Flux, Biotronik) and10 to the ‘multielectrode’ (M) group using the T-VAC (latest ver-sion, 2009). Procedural endpoint was bidirectional block (BDB)demonstrated by double potentials (DPs) or differential pacing. Results: BDB was achieved in all pts with a mean N of applica-tions, procedure and fluoroscopy time respectively in the M and Cgroup of 4±3 vs 9±6 (P = 0,04), 90±45 min vs 71±28 min (NS) and17±9 min vs 15±8 min (NS). After T-VAC ablation, in 7 pts map-ping with the same catheter showed clear (widely split > 100 ms)DPs over the line, indicating BDB. In the remaining 3 pts the aid ofadditional catheters for differential pacing was needed to confirmBDB. No adverse effects occurred. Conclusion: (1) Phased RF energy delivered by the T-VAC provesto be superior to the conventional strategy in number of applica-tions to achieve bidirectional block. (2) If after TVAC ablation double potentials were not clearly pre-sent, mapping and validation of bidirectional block with the T-VAC was difficult, explaining equal procedure times. (3) Therefore, T-VAC is a powerful and safe ablation tool, but it isadvisory to use additional catheters for endpoint validation.

16 - CRYOBALLOON ABLATION OF ATRIAL FIBRILLATION:ACUTE AND LONG TERM RESULTSA. PAPPALARDO1, A. Avella1, G.B. Forleo2, F. Laurenzi1, P.G. De Girolamo1,M. Mansour3, C. Tondo4

1S. Camillo-Forlanini Hospital, Rome, ITALY, 2Tor Vergata University, Rome,ITALY, 3Massachussets General Hospital, Boston, USA, 4Centro CardiologicoIRCCS, Milan, ITALY

Pulmonary vein isolation (PVI) is the mainstay of catheter ablationfor AF. Research focuses on developing new energy sources andcatheter designs. Balloon-based catheter ablation systems are pro-mising because they allow PVI by placing the balloon at the PVostium and ablating circumferentially. In particular the cryoballo-on technology has been demonstrated to be effective and safe. Wereport our experience. Methods: 38 patients (30 males, age 56±13 yrs), with drug-refrac-tory paroxysmal (16 pts) or persistent (22 pts) AF, underwent cryo-balloon ablation. After transseptal puncture, a steerable 12F sheatwas used to guide the cryoballoon towards PV ostium. After defla-tion, PV balloon occlusion was assessed by contrast injection.Ablation consisted in 300 sec. of cryoenergy application with amaximum of 5 applications for each PV. Then, PVI was assessedwith a multipolar circular catheter and if not, completed with irri-gated RF retouch. In persistent AF, left atrial CFAE and/or linearRF ablations, were added.Results: The mean procedural time was 295±78 min. and the meancryoablation time was 47.6±19 min. Complete PVI with the cryo-ballon was obtained in 31 pts (82%) for a total of 136/146 PVs tar-geted, (93%). A mean of 10.4±3.3 cryo pulses, were applied. Amean minimum temperature of - 44.8±11, 4 °C was reached. In 5pts a shift to a smaller (23 mm) balloon was necessary to achieve

PVI. With additional RF retouch, 100% of PVs were isolated. Fourcases of transient phrenic nerve palsy occurred. After a mean fol-low-up of 16.9±6 months, 29 / 38 pts (76%) were free of AF recur-rences. Among 16 pts with paroxysmal AF, 14 pts (87%) were freefrom recurrences.Conclusion: PVI with the cryoballoon technique is feasible andsafe. Acute isolation can be achieved in more than 90% of PVs withhigh percentage of SR maintenance.

17- A COMMON INFERIOR PULMONARY TRUNK DETECTEDBY MAGNETIC RESONANCE IMAGING AFFECTS ATRIALFIBRILLATION ABLATION STRATEGY: CASE REPORTR. DE LUCIA, E. Soldati, G. Zucchelli, A. Di Cori, L. Segreti, M.G. Bongiorni

Division of Cardiovascular Disease Unit 2, University Hospital of Pisa, Pisa, ITALY

A 63-year-old male with paroxysmal atrial fibrillation (AF) under-went cardiac three-dimensional (3D) magnetic resonance angio-graphy (MRA) prior to pulmonary veins (PVs) isolation. The MRAshowed a posterior common trunk formed by an unusual postero-medial confluence of the right and left inferior PVs with an hori-zontal direction and two large superior PVs with a sloping one. Data set of the MRA scan was imported into an electroanatomicalsystem (CartoMerge, Biosense-Webster, Inc., USA). Before the pro-cedure, using a dedicated software we performed anatomical mea-sures of PVs ostium and critical ridges, and, in relation of the 3.5-mm tip catheter ablator, we decided for a tailored ablation appro-ach including a single large set of encircling lesions placed aroundthe common antral trunk region. This approach was performed in order to avoid delivering appli-cations of radiofrequency energy on the left atrium (LA) posteriorwall. In this pattern the latter region could probably be more closeto the oesophagus and the junction of both inferior PVs has beendemonstrated to be never located in the middle of the LA posteriorwall, but rightwardly shifted with the LIPV trunk running behindthe LA posterior wall and in front of the esophagus.Non-pathological variations in the PVs anatomy are frequent, ran-ging from 19 to 44%, and the most common anatomical variant arethe presence of a single left common PV or an additional rightmiddle PV. Although the real prevalence of this anatomical patternis not known, the increasing numbers of reported cases suggeststhat it is not extremely rare and the preoperative 3D imaging willhelp to detect its existence. This case demonstrates the pivotal rule of preprocedural imagingin detecting anatomic variation of PVs, affecting ablation strategyand outcomes of PVs isolation.

18 - IMAGE INTEGRATION-GUIDED EXTENSIVEENCIRCLING PULMONARY VEIN ISOLATION:A PROSPECTIVE, RANDOMIZED STUDYY. TANAKA, H. Hachiya, O. Inaba, A. Yagishita, K. Higuchi, M. Kawabata,K. Hirao

Tokyo Medical and Dental University - Department of cardiovascular medicine,Tokyo, JAPAN

Background: Extensive encircling pulmonary vein isolation(EEPVI) is effective for eliminating atrial fibrillation (AF). The inte-gration of multi-slice computed tomography (CT) into 3-dimensio-nal electroanatomical mapping to guide radiofrequency catheterablation has been shown to be accurate. The purpose of this studywas to compare, in a prospective, randomized fashion, the useful-ness of the CT image integration guided EEPVI and conventionalelectroanatomical mapping guided approach. Methods: This study included 40 patients with drug-resistant AF(34 men, 6 women; 578.9 years; 22 paroxysmal, 18 persistent).EEPVI was performed under guidance with CT image integration(CARTO merge) in 20 patients (merge-group) and with electroana-PO

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tomical mapping alone in 20 patients (non merge-group). Theradiofrequency energy was delivered to the left and right antra toencircle the ipsilateral pulmonary veins, and the endpoint was thecomplete isolation of all 4 PVs.Results: No significant difference was found in the baseline para-meters, including the age, gender, duration of an AF history, leftatrial size, or left ventricular function between the 2 groups.Electrical disconnection of all identified PVs was obtained in allpatients of both groups. A significant reduction in the mappingtime was demonstrated in the merge-group (4.30.7v.s. 19.80.7 min,p<0.0001). Meanwhile, there was no significant difference in thetotal duration of the procedure or duration and number of radio-frequency energy deliveries to isolate the left-sided or right-sidedPVs between the 2 groups. There was no difference in the AF-freesurvival rate, demonstrated by the Kaplan-Meier method, at amean follow-up of 5.33.4 months (p=0.42). No complicationsoccurred during the procedure in either group. Conclusions: CT image integration into the electroanatomicalmapping system was as efficacious and safe as conventional map-ping with a short mapping duration.

19 - MAZE PROCEDURE CONFINED TO LEFT ATRIUMONLY WITH BIPOLAR RADIOFREQUENCY ABLATION INPATIENTS WITH PERMANENT AND PERSISTENT ATRIALFIBRILLATION UNDERGOING CARDIAC SURGERYG. MARCHETTI1, G. Marinelli2, R. Di Bartolomeo2, P. Grazi1, P. Passarelli1,R. Roncuzzi1, A. Zaniboni1, S. Urbinati1

1Cardiologia Ospedale Bellaria, Bologna, ITALY, 2Istituto di CardiochirurgiaPoliclinico Sant’Orsola, Bologna, ITALY

Ablation using bipolar radiofrequency - Maze technique - inpatients with atrial fibrillation (AF) during surgery for valve repla-cement or coronary artery by pass graft, is an approach to replacethe surgical incisions with linear lines of transmural ablation crea-ting conduction blocks.The positive effect is directely related to thehigh success rate and to the amputation of the left atrial appenda-ge with significant reduction in cerebrovascular accidents andtransient ischemic events. 40 patients (pts) with AF submitted to cardiac surgery for valvereplacement or coronary by pass grafting, received Maze procedu-re confined to the left atrium endocardial surface with all fourpumonay veins isolation and a connecting lesion to the mitralvalve isthmus and to left atrial appendage with its amputation.AF was not a primary indication for surgery. Intervention primarymotivation was: mitral replacement in 21 pts, mitral replacementplus tricuspid anuloplasty in 5, mitral plus aortic valve replace-ment in 5, aortic valve replacement in 5, ascending aorta replace-ment in 2, and coronary artery by pass grafting in 2 pts. Complications: 1 pt had transitory cerebral attack in the secondpostoperative day after a ascending aorta replacement with subse-quent total recovery of neurological functions.2 pts had II degree atrio-ventricular block (received pacemakerimplantation).Early postoperative data: SR at discharge was present in 11 pts;regular atrial tachycardia in 12 pts ; permanent AF in 17. All ptsreceived warfarin and pts with atrial tachycardia or AF receivedamiodarone and were treated with electrical cardioversion(ECV)before 3 months after surgery.Follow up: At 3th month all 12 pts with atrial tachycardia hadsinus rhythm (SR) restoration after ECV.Of 12 pts with AF: 5 had SR restoration, 4 had immediate relapseof AF. At one year of follow up SR was present in 21/40 pts.

20 - RARE CASE OF SYNCOPE: 42 SECOND PAUSEDURING TILT TABLE TESTX. AMLEY1, L. Mastrine2, V. Valentino1, Y. Greenberg1

1Mainonides Medical Center, Department of Cardiology, Brooklyn, USA,2Mainonides Medical Center, Department of Medicine, Brooklyn, USA

A 67-year old male was evaluated in the emergency departmentfor an episode of near syncope while standing. Two weeks prior tothis event, he suffered a frank episode of syncope. He had severalprior episodes of syncope over the past four decades (approxima-tely once every ten years). All episodes occurred while standing.His family history is pertinent for having two brothers with hyper-trophic cardiomyopathy; one of whom died of congestive heartfailure.His physical examination demonstrated a murmur sugge-stive of hypertrophic obstructive cardiomyopathy. His electrocar-diogram demonstrated ventricular bigeminy without left ventricu-lar hypertrophy. The patient was hospitalized and cardiac monito-ring was instituted. While in the hospital, the patient had frequentpremature ventricular complexes as well as one episode of non-sustained monomorphic ventricular tachycardia. An echocardio-gram demonstrated a hypercontractile left ventricle with normalejection fraction and asymmetric septal hypertrophic cardiomyo-pathy. A tilt table study was performed. The patient developedsyncope 22 minutes after initiation of a tilt at 80 degrees. The epi-sode was associated with profound bradycardia (sinus arrest for42 seconds) suggestive of cardio-inhibitory syncope. Patients withresistant neurally mediated cardioinhibitory syncope may benefitfrom pacemaker implantation with rate drop response. Ourpatient was unique in that he also suffers from hypertrophic car-diomyopathy and recurrent non-sustained monomorphic ventri-cular tachycardia. A dual chamber implantable cardioverter defi-brillator was implanted for treatment of syncope and preventionof sudden cardiac death. No recurrent syncope has occurred in thepast 9 months.

21 - COMPARISON OF TWO PROTOCOLS FOR HEAD-UPTILT TESTING IN PATIENTS WITH NORMAL HEART ANDRECURRENT UNEXPLAINED SYNCOPEM. ALASTI1, B. Omidvar1, M.H. Nikoo2

1Department of Cardiology, Imam Khomeini Hospital, Azadegan Avenue,Jundishapur University of Medical Sciences, Ahvaz, IRAN, 2Department ofPacemaker and Electrophysiology, Kosar Hospital, Shiraz, IRAN

Purpose: This study aimed to compare two different head-up tilttesting (HUT) protocols in patients with normal heart and recur-rent unexplained syncope.Materials and Methods: Patients with recurrent unexplained syn-cope underwent taking history, physical examination, 12-lead elec-trocardiography and echocardiography. The patients with normalheart submitted to HUT. Thirty patients were randomly assignedto HUT protocol A or B, then the opposite tilt-test 1 week later. Protocol A: Resting phase in supine position for 20 min aftervenous cannulation, Drug-free 70 degree tilt for 45 min, Active 70degree tilt phase (after 400 µg sublingual nitroglycerin administra-tions) for 15 min. Protocol B: Resting phase in supine position for20 min after venous cannulation, Drug-free 70 degree tilt for 45min, Resting phase in supine position for 5 min, Active 70 degreetilt phase (after 400 µg sublingual nitroglycerin administration inhead-up position) for 15 min. Tilt tests were terminated at theonset of syncope or reaching to the end of protocol. Because therewas not significantly difference between the results in thesepatients, next patients randomly assigned to only protocol A or B.Results: Out of 177 consecutive patients underwent HUT, 86patients were in group A versus 91 patients in group B. Bothgroups had an identical distribution for sex and age. The negativeresult was observed in 34 patients in group A versus 36 in groupB. HUT was positive in 52 patients in group A (13 in passive phase,PO

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39 in active phase) versus 55 patients in group B (25 in passivephase, 30 in active phase). There was no significant difference bet-ween results in two groups (P value= 0.09).Conclusion: According to our data, adding a period of rest to HUTprotocol and returning to supine position before nitroglycerinadministration had no additional diagnostic yield.

