Association between lung function and dyspnoea and its variation in the multinational Burden of Obstructive Lung Disease (BOLD) study

BACKGROUND

Dyspnoea is a common symptom of respiratory disease. However, data on its prevalence in general populations and its association with lung function are limited and are mainly from high-income countries. The aims of this study were to estimate the prevalence of dyspnoea across several world regions, and to investigate the association of dyspnoea with lung function.

METHODS

Dyspnoea was assessed, and lung function measured in 25,806 adult participants of the multinational Burden of Obstructive Lung Disease study. Dyspnoea was defined as ≥2 on the modified Medical Research Council (mMRC) dyspnoea scale. The prevalence of dyspnoea was estimated for each of the study sites and compared across countries and world regions. Multivariable logistic regression was used to assess the association of dyspnoea with lung function in each site. Results were then pooled using random-effects meta-analysis.

RESULTS

The prevalence of dyspnoea varied widely across sites without a clear geographical pattern. The mean prevalence of dyspnoea was 13.7 % (SD=8.2 %), ranging from 0 % in Mysore (India) to 28.8 % in Nampicuan-Talugtug (Philippines). Dyspnoea was strongly associated with both spirometry restriction (FVC

CONCLUSION

The prevalence of dyspnoea varies substantially across the world and is strongly associated with lung function impairment. Using the mMRC scale in epidemiological research should be discussed.

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Key Words

• Breathlessness
• Dyspnoea
• Lung function
• Spirometry

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Affiliation(s)

A Müller Ludwig Boltzmann Institute for Lung Health, Vienna, Austria; Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
E F Wouters Ludwig Boltzmann Institute for Lung Health, Vienna, Austria; Sigmund Freud University, Faculty of Medicine, Vienna, Austria; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
P Koul Department of Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Srinagar, India
T Welte Department of Respiratory Medicine/Infectious Disease, Member of the German Centre for Lung Research, Hannover School of Medicine, Hannover, Germany
I Harrabi Faculté de Médecine, Sousse, Tunisia
A Rashid RCSI and UCD Malaysia Campus, Penang, Malaysia
L C Loh RUMC, Penang, Malaysia
M Al Ghobain King Abdullah International Medical Research Center, King Saud ben Abdulaziz University for Health Science, Riyadh, Saudi Arabia
A Elsony The Epidemiological Laboratory, Khartoum, Sudan
R Ahmed The Epidemiological Laboratory, Khartoum, Sudan
J Potts National Heart and Lung Institute, Imperial College London, London, UK
K Mortimer University of Cambridge, Cambridge, UK; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
F Rodrigues Pulmonology Department, Lisbon North Hospital Centre, Lisbon, Portugal; Institute of Environmental Health, Associate Laboratory TERRA, Lisbon Medical School, Lisbon University, Lisbon, Portugal
S N Paraguas Philippine College of Chest Physicians, Manila, Philippines
S Juvekar KEM Hospital Research Centre, Pune, India
D Agarwal KEM Hospital Research Centre, Pune, India
D Obaseki Department of Medicine, Obafemi Awolowo University, Nigeria; Faculty of Medicine, University of British Columbia, Canada
T Gislason Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Department of Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
T Seemungal Faculty of Medical Sciences, University of West Indies, St Augustine, Trinidad and Tobago
A A Nafees Aga Khan University, Karachi, Pakistan
C Jenkins Woolcock Institute of Medical Research, Sydney, Australia
H B Dias Escola Superior de Tecnologia da Saúde de Lisboa, Politecnico de Lisboa, Lisbon, Portugal
F M E Franssen Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Research and Development, Ciro, Horn, the Netherlands
M Studnicka Department of Pulmonary Medicine, Paracelsus Medical University, Salzburg, Austria
C Janson Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
H H Cherkaski Faculty of Medicine, University Badji Mokhtar, Annaba, Algeria
M El Biaze Department of Respiratory Medicine, Faculty of Medicine, Mohammed Ben Abdellah University, Fes, Morocco
P A Mahesh Department of Respiratory Medicine, JSS Medical College and Hospital, Mysore, Karnataka, India
J Cardoso Pulmonology Department, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; NOVA Medical School, Nova University Lisbon, Lisboa, Portugal
P Burney National Heart and Lung Institute, Imperial College London, London, UK
S Hartl Ludwig Boltzmann Institute for Lung Health, Vienna, Austria; Sigmund Freud University, Faculty of Medicine, Vienna, Austria
D J A Janssen Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Ciro, Horn, the Netherlands
A F S Amaral National Heart and Lung Institute, Imperial College London, London, UK; NIHR Imperial Biomedical Research Centre, London, UK

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Ythdf2 regulates cardiac remodeling through its mRNA target transcripts

m6A mRNA methylation controls cardiomyocyte function and increased overall m6A levels are a stereotyping finding in heart failure independent of the underlying etiology. However, it is largely unknown how the information is read by m6A reader proteins in heart failure. Here we show that the m6A reader protein Ythdf2 controls cardiac function and identified a novel mechanism how reader proteins control gene expression and cardiac function. Deletion of Ythdf2 in cardiomyocytes in vivo leads to mild cardiac hypertrophy, reduced heart function, and increased fibrosis during pressure overload as well as during aging. Similarly, in vitro the knockdown of Ythdf2 results in cardiomyocyte growth and remodeling. Mechanistically, we identified the eucaryotic elongation factor 2 as post-transcriptionally regulated by Ythdf2 using cell type specific Ribo-seq data. Our study expands our understanding on the regulatory functions of m6A methylation in cardiomyocytes and how cardiac function is controlled by the m6A reader protein Ythdf2.

