Introduction: Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing (MultiPoint Pacing, MPP) has been shown to improve CRT response, although MPP response using automated pacing vector programming has not been demonstrated in the Middle East. Objective: Compare the impact of MPP to conventional biventricular pacing (BiV) using echocardiographic and clinical changes at 6 months post-implant. Methods: This prospective, randomized study was conducted at 13 Middle Eastern centers. After de novo CRT-D implant (Abbott Unify Quadra MP or Quadra Assura MP) with quadripolar LV lead (Abbott Quartet), patients were randomized to either BiV or MPP therapy. In BiV patients, the LV pacing vector was selected per standard practice; in MPP patients, the two LV pacing vectors were selected automatically using VectSelect. CRT response was defined at 6 months post-implant by a reduction in LV end-systolic volume (ESV) [?]15%. Results: One-hundred and forty-two patients (61 years old, 68% male, NYHA class II/III/IV 19%/75%/6%, 33% ischemic, 57% hypertension, 52% diabetes, 158 ms QRS, 25.8% ejection fraction [EF]) were randomized to either BiV (N=69) or MPP (N=73). After 6 months,

Atrial tachycardia resistant to conventional management may respond to ivabradine. Two cases of resistant tachycardia are presented that responded to ivabradine. Both cases were later successfully ablated and both maintained sinus rhythm and are symptom free 2 years post procedure. The physiological mechanism for this is also briefly discussed. KEYWORDS Atrial tachycardia; Ivabradine Case 1In 2009, a 27-year-old male was referred to our arrhythmia clinic with palpitations. His heart rate (HR) was up to 140 b.p.m., based on electrocardiogram and exclusion of other causes of sinus tachycardia, an initial diagnosis of inappropriate sinus tachycardia (IST) was made. The echocardiogram showed a reduced (25%) left ventricular ejection fraction (LVEF), suggesting tachycardia-induced cardiomyopathy. The first attempt to control HR was with b-blockers and amiodarone, but it was only partially successful. The ivabradine dose was titrated to 7.5 mg twice daily and then a normalization of HR was obtained (i.e. 65 b.p.m.). The echocardiogram also showed normalized LVEF with an EF of 55%. Two years later, in 2011, ivabradine was stopped by his cardiologist. The patient once again developed tachycardia-induced cardiomyopathy (EF of 40%). He was then started on amiodarone (400 mg daily), which failed to control HR and to improve cardiac function. Ivabradine 7.5 mg twice daily was then resumed and after 6 months HR was stabilized at 70 b.p.m. and EF improved to 55%. Figures 1 and 2 show typical electrocardiograms with and without ivabradine.An electrophysiological study (using the 3D Ensite system) was then proposed to the patient and in view of this, ivabradine was stopped for five half-lives. Figures 3 and 4 show this. The activation of this rhythm in the sinus node area was from caudal to cranial. This atrial tachycardia (AT) was mapped at the level of high right atrium below the appendage. The earliest activation was targeted and few seconds of radiofrequency application by a Blazer 4 mm tip catheter not irrigated (50 W, 508C) resulted in termination of AT ( Figure 5). The patient remained in normal sinus rhythm with no recurrence of arrhythmia for the 2 years of follow-up. The final diagnosis of this case was incessant automatic right-sided AT, originating from the anterior wall just below the appendage. Case 2A 24-year-old female presented to our outpatient clinic with incessant supraventricular tachyarrhythmia up to 160 b.p.m., also initially diagnosed as IST (Figure 6). She was offered an electrophysiological study but she refused. The patient was started on ivabradine 7.5 mg twice daily and metoprolol 50 mg twice daily, continued for .1 year and her HR was lowered to 70 b.p.m.Due to pregnancy, the patient stopped all medications, and after the seventh week of pregnancy she complained ofpalpitation,dyspnoea,andeasyfatigability.ThemeanHR was 140 b.p.m. The echocardiogram showed a reduced LVEF of 35%, suggesting a tachycardia-induced cardiomyopathy. Metoprolol 50 mg twice daily was resumed, but did not control her tachyarr...

Background:The implantable cardioverter-defibrillator (ICD) is effective in the prevention of sudden cardiac death in high-risk patients. Little is known about ICD use in the Arabian Gulf. We designed a study to describe the characteristics and outcomes of patients receiving ICDs in the Arab Gulf region.Methods:Gulf ICD is a prospective, multi-center, multinational, and observational study. All adult patients 18 years or older, receiving a de novo ICD implant and willing to sign a consent form will be eligible. Data on baseline characteristics, ICD indication, procedure and programing, in-hospital, and 1-year outcomes will be collected. Target enrollment is 1500 patients, which will provide adequate precision across a wide range of expected event rates.Results:Fifteen centers in six countries are enrolling patients (Saudi Arabia, United Arab Emirates, Kuwait, Oman, Bahrain, and Qatar). Two-thirds of the centers have dedicated electrophysiology laboratories, and in almost all centers ICDs are implanted exclusively by electrophysiologists. Nearly three-quarters of the centers reported annual ICD implant volumes of ≤150 devices, and pulse generator replacements constitute <30% of implants in the majority of centers. Enrollment started in December 2013, and accrual rate increased as more centers entered the study reaching an average of 98 patients per month.Conclusions:Gulf ICD is the first prospective, observational, multi-center, and multinational study of the characteristics and, the outcomes of patients receiving ICDs in the Arab Gulf region. The study will provide valuable insights into the utilization of and outcomes related to ICD therapy in the Gulf region.