22 - SLEEP-DISORDERED BREATHING, ATRIALFIBRILLATION AND TACHYCARDIOMYOPATHY:A CARDIO-RESPIRATORY NOCTURNAL SYNDROME?M. MATASSINI1, F. Guerra1, L. Cipolletta1, S. Maffei1, M. Brambatti1,M. Marchesini1, S. De Luca2, G. Pupita1, A. Capucci1

1Clinica di Cardiologia-Università Politecnica delle Marche, Ancona, ITALY,2U.O. Pneumologia-Ospedale di Osimo, Osimo, ITALY

Purpose: Sleep-disordered breathing (SDB) is a common finding inpatients with atrial fibrillation (AF). SDB could influence the natu-ral history of AF through the alteration in sympatho-vagal balan-ce due to hypoxemia, acidosis, apneas. The aim of the study is toassess the impact of SDB in AF patients, with or without tachycar-dimyopathy (TCM).Methods: 30 consecutive patients with persistent/permanent AFwere investigated at time 0 and three months later with clinical andechocardiographic evaluation, polysomnography and 24h-ECG-recording with HRV analysis. Diagnosis of TCM was made in pre-sence of LV dysfunction due to AF with rapid ventricular response.Among all patients, 18 of them had TCM whereas 12 had not.Results: Patients with TCM have lower EF and higher BNP andPAPs and all these differences remain unchanged at T1 visit (allp<0.05). On 24h-ECG-recordings, patients with TCM have higherheart rates (HRs) compared with patients with only AF even inday-time and night-time recordings (p <0.02). The HRV analysisshows a narrower mean SDaNN for patients with TCM, especial-ly significant during night-time period. Prevalence of centralsleep-apnea (CSA) is higher in patients with AF and TCM (CSA50%, OSA 6%) whereas patients with only AF have more frequen-tly obstructive sleep-apnea (OSA 42%, CSA 17%). Patients withOSA and AF have higher EF, lower PAPs as well as higher AHI andOHI (p<0.02). Patients with CSA and AF have higher HRs as wellas higher AHI and CAI (p<.01).Conclusions: Patients with AF and TCM compared with patientswith AF only have different patterns of SDB: the formers show anhigher prevalence of CSA, the latters of OSA. Patients with CSAand TCM have a worse profile: higher BNP, lower EF, higher HRsand narrower SDaNN that remain unchanged in the follow-up.

23 - TREATMENT FOR SLEEP APNEA SYNDROMEDECREASE THE ABNORMAL POWER INCREASE INFRACTAL ANALYSIS OF HEART RATE VARIABILITYM. FUJIMOTO, M. Kontani, M. Kiyama, K. Okeie, M. Yamamoto

Kouseiren Takaoka Hospital, Takaoka, JAPAN

Purpose: It is well known that sleep apnea syndrome (SAS) com-plicates many diseases. Patients with heart failure also are highlycomplicated by SAS, which is considered as an aggravation factor.It is very important to find out SAS in the therapy for heart failu-re. From Holter recordings of patients with heart failure, we usedfractal analysis as one of the procedure of heart rate variability(HRV) analyses and were able to foresee in presence of SAS byconfirming increase of abnormal power. This abnormal powerincrease disappeared after SAS treatment.Subjects and methods: 15 patients with moderate to severe SAS per-formed 24-hour ambulatory electrocardiographic recordings andsleep apnea examinations before and after SAS treatment. 13 patientswere male and 2 female. The mean age was 72 years old. The basicheart rhythm was sinus rhythm in all cases. HRV analysis performed

by fast Fourier transform analysis and displayed results by methodto calculate a fractal dimension to detect SAS components.Results: Before SAS treatment, apnea hypoxia index (AHI) wasmore than 20 in all patients. They also showed SAS components inHRV analysis at baseline. Their SAS were treated with oxygen the-rapy in 7 cases, continues positive airway pressure in 5 cases andnon-invasive positive pressure ventilation in 3 cases. After SAS tre-atment, their AHI decreased and SAS components also becamesmaller or disappeared But SAS components still presented whenSAS treatment was insufficient.Conclusion: The abnormal power increase in HRV analysis disap-peared by sufficient SAS therapy.

24 - COMPARISON BETWEEN MODIFIED-MOVINGAVERAGE AND SPECTRAL TWA METHODS DURINGEXERCISE-ECGA. MARTINO1, F. Nuccio2, A. Sette2, C. Comisso2, L. Sciarra2, L. De Luca2,L.M. Zuccaro2, M. Rebecchi2, E. De Ruvo2, M. Minati2, S. Matera2,A. Ciccaglioni1, G. Giunta1, F. Guarracini2, A. Fagagnini2, G. Pendenza2,M. Porfirio2, E. Lioy2, F. Fedele1, L. Calo’2

1Cardiology Departement, Policlinico Umberto I, La Sapienza University, Rome,ITALY, 2Cardiology Department, Policlinico Casilino, Rome, ITALY

Purpose: T wave alternans (TWA) is an electrocardiographic indexmeasuring beat-to-beat modification in the amplitude and timing ofthe T wave, which reflects dispersion of repolarization often prece-ding arrhythmic sudden cardiac death. Two different methods, thespectral and the modified moving average (MMA), have been vali-dated to assess TWA. A previous study compared MMA to spectralanalysis during cardiac pacing, showing a trend in the paired rela-tionship between the two analyses. The aim of our study was to com-pare MMA and spectral TWA during exercise ECG. Materials and Methods: We simultaneously assessed spectral andMMA-TWA during exercise-ECG in 49 patients at risk of suddencardiac death.Results: The paired relationship between MMA and spectral TWAshowed a lack of significance (P = 0.8). Mean MMA-TWA valuedid not significantly differ among patients with negative or non-negative spectral-TWA results (P = 0.7). Similar findings wereobserved in the subgroups of patients affected by either ischemicor idiopathic dilated cardiomyopathy. Conclusion: We observed no correlation between spectral andMMA-TWA assessed during exercise ECG in patients at risk ofsudden cardiac death. Our study suggests the existence of diffe-rent faces of TWA, possibly being detected by these two methods.Further studies correlating results of exercise-ECG spectral andMMA-TWA, to arrhythmic events, are needed.

25 - CHARACTERIZATION OF ENDOCARDIAL ANDEPICARDIAL LATE POTENTIALS IN PATIENTSUNDERGOING VT ABLATIONP. VERGARA, N. Trevisi, F. Baratto, F. Petracca, A. Ricco, G. Maccabelli,P. Della Bella

San Raffaele Hospital - Arrhythmology Department, Milan, ITALY

Aim: We sought to describe the characteristics of LPs in endocar-dial and epicardial scar regions in patients undergoing radiofre-quency VT ablation.Methods and Results: Thirty-five patients (pts) (32 male; age65.5±13.9 years) with recurrent VTs and presence of LPs at elec-troanatomic mapping (EAM) were included in the study; 23 ptshad coronary artery disease (CAD), 9 pts had idiopathic dilatedcardiomyopathy (IDCM) and 3 pts had arrhythmogenic right ven-tricular cardiomyopathy (ARVC). LPs were defined as bipolarEGMs following the end of surface QRS complex and classified asisolated, if an isoelectric interval separated the delayed activityPO

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from the higher-amplitude component of the local ventricularEGM, or fractionated, if a continuous deflection from a local ven-tricular EGM was locally recorded. Twenty-one pts underwentendocardial mapping only, 3 pts epicardial mapping only and 11pts a combined approach; epicardial access was more frequentlyrequired in IDCM and ARVC than CAD (p<0.01). A scar tissue area(<1.5 bipolar endocardial or <1.0mV bipolar epicardial voltage)was identified in all pts, with a mean surface extension of31.3±26.4 cm2; average extension of the area containing LPs was21±16 cm2; in each patient LP extension correlated with scar areaextension (r= 0.44, p<0.05). Average LAT was 195.2±45.5 msec andcorrelated with QRS duration (r=0.63, p<0.01). LAT from QRSonset was longer in pts with CAD-related VT (206.5±42.9 msec),than in IDCM (164.8±35.5 msec) and ARVC (150.3±30.3msec). LPswere mainly fractionated (87.2%) in the channel, while in the bor-der and scar zone fractionated and isolated LPs were equally pre-sent (p<0.01). Isolated LPs had a longer LAT from QRS than frac-tionated potentials (205.1±40.1 vs 189.24±47.2 msec, p<0.01). Conclusions: LPs are present in CAD, IDCM and ARVC relatedVT patients. Due to the different characteristics of the scar, LP mor-phology is different in the various pathologies.

26 - REAL-TIME INTEGRATION OF INTRACARDIAC ECHO-CARDIOGRAPHY AND ELECTROANATOMIC MAPPING TOGUIDE ABLATION OF LEFT VENTRICULAR PREMATUREBEATSA. AVELLA1, P. De Girolamo1, F. Laurenzi1, A. Pappalardo1, C. Tondo2

1Cardiology Division, Cardiac Arrhythmia Center, St.Camillo-Forlanini Hospital,Rome, ITALY, 2Centro Cardiologico IRCCS, University of Milan, Milan, ITALY

Introduction: Radiofrequency ablation (RFA) of symptomaticmonomorphic ventricular premature beats (VPBs) may be a usefultherapy when drugs are ineffective or not tolerated. Nevertheless,this procedure usually involves point-by-point reconstruction ofthe 3D virtual anatomy, is time consuming and may require sub-stantial fluoroscopy exposure. Recently, a new mapping system,integrating 2D intracardiac echo (ICE) with 3D electroanatomical(EA) mapping (CartoSoundTM system - Biosense Webster) hasbeen developed. Aim of our study was to assess this innovativesystem as a guide for RFA of symptomatic VPBs arising from leftventricle (LV).Methods: We enrolled 8 patients (pts) (5 men, 56±13 years) withsymptomatic drug resistant LV ectopies. Four pts had no evidenceof structural heart disease, 3 pts had nonischemic DCM and 1 pthad a suspected myocarditis. In all pts a 3D anatomy reconstruc-tion of the LV was initially performed with CartoSoundTM system.A modified phased-array ICE probe, with a location sensor trackedby the mapping system, was positioned in the right heart, enablingsequential acquisition of ECG-gated 2D images of LV, from base toapex. Multiple endocardial contours (36±6), traced on 2D imageswere then used to generate a 3D shell of the LV cavity. Then, detai-led mapping and catheter ablation of VPBs were performed accor-ding to a 3-step protocol: I) identification of the target LV region bypace mapping; II) EA bipolar activation mapping during clinicalectopic activity. III) RFA of the ectopic LV focus.Results: Sampling only 32±16 endocardial points, LV ectopic fociwere identified in the outflow tract (7 pts) and below the lateralportion of the mitral annulus (1 pt). RFA was acutely successful in7 pts but failed in 1 pt with a likely origin from LV outflow tractepicardium. Earliest activation at successful sites preceded theectopic QRS onset by 38±5 msec. Mean duration of the ablationphase was 35±16 minutes. No major complications occurred.Conclusions: CartoSoundTM system provided a reliable 3D ana-tomic guidance for ablation of symptomatic LV ectopies, with alimited fluoroscopy exposure.