Wide Antral Circumferential Re-Ablation for Recurrent Atrial Fibrillation after Prior Pulmonary Vein Isolation Guided by High-Density Mapping Increases Freedom from Atrial Arrhythmias

Performing repeated pulmonary vein isolation (re-PVI) after recurrent atrial fibrillation (AF) following prior PVI is a standard procedure. However, no consensus exists regarding the most effective approach in redo procedures. We assessed the efficacy of re-PVI using wide antral circumferential re-ablation (WACA) supported by high-density electroanatomical mapping (HDM) as compared to conventional re-PVI. Consecutive patients with AF recurrences showing true PV reconnection (residual intra-PV and PV antral electrical potentials within the initial ablation line) or exclusive PV antral potentials (without intra-PV potentials) in the redo procedure were prospectively enrolled and received HDM-guided WACA (Re-WACA group). Conventional re-PVI patients treated using pure ostial gap ablation guided by a circular mapping catheter served as a historical control (Re-PVI group). Patients with durable PVI and no antral PV potentials were excluded. Arrhythmia recurrences ≥30 s were calculated as recurrences. In total, 114 patients were investigated (Re-WACA: n = 56, 68 ± 10 years, Re-PVI: n = 58, 65 ± 10 years). There were no significant differences in clinical characteristics including the AF type or the number of previous PVIs. In the Re-WACA group, 11% of patients showed electrical potentials only in the antrum but not inside any PV. At 402 ± 71 days of follow-up, the estimated freedom from arrhythmia was 89% in the Re-WACA group and 69% in the Re-PVI group (p = 0.01). Re-WACA independently predicted arrhythmia-free survival (HR = 0.39, 95% CI 0.16-0.93, p = 0.03), whereas two previous PVI procedures predicted recurrences (HR = 2.35, 95% CI 1.20-4.46, p = 0.01). The Re-WACA strategy guided by HDM significantly improved arrhythmia-free survival as compared to conventional ostial re-PVI. Residual PV antral potentials after prior PVI are frequent and can be easily visualized by HDM.

Left atrial appendage volume is an independent predictor of atrial arrhythmia recurrence following cryoballoon pulmonary vein isolation in persistent atrial fibrillation

Purpose

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation in persistent AF (persAF), and cryoballoon PVI emerged as an initial ablation strategy. Symptomatic atrial arrhythmia recurrence following successful PVI in persAF is observed more frequently than in paroxysmal AF. Predictors for arrhythmia recurrence following cryoballoon PVI for persAF are not well described, and the role of left atrial appendage (LAA) anatomy is uncertain.

Methods

Patients with symptomatic persAF and pre-procedural cardiac computed tomography angiography (CCTA) images undergoing initial second-generation cryoballoon (CBG2) were enrolled. Left atrial (LA), pulmonary vein (PV) and LAA anatomical data were assessed. Clinical outcome and predictors for atrial arrhythmia recurrence were evaluated by univariate and multivariate regression analysis.

Results

From May 2012 to September 2016, 488 consecutive persAF patients underwent CBG2-PVI. CCTA with sufficient quality for measurements was available in 196 (60.4%) patients. Mean age was 65.7 ± 9.5 years. Freedom from arrhythmia was 58.2% after a median follow-up of 19 (13; 29) months. No major complications occurred. Independent predictors for arrhythmia recurrence were LAA volume (HR 1.082; 95% CI, 1.032 to 1.134; p = 0.001) and mitral regurgitation ≥ grade 2 (HR, 2.49; 95% CI 1.207 to 5.126; p = 0.013). LA volumes ≥110.35 ml [sensitivity: 0.81, specificity: 0.40, area under the curve (AUC) = 0.62] and LAA volumes ≥9.75 ml (sensitivity: 0.56, specificity 0.70, AUC = 0.64) were associated with recurrence. LAA-morphology, classified as chicken-wing (21.9%), windsock (52.6%), cactus (10.2%) and cauliflower (15.3%), did not predict outcome (log-rank, p = 0.832).

Conclusion

LAA volume and mitral regurgitation were independent predictors for arrhythmia recurrence following cryoballoon ablation in persAF. LA volume was less predictive and correlated with LAA volume. LAA morphology did not predict the clinical outcome. To improve outcomes in persAF ablation, further studies should focus on treatment strategies for persAF patients with large LAA and mitral regurgitation.