27 - ACCURACY OF 3D RIGHT VENTRICLE RECONSTRUCTIONPERFORMED WITH CARTOSOUND SYSTEM™ IN ARRHY-THMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHYA. AVELLA1, A. Pappalardo1, F. Re1, P. De Girolamo1, F. Laurenzi1, P. Baratta1,G. d’Amati2, E. Zachara1, C. Tondo3

1Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit,St.Camillo-Forlanini Hospital, Rome, ITALY, 2Department of ExperimentalPathology, Sapienza University, Rome, ITALY, 3Centro Cardiologico IRCCS,University of Milan, Milan, ITALY

Introduction: Electroanatomical voltage mapping is increasinglyused to detect right ventricle (RV) endocardial low-voltageregions, reflecting fibrofatty myocardial replacement, in patientswith arrhythmogenic right ventricular cardiomyopathy (ARVC).Anyhow, this imaging technique, based on point-by-point recon-struction of the 3D virtual anatomy, is time consuming and offersa limited anatomical accuracy. Recently, a new mapping system,integrating 2D intracardiac echo (ICE) with 3D electroanatomicalmapping (CartoSoundTM system - Biosense Webster) has beendeveloped. Aim of the study was to assess the accuracy of RV ana-tomy reconstruction with CartoSoundTM system in patients (pts)with ARVC.Methods: 4 pts (2 men, 44±14 years) with clinical suspicion forARVC, referred for voltage mapping-guided endomyocardialbiopsy (EMB), underwent a 3-step diagnostic procedure: (I) 3Dreconstruction of RV performed with CartoSoundTM system, (II)bipolar voltage mapping of RV endocardium during sinus rhythmand (III) EMB focused on RV low-voltage areas. Initially, a modi-fied phased-array ICE probe (SoundStarTM), with a location sen-sor tracked by the mapping system, was positioned in the rightheart, enabling sequential acquisition of ECG-gated 2D images ofRV from base to apex. Images were acquired from right atrium andventricle while rotating the probe through different scanning pla-nes. Multiple endocardial contours, traced on 2D images werethen used to generate a 3D shell of the RV cavity. The procedurewas then completed with the two remaining steps.Results: A complete 3D reconstruction was performed in all ptsfrom 42±13 ICE-based RV contours. Reconstructed RV mean volu-me was 189±63 cm3. Total rendering time was 20±8 minutes, witha total fluoroscopy exposure £ 7 minutes. No major complicationswere observed while maneuvering the SoundStarTM probe in theright heart as well as during the following steps. In all pts RV low-voltage endocardial areas were documented and voltage-guidedEMB confirmed the ARVC diagnosis.Conclusions: CartoSoundTM system seems to provide an accurate andsafe RV imaging in ARVC pts with a limited fluoroscopy exposure.

28 - TECHNIQUES IN APPROACH ABLATIVE:VENTRICULAR TACHYCARDIAS.L. D’ Ascia 1, C. SARDU1, V, Marino1, V. Schiavone2, V. Marullo2, C. D’ Ascia1

1AOU Federico Ii, Naples, ITALY, 2Istituto Clinico Pineta Grande, Caserta, ITALY

Radiofrequency ablation of TV may potentially be a curative the-rapy. Success rates are up to half of patients in case of absence oforganic heart disease and decrease in patients with chronic ische-mic heart disease and dilated cardiomyopathy.In this case percen-tage of success is higher in the coronary artery especially duringhybrid treatment (ablation and farmacological therapy).According to our experience the success of the ablation procedureis closely linked to the ability to map and identify the site respon-sible for tachyarrhythmia.The mapping techniques used today are:-pace mapping: stimulation through play and map the morphology ofidiopathic TV by 12/12 outlets to locate the site of origin of the circuit.-presence of QS potential by unipolar derivations: intracavitary QSpotential mapping preceding the QRS of BEV alone or as part of a TV.-mesodiastolic potential: identification and mapping of intracavi-tary potentials during electric meso-diastolic phase.PO

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-mapping techniques of substrate: areas of low voltage and latepotentials during sinus rhythm identified as sites effective ablative.-entrainment techniques: stimulation with dragging a site that isthe real part of the circuit.-multipolar systems: in case of a single BEV or of non substainedTV and multiple morphologies of TV or poor hemodynamic tole-rance to TV we can do simultaneous sampling with multi-compu-ter analysis and mapping of activation of whole cardiacroom.Ablation therapy is applied when drug therapy and whenother non-pharmacological options (anti-arrhythmic surgery, ICD)are inapplicable or inadequate. Perforation of the right ventricle,although rare, is the most feared complication of the ablation pro-cedure. Development of more accurate mapping techniques intra-cavitary (new mapping electrodes and navigation systems) willincrease success rates of ablation therapy under different forms ofTV and therapeutic management of patients will make more safeand effective suffering from whatever TV or not the presence ofunderlying organic heart disease.

29 - VENTRICULAR TACHYCARDIA AND FLACCIDPARALYSIS ATTACKSG. GAZZONI, C. Sussenbach, A. Ferrari, E. Lima, R. Etchapare, P. Soliz,R. Manhabosco Moraes, M.A Goldani, R. Piant·, E. Bartholomay, C. Kalil

Hospital São Lucas Pucrs, Porto Alegre, BRAZIL

Introduction: The presence of ventricular tachycardia (VT), facialabnormalities and sporadic paralysis attacks may indicate the dia-gnosis of Andersen-Tawil syndrome.Objective: case report of an Andersen-Tawil syndrome. Casereport: An 11-year-old boy was admitted with history of palpita-tion, syncope and sporadic paralysis attacks at rest. On physicalexamination he had facial abnormalities (micrognathia, low-setears, hypertelorism) and clinodactyly. At 6 months of age his sisterhad sudden death. Complementary tests: ECG with polymorphicand bidirectional premature beats, Holter with frequent and poly-morphic ventricular ectopy (37%) and multiple episodes of bidi-rectional VT; ergometry with bidirectional and symptomatic VT.Based on the clinical and complementary tests abnormalities hewas diagnosed with Andersen-Tawil syndrome. He was submittedto cardiac defibrillator implantation.Conclusion: The Andersen-Tawil syndrome is a rare potassiumchannelopathy which must be remembered in the presence of bidi-rectional VT, facial and musculoskeletal abnormalities and spora-dic paralysis attacks.

30 - ACUTE INTOXICATION BY FLECAINIDE INCHILDHOOD: REPORT OF CASEM. CABRERA ORTEGA1, D. Castillo Meriño2, J. Gell Aboy3, E. DÌaz Berto3,V. Monagas Docasal3

1Cardiocentro Pediatrico William Soler - Department of Arrhytmia and CardiacPacing, Ciudad de la Habana, CUBA, 2Cardiocentro Pediatrico William Soler -Department of Pharmacology, Ciudad de la Habana, CUBA, 3CardiocentroPediatrico William Soler - Intensive Care Unit, Ciudad de la Habana, CUBA

Background: Flecainide is a class Ic anti-arrhytmic drug withsodium channel blocking activities. Overdose is very uncommon,its management is difficult and the mortality high. Objective: To describe a case of flecainide intoxication in a childand the effectiveness of hypertonic sodium bicarbonate as antido-te in flecainide overdose.Case summary: A 2 years old male with history of orthodromicreciprocating tachycardia had been receiving flecainide 5mg/kg/day. The patient was carried into our Intensive Care Unitafter intake of 1 gr of flecainide by himself, he was bradicardic andthe surface electrocardiogram showed a prolongation of QTc inter-val, atrioventricular dissociation and wide QRS complex. He was

treated with high dose of hypertonic sodium bicarbonate and iso-proterenol; a monomorphic ventricular tachycardia triggeredwithout hemodynamic instability which desappeared after bolusadministration of intravenous amiodarone. After twelve hours oftreatment the patient recovered synus rhythm and five days laterhe was discharged from hospital.Conclusion: Our observations suggest that hypertonic sodiumbicarbonate is effective to the treatment of flecainide intoxicationin childhood.

31 - THE ACUTE EFFECTS OF FELODIPINE PLUSRANOLAZINE ON LEFT VENTRICULAR DIASTOLICFUNCTION AND QT DISPERSION IN PATIENTS WITHESSENTIAL HYPERTENSIONN. SINISCALCHI1, T. Cerciello1, F. Oliviero1, L.I. Siniscalchi1, L. Misso1

1Dipartimento di Gerontologia, Geriatria e Malattie del Metabolismo IIUniversità di Napoli, Naples, ITALY, 2Ospedale Civile di Sarno, Sarno (SA), ITALY

The aim of this study was to evalutate the effects of treatment withFelodipine (F) plus Ranolazine (R) on left ventricular diastolic fun-ction and QT dispersion in hypertensive patients (Ps).20 selected Ps, mean age 56±5 years (12 F-8 M) with mild to mode-rate essential hypertension, office blood pressure (OBP)>, 165/95mmHg, without diabetes mellitus and coronary arterial disease,were examined after two weeks of placebo washout.All Ps underwent blood pressure (BP) determination, 12- lead ECGand two- Dimensional-Echocardiography with Doppler (D-2DE)and recordings. 20 mg F tablets plus 1000 mg R tablets were givenorally to all of the Ps and BP determinations and 12 lead ECG andDoppler-Echocardiographic recordings were repeated 3 Hoursafter F plus R. Left ventricular diastolic function was evaluated byusing diastolic mitral valve flow patterns on continous-waveDoppler recordings. The investigated diastolic function parame-ters were peak and mean e and a wave velocities and e and a wavedurations. After 3 hours of treatment both systolic and diastolicblood pressure decreased significantly (p<0,001-p<0,001). MeanQT dispersion value showed an insignificant increase after F plusR (32±5 msec and 40±6 msec respectively) and insignificant heartrate changes. Peak e and a wave velocities were not modify butmean e wave velocity increased significantly after F plus R (46±18cm/sec and 52±22 cm/sec respectively p<0,001) were mean awave velocity was not altered. Both e and a wave durationsdecreased significantly after F plus R (P 224±51 msec vs 196±53msec and 149±32 msec vs 133±21 msec p<0,001).Our results suggest that the acute treatment with F plus R causeda slight improvement of LV filling. On the other hand, QT disper-sion was not altered 3 hours after the drugs.

32 - ADDITIVE EFFECTS OF REMIFENTANIL ANDSEVOFLURANE ON THE ELECTROPHYSIOLOGY OF THESINUS AND AV NODE IN A PORCINE MODELM. ANADON1, J. Almendral2, M. Zaballos1, B. Del Blanco3, F. Atienza4,C. Gimeno3

1University Complutense - Toxicology Dept, Madrid, SPAIN, 2Grupo Hospital deMadrid - University CEU San Pablo - Electrophysiology Dept, Madrid, SPAIN,3Hospital Gregorio Maranon - Anesthesiology Dept, Madrid, SPAIN, 4HospitalGregorio Maranon - Cardiology Dept, Madrid, SPAIN

Electrophysiologic studies sometimes need to be performed underanesthesia and remifentanil is one of the preferred agents.However, in clinical practice, remifentanil usually needs to be sup-plemented with other anesthetics. Sevoflurane is known to havedepressant effects on cardiac electrophysiology. Purpose: The present study was undertaken to characterize theelectrophysiological effects of remifentanil in animals already ane-sthetized with sevoflurane. Materials and Methods: Landrace-Large white pigs were anesthe-tized with sevoflurane 1 MAC [2.66%] 2. Two cuadripolar cathe-PO

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ters were percutaneously inserted. An electrophysiologic evalua-tion was performed under sevoflurane anaesthesia and repeatedafter remifentanil (bolus of 1 g.kg-1, followed by an infusion of 0.5g.kg-1.min-1). Results: Seven animals were studied. Remifentanil caused a signi-ficant prolongation in sinus cycle length (23%, p=0.01), sinus noderecovery time (82%, p=0.04), corrected sinus node recovery time(225%, p=0.01), sino-atrial conduction time (55%, p=0.01), andWenckebach cycle length (21%, p=0.01). There was a non-signifi-cant tendency towards a prolongation of AV nodal refractoriness. Conclusion: In this closed-chest porcine model, remifentanil depres-ses sinus node function and most parameters of AV nodal function inanimals already anesthetized with sevoflurane. This contributes toan explanation for clinical observations of difficulties in induction ofAV nodal related tachycardias and of development of severe bradiar-rhythmias in patients under certain anesthetic regimens.

33 - LONG QT SYNDROME LEADS TO TORSADES DE POIN-TES IN A PATIENT WITH HIV AND HEPATITIS C COINFECTIONJ. John1, X. Amley2, C. GITELIS2, G. Bombino2, B. Topi1, G. Hollander2,J. Ghosh2

1Maimonides Medical Center,Department of Internal Medicine, Brooklyn, USA,2Maimonides Medical Center,Department of Cardiology, Brooklyn, USA

QT prolongation is defined as more than 450 ms in adult male andmore than 470ms in adult female. Long QT syndrome can be eithercongenital or acquired and is associated with dysrhythmia parti-cularly Torsades de Pointes (TdP). The likelihood of drug-inducedTdP is higher if the QTc of the patient is greater than 500 ms befo-re drug administration. Patients with human immunodeficiencyvirus (HIV) infection have an increased prevalence of QTc prolon-gation especially in those with concomitant Hepatitis C infection.Many drugs used during the treatment of HIV are known to causeQTc prolongation. A 50-year old HIV-positive patient withHepatitis C coinfection was admitted with syncope. An EKG onpresentation showed a QTc greater than 500 ms. The followingdrug-related regimens were relevant to this case: (1) Atazanavir forHIV, (2) trimethoprim/sulfamethoxazole and (3) methadone. Allof these treatments are known to cause long QT syndrome. Thepatient exhibited two episodes of TdP in the ER, which spontane-ously terminated. Amiodarone and Magnesium Sulfate wereadministered intravenously. HIV medications were changed toagents that are not known to be associated with prolongation ofQTc. An automatic implantable cardioverter defibrillator was uti-lized as the patient continued to experience QTc prolongation 23days after his initial episodes. At present, he remains free of fur-ther arrhythmia. This unusual case demonstrates how the interac-tion of multiple risk factors, including HIV, Hepatitis C infection,cirrhosis of the liver, hypoalbuminemia, abnormal liver functionenzymes, the use of protease inhibitors, trimethoprim/sulfame-thoxazole and methadone can contribute to QTc prolongation andto TdP with syncope. Physicians must be aware of the potentialrisks of drugs that prolong QTc and be cautious when prescribingthem to patients who are at high risk of TdP.

34 - ECG ABNORMALITIES AND RISK OF DEVELOPMENTOF SEVERE CARDIAC INVOLVEMENT IN SARCOIDOSISS. NAGAO1, H. Watanabe1, M. Kodama1, J. Tanaka2, E. Suzuki2, I. Narita2,Y. Aizawa1

1Division of Cardiology, Niigata University Graduate School of Medical andDental Sciences, Niigata, JAPAN, 2Division of Respiratory, Niigata UniversityGraduate School of Medical and Dental Sciences, Niigata, JAPAN

Background: Cardiac involvement is associated with increasedmortality in sarcoidosis, and thus early diagnosis and risk stratifi-cation are important.

Methods: The aims of this study were 1) to compare ECG findingsbetween 262 patients with non-cardiac sarcoidosis and 262 age-and sex-matched healthy controls and 2) to identify electrocardio-graphic risk factors for cardiac involvement in 205 patients withnon-cardiac sarcoidosis who were followed >1 year. Results: 1) PR interval was longer in sarcoidosis group than con-trol group, although heart rate, QRS duration, and QT and QTcintervals were similar between two groups. First-degree atrioven-tricular block (5% vs. 0%), right bundle branch block (4% vs. 0%),and ST segment abnormalities (9% vs. 2%) were more common insarcoidosis group than control group. The frequency of fragmen-ted QRS complex defined as various RSR?Åf patterns withouttypical bundle branch block was higher in sarcoidosis group thancontrol group (8% vs. 1%). 2) During a follow up of 6.2±3.6 years, conduction disorder, STsegment abnormalities, and fragmented QRS complex newlyoccurred in 18, 19, and 18 patients with non-cardiac sarcoidosis,respectively. Eleven patients with non-cardiac sarcoidosis develo-ped severe cardiac involvement including advanced atrioventricu-lar block (N=4), ventricular tachyarrhythmia (N=4), and systolicdysfunction (N=3). Baseline conduction disorder (hazard ratio[HR], 11.27; 95% confidence interval [CI], 3.29-38.64), ST segmentabnormalities (HR, 6.26; 95% CI, 1.67-23.42), and fragmented QRScomplex (HR, 9.09; 95% CI, 2.59-31.96) were associated withincreased risk of cardiac involvement. Conclusions: There were increased prevalence and incident ofelectrocardiographic abnormalities in non-cardiac sarcoidosis. Weidentified electrocardiographic risk factors and the predictive abi-lities for the development of severe cardiac manifestation indica-ting that patients with sarcoidosis who have such risk factorsrequire further examination and careful follow-up.

35 - PREVALENCE OF PATENT FORAMEN OVALE INPATIENTS WITH CRYPTOGENETIC STROKEV. Giudici1, A. LOCATELLI1, B. Casiraghi1, R. Grandi2, G.B. Antongiovanni1,P. Scopelliti1

1Azienda Ospedaliera Bolognini - Department of Cardiology, Seriate, ITALY,2Azienda Ospedaliera Bolognini - Department of Neurology, Seriate, ITALY

Background: Frequently, in patients (Pts) with history of TransientIschemic Attack (TIA) or Stroke the mechanism cannot be determi-ned despite extensive evaluation (Cryptogenic Stroke - CS). ThesePts represent approximately 25-35% of the survivors of theseevents. Literature data show that about 5-20% of these cases can berelated to cardioembolic source due to an arrhythmic cause (main-ly atrial fibrillation - AF). Another plausible cause of CS is a para-doxical embolism through patent foramen ovale (PFO). In autop-sy series the prevalence of PFO ranges from 17 to 28 %. In generalpopulation the prevalence is 24%. Purpose: To assess the prevalence of PFO in a group of Patients(Pts) with cryptogenic stroke admitted in the NeurologyDepartment in a General Hospital.Methods: From June 2009 to August 2010 we studied all the Ptsadmitted to the Neurology Department of our Hospital. All the Pts(age 18 to 75) underwent: cerebral CT scan or cerebral MRI, caro-tid doppler ultrasonography, prothrombotic state (if<55 years),transthoracic and transesophageal echocardiography evaluation. Results: We evaluated 59 Pts affected by Cryptogenic IschemicStroke (36 Male; 59.3 + 9.7 years). In 23 pts (38.9%; 15 male; 56.9 +10.1 years) a patent foramen ovale and a right-to-left shunt wasdiagnosed. The clinical characteristics werw similar in both groups(age, sex, hypertension, hypercholesterolaemia, diabetes, historyof smoking, family history, recurrent storke/TIA episodes).We present echocardiographic data in patients submitted to thePFO closure compared with tose of the medically treated group.

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36 - A NOVEL LOSS-OF-FUNCTION SCN5A MUTATIONASSCOCIATED WITH BRUGADA SYNDROME, CONDUC-TION DISEASE, AND MONOMORPHIC VENTRICULARTACHYCARDIAN. YAGIHARA1, H. Watanabe1, A. Sato1, Y. Hosaka2, M. Chinushi3, Y. Aizawa1

1Division of Cardiology, Niigata University Graduate School of Medical andDental Science, Niigata, JAPAN, 2Niigata City General Hospital, Niigata, JAPAN,3School of Health Sciences, Faculty of Medicine, Niigata University, Niigata,JAPAN

Purpose: Brugada syndrome is characterized by ST-segment ele-vation in the right precordial leads of 12-lead electrocardiogramand ventricular fibrillation. Mutations in SCN5A, which encodesthe cardiac sodium channel α subunit (Nav1.5), is one of theresponsible genes for Brugada syndrome. Materials and Methods: We screened for mutations of SCN5A inpatients with Brugada syndrome. An identified mutation wastransiently expressed in a heterogonous expression system andwas analyzed for electrophysiological properties using a whole-cell patch-clamp technique. Results: We identified a novel heterozygous missense mutation, c.2678G→A resulting in p.R893H in a 58-year-old man. Physical exa-mination, echocardiography, and coronary angiography were nor-mal. His electrocardiogram showed coved type ST-segment eleva-tion (type I Brugada electrocardiogram) in leads V1 and V2 and PRprolongation. He had a family history of sudden cardiac death. Hedid not experience syncope or resuscitation. Ventricular fibrillation,but not ventricular tachycardia, was induced during electrophysio-logic study. He received an implantable cardioverter defibrillatorand had multiple shocks for ventricular fibrillation. He also had anepisode of monomorphic ventricular tachycardia successfully ter-minated by antitachycardia pacing therapy. Cellular electrophysio-logic study revealed loss-of-sodium channel function in an R893HSCN5A mutation compared to wild-type channel. Conclusion: We identified a novel SCN5A mutation associatedwith ventricular fibrillation monomorphic ventricular tachycardia,and conduction disease.Results: of cellular electrophysiologic study implicate that sodiumchannel dysfunction increases susceptibility for monomorphicventricular tachycardia.

37 - VALUE AND SECURITY OF ORAL ADMINISTRATIONOF FLECAINIDE STRESS TEST TO UNMASK THE TYPE 1BRUGADA ELECTROCARDIOGRAPHIC PATTERNS. GALLINO, S. Dubner, A. Cerantonio, R. Bonato

Clinica Y Maternidad Suizo Argentina, Buenos Aires, ARGENTINA

Brugada Syndrome covers a group of patients with an electrocar-diographic pattern of right bundle branch block and elevation ofthe ST segment in right precordial leads, without structural heartdisease who are at risk for ventricular fibrillation. The conditionmay be transitory in up to 40% of the cases and can be unmaskedby sodium channel blockers.Objectives: Assess the value and security of oral administrationflecainide stress test in the evaluation of patients with electrocar-diographic suspect of Brugada Syndrome. Materials and Methods: we studied prospectively seven asympto-matic patients referred to the electrophysiology section of our centerwith an electrocardiogram suspected of Brugada Syndrome. Singledose flecainide p.o. 400 mg. was administered. Rest 12- lead electro-cardiogram conventional and right modified precordial leads wereperformed for the evaluation of the response to medication.Results: seven patients were analyzed, 6 men, median age 36.28years 10.38 (range 22-50). All of them with normal left ventricularfunction and without structural heart disease. Five positiveresponses were observed, in 2 of them with family history, suddendeath in a brother of one and Brugada Syndrome with ICD

implant in the father of the other. In the elecrocardiogram findingsmedian PR interval before flecainide administration was 184 16.73mseg. and 195 8.19 mseg. after (P: 0.100), median QRS durationbefore the test was 86 18.16 mseg. and 113 11.42 mseg.(P: 0.100)after. The QTc interval increased from 399,60 27,58 mseg. beforethe test to 422,29 27,04 mseg after (P: 0.201). AV block, atrial or ven-tricular tachyarrhythmia were not documented during the study.Conclusion: Oral administration of flecainide stress test singledose 400 mg. to unmask the type 1 Brugada electrocardiographicpattern is a secure method and from this preliminary results analternative element to intravenous drugs could be considered.

38 - PRKAG3 POLYMORPHISMS ASSOCIATED WITHSPORADIC WOLFF-PARKINSON-WHITE SYNDROMEIN TAIWANESE PEOPLEK. WENG, C. Chiou, C. Lin, L. Ger, K. Hsieh

Kaohsiung Veterans General Hospital, Kaohsiung, TAIWAN

Introduction: Mutations in the isoforms of AMP-activated proteinkinase may lead to Wolff-Parkinson-White (WPW) syndrome asso-ciated with abnormal glycogen storage in human heart. PRKAG3plays a role in gene control in muscle glycogen content. We inve-stigated whether genetic variance in PRKAG3 is associated withsporadic WPW syndrome in Taiwanese people.Methods: A total of 87 patients with sporadic WPW syndrome and94 sex-matched healthy controls were recruited. WPW syndromewas diagnosed by electrophysiologic study. Echocardiographyexcluded hypertrophic cardiomyopathy. PCR assays were used forthe genotyping of PRKAG3 polymorphisms.Results: A total of 87 patients (M/F 53/34, mean age 12.4°”5.9years) and 94 sex-matched healthy controls (M/F 58/36, mean age13.6°”1.8 years) were recruited for polymorphism analysis. Thegenotype distributions of healthy controls were in Hardy-Weinberg equilibrium (p=0.926). A significant increase in WPWsyndrome risk was observed for PRKAG3 CG and CG+CC geno-types (AOR=1.99, 95% CI: 1.01-3.89, p=0.046; AOR=1.95, 95% CI:1.03-3.71, p=0.042, separately). CC genotype and allelic types werenot correlated with risk of WPW syndrome.Conclusions: PRKAG3 polymorphisms might be associated withsporadic WPW syndrome in Taiwanese people.

39 - CORRELATION BETWEEN PVS ELECTRICALISOLATION AND ENCIRCLING LESION CONTINUITY

C. LAVALLE, C. Pandozi, S. Ficili, M. Russo, M. Galeazzi, F. Giovannetti, A.Tranquilli, M. Santini

Department of Cardiovascular Disease, San Filippo Neri Hospital, Rome, ITALY, St.Jude Medical, ITALY

Background: The encircling of the pulmonary veins (PVs) hasbeen shown to be effective in atrial fibrillation (AF) ablation. PVsisolation (PVI) can be performed using a segmental ostial or a cir-cumferential extra-ostial approach.In both methods, FA relapses are caused by PV reconnection to leftatrium (LA) and conduction gaps along the scar created with pre-vious ablation.It is still unknown if the pure electrical trigger-related isolation iscorrelated with the encircling lesion line continuity and thereforewith late arrhythmia recurrence, due to PVs reconnection to LA.Objective: The purpose of this study is to report the correlationbetween PVs electrical isolation and the continuity of the circum-ferential ablation line, verified with acute lesion assessment. Methods: All patients underwent an AF ablation procedure withPVs encircling. A nonfluoroscopic mapping system (Ensite NavX,St. Jude Medical) was used to create a 3D electro-anatomic modelof the left atrium. Geometry was acquired with a circular (InquiryPO

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Optima, St. Jude Medical) and an ablation catheter (TherapyCoolPath, St. Jude Medical). After PVs electrical isolation, demon-strated by bi-directional block, voltage map was created to evalua-te the effective continuity of lesions along the ostia. Areas withpotential below 0.1 mV were defined as scar.Results: We enrolled 7 consecutive patients with paroxysmal AFfor a total of 28 veins ablated. A voltage map (P-P map of EnsiteNavX system) was performed after PVs encircling and validationof bi-directional block. In 20 veins, despite validation of bidirectio-nal block, voltage map demonstrated that the lesion line createdwas not complete.Conclusions: This study shows that pure electrical isolation vali-dation is not always correlated with lesion line continuity.Therefore, in order to obtain a complete encircling of PVs, a volta-ge map is a necessary tool to validate the formation of a close scarline at the PVs ostia. It is still to be demonstrated if ablating thescar gaps shown in the P-P map, leads to an improvement ofpatients prognosis.

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LIST OF AUTHORS

111

LIST OF AUTHORS

AAbbate R. V, 20Abdelaziz A. X, 48Abinader M. XII, 58Accardi F. XVII, 88Aglar B. XIX, 100Aimè E. XV, 79Aizawa Y. XX, 108, 109Akdemir B. XIX, 99, 100Ako J. XII, 57Alasti M. XVI, XX, 81, 104Alfano F. X, 45Algeri E. XVI, 85Ali H. I, VI, 4, 26Alizadeh A. XVI, 81Allain M. II, 6Allocca G. I, IV, V, VII, XVII, 4, 14, 23, 32, 88Almendral J. XX, 107Altamura V. II, XII, XIII, XVI, XVII, XVIII, 6, 59, 64, 83, 88, 92Altekin R.E. XIX, 99Alves M. IV, VI, 14, 29Amati F. VII, 32, 33Amellone C. I, 3Amino M. XVIII, 94Amley X. XX, 104, 108Ammirati F. VII, XIII, 31, 63, 64Anaclerio M. XII, XIV, XVI, 59, 71, 82Anadon M. XX, 107Andraghetti A. XVII, 87Andriani A. X, 45Andriani C. XIV, 68Andrsova I. VIII, 38, 39Angheben C. IV, XI, XIV,16, 51, 69Anselme F. XV, 79Antonelli D. XII, 57Antongiovanni G.B. XIX, XX, 99, 108Antoniadis A. VII, 31Appl U. XII, 58Aquilani A. XVII, 88Aquilani S. II, IX, XII, XIII, XVI, XVIII, 6, 43, 59, 64, 83, 92Ardente V. XVI, 85Arefi G. X, 48Arena G. XIV, 68Argnani S. IX, XI, 40, 53Armetta L. VII, VIII, 30, 38Artale P. IV, IX, XIII, 16, 41, 65Ascione L. V, 23Ashofair N. VIII, XIV, XV, 34, 73, 74Aspromonte V. I, XIX, 3, 102Assaidi A. XVIII, 94Atienza F. XX, 107Auricchio L. X, 49

Avella A. XIV, XIX, XX, 69, 103, 106Ayala-Paredes F. II, 6, 7

BBaady N. XVIII, 94Babuty D. X, 45Bacchiega E. II, IX, XVIII, 7, 42, 95Baccillieri S. XII, XIV, 60, 70Badra M. II, 6, 7Balbo M. VI, XVI, 29, 81, 84Baldazzi D. XVI, 85Baldo E. IV, XIII, 16, 65Baraldi P. XVII, 87Baratta P. XX, 106Baratto F. XII, XX, 61, 62, 105Barbetta A. XVI, 82Barnay C. XVIII, 97Bartholomay E. XX, 107Bartoletti A. VI, 25Bartoletti S. VIII, XIII, 39, 65Bartoli C. XIV, 68Bartolini P. V, 20Baruteau A. III, 10Basarici I. XIX, 100Baszko A. III, 12Beccagutti G. I, 2Bednarek J. XI, 51Bel Hadj K. XII, 58Beleveslis T.H. IV, V, 17, 20Belgi Yildirim A. XIX, 100Bellanti G. XVII, 90Belli P. X, XII, 49, 58Bellocci F. VIII, 35, 39Bencivenni M. XVI, 85Bencsik G. XII, 57Bennis A. XVIII, 94Berdague P. XII, 58Berkowitsch A. XIV, 68Berlinghieri N. VIII, 34Bernardi C. VII, 33Bernardi M. XII, 60Bernasconi M. VI, XIX, 25, 101Bertaglia E. II, IV, VI, VIII, IX, XVIII, 7, 16, 26, 36, 42, 95Bertaglia M. I, 2Bertagnolli L. I, II, X, 4, 9, 46Berti S. XIV, 68Bertini M. IV, IX, XIII, 16, 41, 65Beshliaga V. XVI, 81Biancalana G. V, 20Bianchi F. VIII, 36, 37Bianco E. I, VI, 4, 26Biasi S. IV, 14LI

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Bielli M. XVI, 83Biffi M. VI, XVI, 29, 81, 84Bilynskyi Y. XVI, 81Binner L. XVII, 86, 87Bisceglia C. XII, 62Bisleri G. V, 21Bittnerova A. VIII, 39Bizeau O. XII, 58Blaszyk K. III, 12Bobbio M. XI, 55Bobrov A. IV, V, 14, 23Bocchino M. VII, XIII, 31, 64Boem A. XV, 75, 76Bombino G. XX, 108Bonadiman C. IX, 42Bonajdar H.R. XVI, 81Bonato R. XX, 109Bonetti L. VII, 33Bonfatti F. VI, XVI, 29, 81, 84Bongiorni M.G. VIII, IX, XII, XV, XIX, 36, 37, 43, 61, 75, 76, 103Bonnet C. III, 10Bontempi L. V, VIII, IX, XIV, XV, 21, 34, 40, 73, 74Borghetti F. I, II, 2, 9Boriani G. VI, XVI, 29, 81, 84Borio S. XVII, 89Bornstein J. VIII, 39Borrello V.M. XIV, 68Boscolo G. II, VI, 6, 26Bostock J. IX, 42Botto G.L. V, X, 22, 46Bottoli M.C. IX, 42Bowser E.K. XVIII, 92Brada J. IV, XI, XVIII, 17, 55, 92Brambatti M. X, XVII, XX, 48, 89, 105Brambilla A. XIX, 99Brambilla R. V, 21Branco P. IV, 14Brandolino G. II, IV, IX, XVIII, 7, 16, 42, 95Brecka D. XVIII, 92Breda R. II, 9Brieda M. I, XIII, 2, 63Brignola C. V, 20Brignole M. IX, 40Brignoli M. XVIII, 96Brioschi P. IV, 14Broso G. IV, XIV, 16, 69Brunelli M. IV, 15Brusich S. IX, 42Bucknall C. IX, 42Buja G. I, II, VI, 5, 6, 9, 26Bulava A. III, 12Bulkova V. IV, XI, 17, 55Busca R. I, 2

CCabanelas N. IV, VI, 14, 29Cabrera Ortega M. IV, XVIII, XX, 15, 95, 107Cadeddu N. XII, XIII, 59, 64Caico I. I, IX, 5, 40Calabrò R. VII, VIII, 30, 38Calcagnini G. V, 20Caldwell J. VIII, 38Caliari E. XII, 60Calò L. I, II, III, IV, VI, VII, IX, XI, XII, XIII, XIX, XX, 4, 5, 8, 10, 11,

16, 29, 30, 32, 43, 56, 60, 62, 63, 100, 101, 105Calovic Z. VIII, X, 35, 49Calù L. 65Calvagna G.M. XVIII, 94Calvanese R. V, 23Calvi V. II, XI, 6, 52Calzavara P. II, 9Calzolari V. I, 5Camanini C. V, 20Camerale S. XVI, 82Campagna G. XIX, 102Campana A. I, XIX, 5, 100Campana M. X, 49Campisi F. XIV, 70Canciello M. V, 23Candelmo F. XIX, 100Canovese D. XII, 60Cantù F. V, IX, 21, 40Capella G. VII, 31Capelli S. 33Capogrosso P. X, 49Capparuccia C. XVII, 89Cappato R. I, VI, 4, 26Capponi E. V, 20Capria A. XVIII, 96Capucci A. V, X, XV, XVII, XX, 20, 48, 77, 78, 89, 105Caravati F. I, IX, 5, 40Carbucicchio C. VIII, 39Carreras G. V, VIII, 23, 37Carretta D. X, 45Casali E. X, XI, 48, 54Casarotto R. IX, 42Casassus J. XII, 58Casella M. VIII, XIII, 39, 65Casiraghi B. XII, XIX, XX, 59, 99, 108Caso P. XVI, 82Castaldini V. XIX, 99Castillo Meriño D. XX, 107Castro A. V, 20Catalano A. XIX, 100Catanzariti D. IV, XI, XII, XIV, 16, 51, 58, 69Cattin A. XII, 60Cavallaro C. V, IX, XVI, 24, 40, 82LI

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Cavallaro M. XVI, 82Cavazza C. IV, XIII, 16, 65Censi F. V, 20Centonze M. IV, 16Ceoldo E. XIV, 70Cera A. IV, 14Cerantonio A. XX, 109Cerciello T. II, XI, XX, 8, 52, 107Cerini M. VIII, XIV, XV, 34, 73, 74Cerisano S. XV, 77, 78, 79Cerutti S. VI, 25Cervellati A. V, 20Cervellati D. V, 20Cesari F. V, 20Cesario M. V, XIV, XVI, 22, 71, 83Chantepie A. III, 10Chattipakorn N. XVII, 89Chatzizisis I. XI, XIX, 55, 99Chiarelli G. III, VII, XII, XIII, XIV, 12, 32, 61, 66, 68Chinushi M. XX, 109Chiodi L. IX, 40Chiostri M. VIII, XIV, 35, 71, 72Chiou C. XX, 109Chitovova Z. VIII, 36Chiusso F. II, XVII, 6, 88Chouvarda I. XI, XIX, 55, 99Chovancik J. IV, XI, 17, 55Ciaramitaro G. IX, 40Ciardiello C. V, 24Ciccaglioni A. XV, XX, 78, 105Ciminelli E. III, 10Cini R. IV, 18Cioè R. II, VI, 8, 27Cipolletta L. XX, 105Cireddu M. XII, 62Cirillo G. I, 3Cirrincione C. XIV, 69Clari F. I, II, 4, 9Clementy N. X, 45Colaceci R. VII, XIII, 31, 64Colangelo G. I, XIX, 3, 102Colimodio F. VII, VIII, 30, 38Coluccia G. XV, 76Comerci G. XVII, 88Comisso C. XX, 105Comisso J. I, II, XI, XII, 2, 9, 51, 60Commisso C. II, III, VII, XI, XIX, 8, 11, 30, 56, 100Conte M.R. VIII, 36Conti S. II, 6Coppi T. III, XII, XIII, XIV, 12, 61, 66, 68Corino V.D.A. VI, 25Corò L. I, 4

Corsi C. XI, 53Costa-Vitali A. XVII, 91Coutrot L. XII, 58Covino G. X, 49Crisuolo E. XV, 78Crystal E. XVII, 91Cucchi L. XVI, 83Cuccia C. X, 49Curnis A. V, VIII, IX, XI, XIII, XIV, XV, 21, 34, 40, 52, 63, 73, 74Cvijic M. VIII, 34Czajkowski M. XV, XVIII, 75, 93

DD’Acri M. IX, 40 D’Aloia A. VIII, 34d’Amati G. XX, 106D’Ascia C. I, V, XX, 5, 22, 106D’Ascia S.L. V, XIX, XX, 22, 100, 106D’Onofrio A. I, V, VI, IX, X, XIII, XVI, 5, 24, 25, 40, 46, 63, 82Dakos G. X, XI, XVI, XIX, 46, 55, 85, 99Daleffe E. VI, 26Danisi N. VII, XIII, 31, 64Daubert J.C. III, 10Davinelli M. I, 3Davoodi G. XVII, 86Davoudi R. XVII, 87De Ambroggi G. I, VI, 4, 26De Crescenzo I. XVIII, 96De Filippo P. IX, 40De Girolamo P. XX, 106De Girolamo P.G. XIV, XIX, 69, 103De Greef Y. XVII, XIX, 88, 103De La Morena G. XVI, 84De Luca L. I, II, III, IV, VI, VII, IX, XI, XII, XIII, XIX, XX, 4, 8, 10, 11,16, 29, 30, 32, 40, 56, 60, 62, 63, 65, 100, 101, 105De Luca S. XX, 105De Lucia R. VIII, XII, XV, XIX, 36, 37, 61, 75, 76, 103De Marchis E. III, 10, 11De Maria E. VII, 33De Martino G. VIII, 37De Meyer G. XVII, XIX, 88, 103De Michele M. XIX, 100De Ponti R. XIX, 101De Ruvo E. I, II, III, IV, VI, VII, XI, XII, XIII, XIX, XX, 4, 8, 10, 11,16, 29, 30, 32, 56, 60, 62, 63, 65, 100, 101, 105De Santo T. IV, VIII, 14, 35De Seta F. I, 2De Simone A. V, IX, 24, 40De Vivo S. V, XVI, 24, 82Deblasi G. XVII, 89Defaye P. VI, 25Defilippo P. V, 21LI

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Deger N. XIX, 99Deguchi Y. XVII, XVIII, 87, 94Deharo J.C. XV, 77Dei Cas L. VIII, XIV, XV, 34, 73, 74Del Blanco B. XX, 107del Castillo-Arroys S. VI, 25Del Gatto A. XI, 52Del Greco M. VIII, 36Del Rosso A. IX, 40Delise P. I, IV, V, VII, XVII, 2, 4, 14, 23, 32, 88Della Bella P. XII, XX, 61, 62, 105Della Rocca D.G. I, II, V, VI, X, XIV, XVI, 3, 8, 22, 25, 27, 45, 71,72, 83Dellavesa P. XVI, 83Dello Russo A. VIII, XIII, 39, 65Delurgio D. VIII, 35Delvizi E. XVII, 90Demir I. XIX, 100Deriouich B. XVII, XVIII, 91Di Bartolomeo R. XX, 104Di Biase L. VIII, 39Di Cori A. VIII, XII, XV, XIX, 37, 61, 75, 76, 103Di Grazia A. II, 6Di Gregorio F. XVI, 82Di Maggio D. XVIII, 96Di Marco A. XIV, 70Di Molfetta A. V, XIV, XVI, 22, 71, 72, 83Di Pede F. VI, XIII, 26, 63DÌaz Berto E. XX, 107Dicandia C.D. V, 22Didenko M. IV, V, 14, 23Donnici G. XIII, XIV, 66, 69Dorda M. XI, 55Dore L. VI, 25Dottori S. IV, VIII, XI, XII, XIII, 16, 37, 56, 62, 65, 66Dovellini E. XV, 79Dovigo P. V, 23Droghetti A. IX, XI, 42, 53Dubner S. XX, 109Duckett S. IX, 42Dulac Y. III, 10Dupuis J.M. XIV, XVII, 72, 90Durante A.M. XII, 59Durão D. IV, VI, 14, 29Duro L. II, VI, X, 8, 25, 27, 47Dyrda M. XVI, 81Dzhordzhikiya T. III, 12

EEckhard T. XIV, 68Efthimiadis G. XVI, 85El-Chami M. VIII, 35

Eldadah Z. XV, 74Elhonsali Z. XVIII, 94Elhussini R. X, 48Elia M. VI, 25Ellis J. XVII, 89Emdin M. VIII, 35Endrizzi I. I, II, X, 4, 9, 46Eriksson M.J. XVII, 86Ermis C. XIX, 99, 100Espaliat E. XII, 58Etchapare R. XX, 107Evola R. XVIII, 94

FFabiani I. XV, 76Fabiano G. I, XIX, 3, 102Facchin D. XI, 52Fadili S. XVIII, 94Faerestrand S. V, VIII, 24, 34Fagagnini A. I, II, III, IV, VI, VII, XII, XIII, XIX, XX, 4, 8, 10, 11, 16,29, 30, 32, 60, 62, 63, 65, 100, 101, 105Faganini A. XI, 56Fantappiè C. XIV, 72Fantini F. XIV, 72Farah R. VIII, 39Fassini G. VIII, 39Fatini C. V, 20Fattorini F. XV, 78Fauchier L. X, 45Faustino M. VIII, 37Favale S. III, IX, XII, XIV, XVI, 10, 40, 59, 71, 82Favero E. XV, 77Fazi A. VI, 25Fedele F. XV, XX, 78, 105Fedyainova A. IV, V, 14, 23Ferek-Petric B. IX, 42Ferrari A. XX, 107Ferrari G. XIV, 71Ferrari P. V, 21Ferrari R. IV, IX, XIII, 16, 41, 65Ferreira R. VII, 30Ferrero P. V, 21Fetisova E.A. III, XIII, 13, 66Fiala M. IV, XI, XI, 17, 55Ficili S. III, VII, VIII, XII, XIII, XIV, 12, 32, 33, 37, 61, 66, 68, 109Fiorentini C. XIII, 65Florianova A. VIII, 38, 39Folino A. II, VI, 6, 9, 26Foresti S. I, VI, 4, 26Forleo C. III, 10Forleo G.B. I, II, V, IX, VI, X, XIII, XIV, XVI, XVIII, XIX, 3, 8, 22, 25,27, 40, 43, 45, 47, 63, 69, 71, 72, 83, 96, 103LI

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115

Fornerone R. VII, 31Forster T. XII, 57Fragakis N. VII, 31Fraisse A. III, 10Franchetti Pardo N. XVI, 83Franchi F. XI, 54Franciosa P. XV, 78Francisco A. IV, VI, 14, 29Franculli F. XIX, 100Franzë D. XIX, 99Frascarelli F. XV, 79Freedberg N.A. XII, 57Fresiello L. XIV, 71Fujibayashi D. XVII, XVIII, 87, 94Fujimoto M. XX, 105Fujino N. X, 50Furber A. XIV, XVII, 72, 90Fusco A. IX, 42

GGadler F. XVI, XVII, 84, 86Gaggini G. XIV, XVII, 72, 90Gaillyova R. VIII, 38, 39Gaita F. VIII, 36Galeazzi M. III, VII, VIII, XII, XIII, XIV, 12, 32, 33, 37, 61, 66, 68,109Gallino S. XX, 109Gallo P. V, X, XI, 23, 45, 54Garagaro A. XVI, 82GarcÌa A. XVI, 84Gardas R. X, 48Gardini B. VI, XVI, 29, 81, 84Gargaro A. I, V, XIII, XVIII, 4, 5, 20, 63, 94Garratt C. VIII, 38Garrido I. XVI, 84Gasparini G. I, II, V, VI, 5, 6, 20, 26Gasparini M. XVII, 88Gazzoni G. XX, 107Geleris P. VII, 31Gell Aboy J. XX, 107Geller J.C. IV, 15Gelmini G.P. X, XI, XVII, 46, 53, 88Gensini G.F. V, 20Gentilini C. XV, 79Ger L. XIX, XX, 101, 109Geraldes V. VII, 30Ghosh J. XX, 108Giannotti F. III, XVII, 10, 90Gibinski M. X, 48Gigli N. XIV, 68Gilardi S. IV, VII, XII, 14, 31, 59Gimeno C. XX, 107Giomi A. II, XIII, 8, 63

Gionti V. VII, VIII, 30, 38Giordano B. I, 3Giordano V. VII, VIII, 30, 38Giovagnoli A. X, 48Giovannetti F. III, 109Gitelis C. XX, 108Giudici G. IX, 40Giudici V. XI, XII, XVII, XIX, XX, 53, 59, 88, 99, 108Giuggia M. I, 3Giunta G. XV, XX, 78, 105Giusti F. X, 45Godart F. III, 10Goldani M.A. XX, 107Goldman B. XVII, 91Golino P. VII, VIII, XVIII, 30, 38, 96Golnitz J. IX, 43Gonzales Morejon A.E. IV, 15Gorini D. IX, 40Gorzolka J. IV, XI, XI, 17, 55Goscinska-Bis K. X, 48Gourineni V. XVII, 87Gournay V. III, 10Grabowski M. XV, 75Grajek S. III, 12 Gramondo A. VIII, 37Grandi R. XIX, XX, 99, 108Grazi P. XX, 104Greco E.M. VI, 25Greenberg Y. XX, 104Grofle-Heitmeyer W. XVIII, 95Große A. IV, 15Grossi S. VIII, 36, 37Grossmann G. XVII, 86Grussmannova K. XVIII, 92Grzegorzewski B. X, 48Guardiani S. X, XVII, 48, 89Guarini P. V, X, XI, 23, 45, 54Guarracini F. I, II, III, VI, VII, XI, XII, XIII, XIX, XX, 4, 8, 10, 11, 29,30, 56, 62, 63, 65, 100, 105Guarricini F. XIX, 101Guenoun M. XVIII, 97, 98Guenzati G. XIX, 101Guerra F. X, XX, 48, 105Gugliotta F. XII, 61Guillaumont S. III, 10Guillemot A. XII, 58Gulcan A.R. XIX, 99Gwizdala A. III, 12

HHachiya H. VII, XIX, 32, 103Haghjoo M. XVI, 81Hamid S. IX, 42LI

ST OF AUTHORS

116

Hanis J. III, 12Hashida T. XVII, XVIII, 87, 94Hatzinikolaou-Kotsakou E. IV, V, 17, 20Havranek S. XI, 55Hayashi K. X, 50Hedberg S-E. XVII, 86Hero M. V, VI, XVII, XVIII, 22, 28, 91, 97, 98Higuchi K. VII, XIX, 32, 103Hirahara T. XII, 57Hirao K. VII, XIX, 32, 103Holdova K. XVIII, 92Hollander G. XX, 108Holmstrom N. XVII, 86Holy F. VIII, XVIII, 36, 92Homann J. XVII, 87Horlbeck F. VI, 26Hosaka Y. XX, 109Hoskins M. VIII, 35Hovstad T. V, VIII, 24, 34Hsieh K. XIX, XX, 101, 109Humera A. VIII, 36Hyder M. XVII, 87

IIacopino S. I, IX, XI, XIX, 3, 43, 52, 102Iacoviello M. III, XII, 10, 59Iannucci L. I, 4Iengo R. V, 23Iezzi F. IV, 18Ikari Y. XVIII, 94Iliceto S. II, VI, 6, 9, 26Imbimbo G. XI, 52Inaba O. VII, XIX, 32, 103Inama G. XVI, 83Inama L. XVI, 83Indino B. I, 3Infusino T. I, VI, 4, 26Ino H. X, 50Ioannidis P. XVI, XVII, 85, 90Ionno M. XVI, 82Iovino M. VII, 30Ishi M. XVIII, 94Isobe M. VII, 32Iuianella V. VII, 30Iulianella R. XIX, 100Iulianella R.V. XI, XII, 56, 62Iuliano A. V, 24Ivanova K. XI, 55

JJanuska J. IV, XI, 17, 55Jaswal A. X, XI, 45, 53

Jiravsky O. XI, 55John J. XX, 108Jovanovic V. VIII, X, 35, 49

KKabukcu M. XIX, 100Kadlecova J. VIII, 38, 39Kaiyal R.S. VIII, 39Kalil C. XX, 107Kalinin V.V. III, XIII, 12, 13, 66Kallergis E. VIII, 35Kaltofen G. XII, 58Kamperidis V. X, 46Kanitkar M. VIII, 35Karakas S. XIX, 99Karamitsos T. XIX, 101Kargul W. X, 48Karlsson A. XVII, 86Karvounis H. XIX, 99Kastner J. XVI, 85Katsaris G. VII, 31Kawabata M. VII, XIX, 32, 103Kaya E. XIX, 100Kazemisaeed A. XVII, 86Keanprasit K. XVII, 89Keavey S. V, XII, 21, 57Keklikoglou E. XVI, XVII, 85, 90Kerzin-Storrar L. VIII, 38Khan N. VIII, 38Khokhlunov S. III, 11Khubulava G. IV, V, 14, 23Kirchhof N. IX, 43Kiyama M. XX, 105Klausz G. XII, 57Kloppe A. VI, 25Knyshov G. XVI, 81Kobeissi A. XIV, XVII, 72, 90Koc S. XIX, 99 Kodama M. XX, 108Komanova E. XIX, 102Kontani M. XX, 105Kotsakou M. IV, V, 17, 20Kralovec S. IV, VIII, XVIII, 17, 36, 92Kravchuk B. XVI, 81Krawiec S. IV, XI, 17. 55Kristiansen H. V, VIII, 24, 34Kubus P. VIII, 38 Kuniss M. XIV, 68Kupec J. XVIII, 92Kurata T. XII, 57Kutarski A. IX, XV, XVIII, 41, 74, 75, 93, 96Kyriakoy P. VII, 31LI

ST OF AUTHORS

117

LLa Rocca L. VII, XIII, XIII, XV, 31, 63, 64, 78La Rocca V. V, IX, 24, 40La Rosa C. V, 23Lago P. I, 2Landolina M. I, XVI, 2, 83Langberg J. VIII, 35Lanzillo C. III, IV, VII, XI, XIII, 10, 16, 30, 32, 56, 65Laranjo S. VII, 30Latsios P. IV, V, 17, 20Lau C. XVII, 91Laurenzi F. XIV, XIX, XX, 69, 103, 106Lavalle C. III, VII, VIII, XII, XIII, XIV, XVII, 12, 32, 33, 37, 61, 66,

68, 88, 109Lazarevic Z. III, 10, 11Lazoryshynets V. XVI, 81Le Franc P. VI, XII, 28, 58Le Marec H. III, 10Lebini S. VIII, 36Leclercq Ch. V, 22Leitner L. XVI, 85Lelakowski J. IV, XI, 17, 51Leon A. VIII, 35Leoni L. I, XI, 2, 52Lettica V. I, XVII, 5, 89Levorato D. XV, 75, 76Lezaic L. VIII, 34Libralon A. XII, 60Liccardo M. X, XI, 45, 54Liguori V. V, 22Liliegren N. VI, 26Lima E. XX, 107Lin C. XX, 109Linde C. XVI, 84Liotta C. II, 6Lioy E. I, II, III, IV, VI, VII, XI, XII, XIII, XIX, XX, 4, 8, 10, 11, 16,

29, 32, 56, 60, 62, 63, 65, 100, 101, 105Lipari A. VIII, XIV, XV, 34, 73, 74Lo Cane I. I, XIX, 3, 102Locatelli A. XII, XVII, XIX, XX, 59, 88, 99, 108Loiaconi V. IV, 18Lolli G. I, 5Longobardi M. XV, 79Lord M. II, 6Lorini M. XV, 79Louridas G. XVI, 85Lukl J. IX, 40Lunati M. VI, XV, 25, 77, 78Lupo A. II, IX, XVIII, 7, 42, 95Lupo P. I, VI, 4, 26Lusson J.R. III, 10Luzzi G. XII, XIV, XVI, 59, 71, 82Lyadzhina O.S. III, XIII, 13, 66

MMabo P. III, 10Macca G. IV, 14Maccabelli G. XII, XX, 61, 62, 105Maffè S. XVI, 83 Maffei S. XX, 105Maggio R. XII, 61Maglaveras N. XI, XIX, 55, 99Magliano G. I, II, VI, X, XIII, XIV, XVI, XVIII, 3, 8, 25, 27, 45, 47,

63, 71, 72, 83, 96Magliari F. I, 4Magris B. II, XII, XIII, XVI, XVII, XVIII, 6, 59, 64, 83, 88, 92Magris M. XII, 59Maines M. IV, XI, XII, XIV, 16, 51, 58, 69Makai A. XII, 57Malagoli A. X, 48Malaspina D. XIX, 101Malecka B. IV, IX, XI, XV, XVIII, 17, 41, 51, 74, 75, 96Malinverni C. XII, 59Manfredini R. XV, 79Manfrin M. I, II, X, 4, 9, 46Mango R. VII, 33Manhabosco Moraes R. XX, 107Manotta L. VI, 25Mansour M. XIX, 103Mantica M. V, VIII, X, 22, 37, 46Mantovan R. I, II, VI, 2, 6, 26Mantovani E. XIV, 70Mantovani G. XV, 79Mantovani V. VI, XVI, 29, 81, 84Mantovano S. VI, 25Mantziari L. X, XVI, XIX, 46, 85, 99Marangelli V. III, 10Marangon D. XII, 60Marangoni E. V, 22Marchesini M. X, XX, 48, 105Marchetti G. XIX, XX, 99, 104Marcian M. IX, 40Marcon C. V, 23Marcon F. III, 10Marconi R. XI, 53Marek D. IX, 40Margheri M. III, XI, XVII, 10, 53, 90Marie O. X, 45Marinelli G. XX, 104Marini M. XVII, 87, 89Marino V. V, XX, 22, 106Marras E. I, II, IV, V, VI, VII, XIII, XVII, 4, 6, 14, 23, 26, 32, 63, 88Marrazzo C. XIII, 66Marrazzo N. V, XIV, 23, 24, 69Marruncheddu L. XV, 78Marseglia A. VI, 25Martignon M. XII, 60LI

ST OF AUTHORS

118

Martínez J. XVI, 84Martini B. VI, 26Martini G. XI, 53Martino A. III, VII, XII, XIII, XX, 10, 11, 30, 32, 60, 62, 63, 105Martins V.P. IV, VI, 14, 29Marullo V. V, XX, 22, 106Marzegalli M. VI, XIX, 25, 101Marziali M. I, VII, 4, 32Masaro G. XVI, 82Mascia G. XI, XIV, 56, 71Mascioli G. VIII, IX, XI, 35, 40, 53Masia A. VI, 29Massaro G. VI, XVI, 29, 81, 84Mastrine L. XX, 104Matassini M.V. X, XX, 48, 105Matera S. I, II, VI, VII, XII, XIII, XIX, XX, 4, 8, 29, 30, 60, 62, 63,100, 105Mattei E. V, 20Mazel J. XV, 74Maziarz A. XI, 51Mazzini M. XIV, 68Mazzotti A. VI, XVI, 29, 81, 84Megna A. II, 6Mele F. VII, 32Melissano D. XIII, 63Melloni R. VII, 31Memeo R. XII, XIV, XVI, 59, 71, 82Menardi E. VIII, XI, 37, 55Menegazzo A. XII, 60Mermi J. VI, 25Metcalfe K. VIII, 38Mezzetti M. VI, 25Michaelsen J. XVIII, 95Michelucci A. V, VIII, XI, XIV, 20, 35, 56, 71, 72Milasinovic G. VIII, X, 35, 49Minarik T. XVIII, 92Minati M. I, II, III, IV, VI, VII, XI, XII, XIX, XX, 4, 8, 11, 16, 29, 30,32, 56, 60, 62, 100, 101, 105Minni V. V, XIV, XVI, 22, 71, 83Misikova S. 102, XIXMisso L. II, XI, XX, 8, 52, 107Misuraca L. VIII, XII, 37, 61Mochlas S. XVI, 85Mocini A. XI, 53Molendi V. XIV, 68Molini S. X, XVII, 48, 89Molon G. I, X, XI, XV, 2, 46, 52, 77Moltrasio M. XIII, 65Momomura S. XII, 57Monagas Docasal V. XX, 107Monitillo F. III, XII, 10, 59Montin A. VII, XVI, XVII, 33, 85, 87

Morales M. XI, 51Morandi F. X, 49Morani G. VI, IX, 26, 43Moreton N. VIII, 38Morice R. XVIII, 97Morichelli L. I, II, XII, XIII, XVII, 5, 6, 59, 63, 64, 88Moro E. IV, V, XV, 14, 23, 79Mosaner W. IX, 42Moschos G. IV, V, 17, 20Mouton E. XII, 58Muneretto C. V, 21Muriana G. IX, XI, 42, 53Muto C. V, 23Mutti M. VIII, XV, 34, 74Myroshnyk M. XVI, 81

NNacci F. XII, XIV, XVI, 59, 71, 82Nagao S. XX, 108Nalin I. III, 10Naranjo Ugalde A. XVIII, 95Narducci M. IX, 40Narita I. XX, 108Nastasi M. V, 23Natale A. VIII, XIII, 39, 65Natalizia A. XIII, 66Navone G. XII, 62Navrozidis G. VII, 31Nawar A. X, 48Neri G. VI, XVI, 26, 82Neri P. XII, 59Neumann T. XIV, 68Neuzil P. VIII, XVIII, 36, 92Nevralova R. XI, 55Newman W. VIII, 38Nickenig G. VI, 26Nigro G. VII, VIII, 30, 38Nikcevic G. VIII, X, 35, 49Nikoo M.H. XVI, XX, 81, 104Nizam I. XIX, 99, 100Nocerino P. X, XI, 45, 46, 54Norlander B.E. XVIII, 92Novelli G. VII, 33Novotny T. VIII, 38, 39Nuccio F. II, XI, XII, XX, 8, 56, 62, 105Nuzzi L. XIV, XVI, 71, 82

OO’Connor S. VI, 26O’Donoghue S. XV, 74Occhetta E. XVII, 88Okeie K. XX, 105LI

ST OF AUTHORS

119

Olalere S. IV, 17Olexa O. XIX, 102Oliveira E. VII, 30Oliveira M. VII, 30Oliviero F. II, XI, XX, 8, 52, 107Olna F. XVI, 83Ometto R. VI, 26Omidvar B. XVI, XX, 81, 104Orazi S. XV, XVII, 77, 78, 88Ottaviano L. V, 22, 23

PPadeletti L. IX, V, VI, VIII, XI, XIV, XV, 20, 25, 35, 40, 56, 71, 72,

77, 78, 79Paffoni P. XVI, 83Pagnoni C. VIII, XIV, XV, 34, 73, 74Paino A.M. XVI, 83Pajietnew D. XIV, 68Pala M. XIX, 101Palmisano P. XIV, XVI, 71, 82Panattoni G. I, II, V, VI, X, XIII, XIV, XVI, 3, 8, 22, 25, 27, 45, 63,

71, 72, 83Panchetti L. XI, 51Pandozi A. III, XIII, XIV, 12, 66, 68Pandozi C. III, VII, VIII, XII, XIII, XIV, 12, 32, 33, 37, 61, 66, 68,

109Pantaleo P. V, 22Paoletti Perini A. XIV, 71Paolillo C. XIV, 69Paoloni P. V, 20Paolucci M. VIII, 36Pap R. XII, 57Papakonstantinou D. XVI, XVII, 85, 90Paparoni F. V, XIV, XVI, 22, 71, 83Papavasileiou L. I, II, VI, 3, 8, 25Papavasileiou L.P. II, V, VI, X, XIII, XIV, XVI, XVIII, 8, 22, 25, 27,

45, 47, 63, 71, 72, 83, 96Paperini L. VIII, XII, XV, 37, 61, 75, 76Pappalardo A. VIII, XIV, XIX, XX, 37, 69, 103, 106Pappone C. VIII, X, 35, 49Paraskevaidis S. X, XI, XVI, XIX, 46, 55, 85, 99, 101Parcharidis G. XVI, 85Parisi A. III, 10Parravicini U. XVI, 83Pascual D. XVI, 84Pasowicz M. XI, 51Pasqualini M. XII, 58Passarelli P. XX, 104Pastor F. XVI, 84Pastore G. IX, 40Patel N. IX, 42Patrizi G. VII, 33

Pavese R. VI, 29Pavia L. I, 5Pecora D. X, 46, 49Pedrinazzi C. XVI, 83Pelargonio G. VIII, IX, XIII, 39, 40, 65Pellicano S. I, XIX, 3, 102Peñafiel P. XVI, 84Pendenza G. II, III, VI, XII, XIX, XX, 8, 11, 29, 62, 100, 101, 105Pennesi M. XIV, 71Pensabene O. XV, 79Pepi P. IX, XII, 42, 58Perna F. VIII, 37Perri C. XVII, 91Perrone C. I, 2Perrotta L. V, VIII, XI, XIV, 20, 35, 56, 71, 72Perucca A. V, XVI, 22, 83Pescoller F. I, II, 4, 9Petracca F. XII, XX, 61, 62, 105Petru J. VIII, XVIII, 36, 92Pezawas T. XVI, 85Pezzotta A. XV, 77Pezzulich B. XII, 61Philippova I. III, 11Phrommintikul A. XVII, 89Piacenti M. XI, XV, 51, 79Piant R. XX, 107Pieragnoli P. V, VIII, IX, XI, XIV, 20, 35, 40, 56, 71, 72Pieroni M. VIII, 39Pierre B. X, 45Pietura R. IX, XV, XVIII, 41, 75, 93Pighini G. VII, XIII, 31, 64Pignalberi C. II, XII, XIII, XVI, XVII, XVIII, 6, 59, 64, 83, 88, 92Pigozzi F. III, XIII, XIX, 10, 11, 65, 101Pindor J. IV, XI, 17, 55Piot O. VI, IX, XV, 25, 40, 79Piovesana P.G. XIV, 70Piraino L. IX, 43Pirani L. IV, XIII, 16, 65Pisanò E. I, 4Pisoni M. XII, 59Pitrone P. IV, XIII, 16, 65, 66Pitscheider W. I, II, X, 4, 9, 46Pitschner H.F. XIV, 68Pittalis M. I, VI, 4, 26Pizzimenti E. XVII, 89Pizzimenti G. XVII, 89Placci A. III, XVII, 10, 90Platia E.V. XV, 74Plevkova L. XVIII, 92Podolec P. XI, 51Politano A. I, VI, X, XIII, 3, 25, 45, 63Pollastrelli A. VI, 29LI

ST OF AUTHORS

120

Polymeropoulos K. XVI, XVII, XIX, 85, 90, 101Pontecorboli G. VIII, 35Popiel M. III, 12Porcellini S. IV, 14Porciani M.C. VIII, XIV, 35, 71, 72Porfili A. II, XII, XIII, XVII, 6, 59, 64, 88Porfirio M. II, III, VI, VII, XI, XII, XIX, XX, 8, 11, 29, 30, 32, 56, 62,

100, 101, 105Pozzetti D. XII, 58Pratola C. IV, VIII, IX, XIII, 16, 36, 41, 65Probst V. III, 10Proclemer A. I, VI, XV, 2, 25, 79Provvisiero C. X, XII, 49, 58Pruiti G.P. II, 6Puntrello C. XVII, 89Pupita G. X, XVII, XX, 48, 89, 105Puzzangara E. II, 6Puzzovivo A. III, XII, 10, 59

QQuadrini F. XII, XIV, XVI, 59, 71, 82Quaglione R. I, V, 4, 5, 20Quaranta F. III, XIII, 10, 11, 65Quarta L. II, XII, XIII, XVII, 6, 59, 64, 88

RRacca E. XI, 55Raffa S. IV, 15Ragab D. X, 48Rastogi M. XV, 74Ratti G. X, 49Ratti M. XIV, 68Rauhe W. I, II, X, XI, 4, 9, 46, 52Raytcheva E. I, 4Re F. XX, 106Rebecchi M. I, II, III, IV, VI, VII, XI, XII, XIII, XIX, XX, 4, 8, 10, 11,

16, 29, 30, 32, 56, 60, 62, 63, 65, 100, 101, 105Reddy V. VIII, 36Reggiani A. IX, XI, XII, 40, 42, 53, 58Rehouskova K. III, 12Renzullo E. VI, 26Reppas E. IV, V, 17, 20Revelchion R. IV, IX, 16, 41Revishvili A.Sh. III, XIII, 12, 66Revishvili F.Sh. III, 13Rey J.L. VI, 28Ricci R.P. I, II, IX, XII, XIII, XV, XVI, XVII, XVIII, 5, 6, 43, 59, 63,

64, 77, 78, 83, 88, 92Ricciardi G. V, VIII, IX, XI, XIV, 20, 35, 40, 56, 71, 72Ricco A. XII, XX, 61, 105Rimini A. IV, 14Rinaldi C. IX, 42

Ritter P. XIV, XV, XVII, 72, 77, 78, 90Riva S. XIII, 65Rocca P. XII, 59Roccaro D. I, 3Rocha I. VII, 30Rocoma F. II, 7Roguin N. VIII, 39Romano E. VIII, 37Romano M.G. VII, XIII, 31, 64Romano V. I, II, VI, X, XIV, XVIII, 3, 8, 25, 45, 47, 72, 96Romeo F. I, II, V, VI, VII, X, XIII, XIV, XVI, XVIII, 3, 8, 22, 25, 27,

33, 45, 47, 63, 69, 71, 72, 83, 96Roncuzzi R. XX, 104Rosato M.L. VII, VIII, 30, 38Rossetti G. XI, 55Rossi L. X, 48Rossi P. V, 22Rottbauer W. XVII, 86Rouault F. III, 10Roux J-F. II, 6, 7Rovai N. I, XVIII, 5, 94Roy D. IX, 42Rubino I. IX, 40Rubino P. XIV, 69Rudenko K. XVI, 81Ruffa F. XI, 53Russo M. III, VII, VIII, XII, XIII, XIV, 12, 32, 33, 37, 61, 66, 68,

109Russo M.G. VII, VIII, 30, 38Russo S. XVI, 85Russo V. VII, VIII, 30, 38Rusticali G. X, 48

SSàghy L. XII, 57Sabino G. XI, 56Sacchi P. I, 2Sacchi S. V, XIV, 20, 71Saint-Cricq G. XII, 58Salacata A. V, XII, 21, 57Salierno M. XIX, 102Salomoni M. VI, XVI, 29, 81, 84San Giovanni L. VI, XIII, 29, 63Sanchez J.J. XVI, 84Sangiuolo R. V, XVII, XIX, 23, 88, 100Santamaria M. VIII, 37Santangeli P. VIII, XIII, 39, 65Santangelo L. V, XIX, 22, 100Santi E. VI, 25Santinelli V. VIII, X, 35, 49Santini L. I, II, V, VI, VII, VII, IX, X, XIII, XIV, XVI, XVIII, 3, 5, 8, 22,

25, 27, 32, 33, 40, 43, 45, 47, 63, 69, 71, 72, 83, 96LIST OF AUTHORS

121

Santini M. II, III, IV, VI, VII, VIII, IX, XI, XII, XIII, XIV, XVI, XVII, XVIII,XX, 6, 12, 18, 25, 32, 33, 37, 43, 52, 59, 61, 64, 66, 68, 83, 88, 92, 109

Santobuono V.E. III, XII, XIV, XVI, 10, 59, 71, 82Santos S. VII, 30Saputo F. II, XII, XIII, XVI, 6, 59, 64, 83Sardanelli F. I, 4Sardu C. V, XVIII, XX, 22, 96, 106Sassara M. XVII, 88Sassi A. XII, XIII, XVII, 59, 64, 88Sato A. XX, 109Saviano M. VIII, 35Saxena A. X, XI, 45, 53Scarà A. XIII, 65Scarabeo V. XIV, 70Scarfù I. XVIII, 96Scattolin G. VI, 26Schaerf R.H.M. XVIII, 92Schepers E. XVII, 88Schiavone V. V, XX, 22, 106Schirripa V. I, VI, X, XIII, 3, 25, 45, 63, Schleich J.M. III, 10Schmidinger H. XVI, 85Schneiderka P. IX, 40Schott J.J. III, 10Schukro C. XVI, 85Schwab J.O. VI, 26Schwagten B. XVII, XIX, 88, 103Sciahbasi A. VI, 29Sciarpa L. XIII, 63Sciarra L. I, II, III, IV, VI, VII, XI, XII, XIII, XIX, XX, 4, 8, 10, 11, 16,29, 30, 32, 56, 60, 62, 63, 65, 100, 101, 105Sciotto F. IX, 43Scipione P. IX, XV, 40, 79Scopelliti P. XIX, XX, 99, 108Scrivener J. VII, 33Sebastiani F. VII, IX, XI, XII, 30, 40, 56, 62Secchi F. I, 4Sediva L. VIII, XVIII, 36, 92Segreti L. VIII, XII, XV, XIX, 37, 61, 75, 76, 103Selman-Houssein Sosa E. XVIII, 95Semagin A. III, 11Senatore G. I, 3Seniuk W. III, 12Seregni R. VII, 31Sergi D. XIV, 71Sette A. I, II, VII, XI, XII, XX, 4, 8, 30, 32, 56, 62, 105Severi S. XI, 53Sforza M. VI, XII, XIII, 29, 60, 63Sgueglia M. I, II, VI, X, XIII, XIV, 3, 8, 25, 27, 47, 63, 71, 72Shafiee A. XVII, 86Shah M. XV, 74

Shetty A. IX, 42Shima M. XVII, XVIII, 87, 94Shopova G. XIII, XIV, 66, 69Sibilio G. XI, 54Sibona Masi A. VIII, 36Siebermair J. XVI, 85Signorotti F. XVI, 83Silva G.F. IV, VI, 14, 29Silva R. VI, 29Silva V. VII, 30Silvestri V. VII, 31Simek J. XI, 55Simonyan G.Yu. III, XIII, 12, 13, 66Singhal R. X, XI, 45, 53Siniscalchi L.I. II, XI, XX, 8, 52, 107Siniscalchi N. II, XI, XX, 8, 52, 107Sisakova M. VIII, 39Sitek D. III, 12Sitta N. IV, V, XVII, 14, 23, 88Sknouril M. XI, 55Skoda J. VIII, XVIII, 36, 92Smurra F. XVIII, 96Solarino G. XV, 76Soldati E. VIII, XII, XV, XIX, 36, 37, 61, 75, 76, 103Solimene F. V, XIII, 23, 24, 66Solimeno F. XIV, 69Soliz P. XX, 107Sopov O.V. III, XIII, 12, 13, 66Sordini P. IV, 18Sorrenti P. XIX, 102Sorrentino S. III, 10Spataro A. III, 10, 11Sperandii F. III, 10, 11Spinar J. VIII, 38, 39Spotti A. XI, 53Spurny P. XIX, 102Stabile G. V, 24Stancak B. XIX, 102Startari U. XI, 51Stavropoulos G. X, XI, XVI, XIX, 46, 55, 85, 99Stendardo A. XIV, 70Sticchi E. V, 20Stiller P. XVII, 86Stiller S. XVII, 86, 87Stirpe F. VI, XIII, 29, 63Stix G. XVI, 85Stockman D. XVII, XIX, 88, 103Stokes K. IX, 43Storti C. X, XV, 46, 79Straccio C. XV, 78Styliadis I. X, XI, XVI, XIX, 46, 55, 85, 99Styliadis J. XIX, 101LI

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122

Suga C. XII, 57Sugawara Y. XII, 57Suslina E. III, 11Sussenbach C. XX, 107Suzuki E. XX, 108Svandova E. VIII, 38Svetlich C. IX, 43

TTaborsky M. XVIII, 92Taïeb J. XVIII, 97, 98Talarico A. XVII, 88Talerico A. I, XIX, 3, 102Tamburino C. II, 6Tammaro P. X, 49Tanabe T. XVIII, 94Tanaka J. XX, 108Tanaka Y. VII, XIX, 32, 103Taôeb J. XVIII, 97Tassin A. XIV, XVII, 72, 90Tavares C. VII, 30Terrosu P. XI, 56Tespili M. XIX, 99Thambo J.B. III, 10Theofilogiannakos S. X, 46Thomas O. XII, 58Ticchi C. II, 8Tiffany-Ellis E. XVII, 87Tognazzolo L. I, 3Tokarska L. XVI, 81Tolaszova H. IV, XI, 17, 55Tomaino M. I, X, 4, 46Tomaselli M. XII, 59Tomasi C. III, IX, XI, XVII, 10, 40, 53, 90Tomasi L. I, XI, 2, 52Tomasic D. IX, 42Tomaszewski A. XVIII, 93Tondo C. VI, VIII, XIII, XIX, XX, 25, 39, 65, 103, 106Tongiani R. XIV, 68Topa A. I, II, XIV, XVI, 3, 8, 71, 83Topi B. XX, 108Tortora G. IV, 14Toselli T. I, IV, IX, X, XIII, 5, 16, 41, 46, 65Tota C. V, XIV, XVI, 22, 71, 83Tracht J. III, 11Tranquilli A. III, 109Trapani G. I, 3Treguer F. XIV, XVII, 72, 90Trembovetska O. XVI, 81Trevisi N. VIII, XII, XX, 37, 61, 62, 105Tsakiridis K. IV, V, 17, 20Tsilonis K. X, XVI, 46, 85

Tsinopoulos G. XVII, 90Tsuda T. X, 50Tsyganov A. IV, V, 14, 23Tuccillo B. V, 23Tundo F. VIII, 39Turco D. XI, 53Turco P. V, 24Turgeman Y. XII, 57Turner S. XVII, 91Turrini P. XII, XIV, 60, 70

UUcar M. XIX, 99Urbinati S. XIX, XX, 99, 104Ussia G.P. II, 6

VVaccari D. I, II, IX, XIII, XV, XVI, 5, 6, 40, 63, 77, 78, 82Vado A. XI, 55Vaglio A. II, VI, 6, 26Valaskova I. VIII, 38Valdés M. XVI, 84Valente F. IV, VI, 14, 29Valentino V. XX, 104Valsecchi S. I, V, XI, XIV, 2, 23, 51, 72Valzania C. XVII, 86Varbaro A. V, XI, 23, 52Vasheghani-Farahani A. XVII, 86Vassallo P. V, 20Vassanelli F. VIII, XIV, XV, 34, 73, 74Vassilikos V. X, XI, XVI, XIX, 46, 55, 85, 99, 101Vavrik D. IV, XI, 17, 55Vecchio F. V, XIV, XVI, 22, 71, 83Vecchione A. XVI, 82Vecchione F. V, 24Venditti F. III, XII, XIII, 12, 61, 66Verbo B. XIII, 66Vergara G. I, IV, XI, XII, XIV, 2, 16, 51, 58, 69Vergara P. XII, XX, 61, 105Verlato R. I, VIII, IX, X, XII, XIV, 2, 36, 43, 46, 60, 70Viani S. VIII, XII, XV, 37, 61, 75, 76Vicedomini G. VIII, X, 35, 49Vicentini A. IX, XV, 42, 77Viele A. VI, 25, 96, XVIIIViganego F. XV, 74Villa M.T. XII, 59Villain E. III, 10Villani G.Q. V, X, XV, 22, 48, 78Viscardi L. XII, 59Viscusi M. XVIII, 96Vit P. VIII, 38, 39Vitadello S. IX, 40LI

ST OF AUTHORS

123

Vitali L. XIV, XVII, 72, 90Vitovskyi R. XVI, 81Vittadello S. XVI, 82Vitulano N. VIII, 35Vizzardi E. XV, 74Vollan G. V, VIII, 24, 34Volpicelli M. X, 49Volzone V. XIX, 99Vosnakidis A. XVI, 85

WWalcher D. XVII, 86, 87Wasniewski M. III, 12Watanabe H. XX, 108, 109Wauters K. IV, 15Wenig K. XIX, XX, 101, 109Wichterle D. XI, 55Wilcox J. XVIII, 95Wilczek J. X, 48Wolzt M. XVI, 85Wong K. XVII, 87Wongcharoen W. XVII, 89

YYagihara N. XX, 109Yagishita A. VII, XIX, 32, 103Yahalom M. VIII, 39Yalçinkaya S. XIX, 100Yamagishi M. X, 50Yamamoto M. XX, 105Yaminisharif A. XVII, 86Yaminisharif R. XVII, 86Yang P. IX, 43Yanikoglu A. XIX, 100Yilmaz H. XIX, 99Yoshioka K. XVIII, 94

ZZaballos M. XX, 107Zabek A. IV, XI, 17, 51Zachara E. XX, 106Zalevsky V. XVI, 81Zaltsberg S. XIV, 68Zanetta M. XVI, 83Zaniboni A. XIX, XX, 99, 104Zanini R. XI, 53Zannad N. X, 45Zanon F. I, VI, IX, 2, 26, 40Zanotto G. I, II, VI, XI, XIII, 2, 5, 6, 26, 53, 63Zarifis J. XVI, XVII, 85, 90Zecchi P. XIII, 65Zemlyanova M. III, 11

Zenone F. XVI, 83Zerbo F. II, IV, IX, XVIII, 7, 16, 42, 95Ziacchi M. VI, XVI, 29, 81, 84Zizek D. VIII, 34Zoni Berisso M. XVI, 83Zoppo F. II, IV, IX, XVIII, 7, 16, 42, 95Zorzi E. IV, V, 14, 23Zuccaro L. I, IV, XII, XIII, 4, 16, 60, 63, 65Zuccaro L.M. I, II, III, VI, VII, XI, XII, XIII, XIX, XX, 4, 8, 10, 11, 29,

30, 32, 56, 62, 63, 100, 101, 105Zucchelli G. VIII, XII, XV, XIX, 37, 61, 75, 76, 103Zucchetti M. VIII, 39Zuccon G. VII, XVI, XVII, 33, 85, 87Zupan I. VIII, 34

LIST OF AUTHORS

124

Printed on November 12, 2010