Deep learning-assisted radiomics facilitates multimodal prognostication for personalized treatment strategies in low-grade glioma

Determining the optimal course of treatment for low grade glioma (LGG) patients is challenging and frequently reliant on subjective judgment and limited scientific evidence. Our objective was to develop a comprehensive deep learning assisted radiomics model for assessing not only overall survival in LGG, but also the likelihood of future malignancy and glioma growth velocity. Thus, we retrospectively included 349 LGG patients to develop a prediction model using clinical, anatomical, and preoperative MRI data. Before performing radiomics analysis, a U2-model for glioma segmentation was utilized to prevent bias, yielding a mean whole tumor Dice score of 0.837. Overall survival and time to malignancy were estimated using Cox proportional hazard models. In a postoperative model, we derived a C-index of 0.82 (CI 0.79-0.86) for the training cohort over 10 years and 0.74 (Cl 0.64-0.84) for the test cohort. Preoperative models showed a C-index of 0.77 (Cl 0.73-0.82) for training and 0.67 (Cl 0.57-0.80) test sets. Our findings suggest that we can reliably predict the survival of a heterogeneous population of glioma patients in both preoperative and postoperative scenarios. Further, we demonstrate the utility of radiomics in predicting biological tumor activity, such as the time to malignancy and the LGG growth rate.

Prognostic Utility of Coronary Computed Tomography Angiography-derived Plaque Information on Long-term Outcome in Patients With and Without Diabetes Mellitus

PURPOSE

To investigate the long-term prognostic value of coronary computed tomography angiography (cCTA)-derived plaque information on major adverse cardiac events (MACE) in patients with and without diabetes mellitus.

MATERIALS AND METHODS

In all, 64 patients with diabetes (63.3±10.1 y, 66% male) and suspected coronary artery disease who underwent cCTA were matched with 297 patients without diabetes according to age, sex, cardiovascular risk factors, and statin and antithrombotic therapy. MACE were recorded. cCTA-derived risk scores and plaque measures were assessed. The discriminatory power to identify MACE was evaluated using multivariable regression analysis and concordance indices.

RESULTS

After a median follow-up of 5.4 years, MACE occurred in 31 patients (8.6%). In patients with diabetes, cCTA risk scores and plaque measures were significantly higher compared with nondiabetic patients (all P <0.05). The following plaque measures were predictors of MACE using multivariable Cox regression analysis (hazard ratio [HR]) in patients with diabetes: segment stenosis score (HR=1.20, P <0.001), low-attenuation plaque (HR=3.47, P =0.05), and in nondiabetic patients: segment stenosis score (HR=1.92, P <0.001), Agatston score (HR=1.0009, P =0.04), and low-attenuation plaque (HR=4.15, P =0.04). A multivariable model showed a significantly improved C-index of 0.96 (95% confidence interval: 0.94-0.0.97) for MACE prediction, when compared with single measures alone.

CONCLUSION

Diabetes is associated with a significantly higher extent of coronary artery disease and plaque features, which have independent predictive values for MACE. cCTA-derived plaque information portends improved risk stratification of patients with diabetes beyond the assessment of obstructive stenosis on cCTA alone with subsequent impact on individualized treatment decision-making.

Pearls and Pitfalls of Pulsed Field Ablation

Pulsed field ablation (PFA) was recently rediscovered as an emerging treatment modality for the ablation of cardiac arrhythmias. Ultra-short high voltage pulses are leading to irreversible electroporation of cardiac cells subsequently resulting in cell death. Current literature of PFA for pulmonary vein isolation (PVI) consistently reported excellent acute and long-term efficacy along with a very low adverse event rate. The undeniable benefit of the novel ablation technique is that cardiac cells are more susceptible to electrical fields whereas surrounding structures such as the pulmonary veins, the phrenic nerve or the esophagus are not, or if at all, minimally affected, which results in a favorable safety profile that is expected to be superior to the current standard of care without compromising efficacy. Nevertheless, the exact mechanisms of electroporation are not yet entirely understood on a cellular basis and pulsed electrical field protocols of different manufactures are not comparable among one another and require their own validation for each indication. Importantly, randomized controlled trials and comparative data to current standard of care modalities, such as radiofrequency- or cryoballoon ablation, are still missing. This review focuses on the "pearls" and "pitfalls" of PFA, a technology that has the potential to become the future leading energy source for PVI and beyond.

Bronchial Safety After Pulsed-Field Ablation for Paroxysmal Atrial Fibrillation

BACKGROUND

Thermal left atrial ablation can cause bronchial damage. Pulsed-field ablation (PFA) is a novel, nonthermal ablation modality for paroxysmal atrial fibrillation. We report on bronchial effects after pulmonary vein isolation using PFA for paroxysmal atrial fibrillation.

METHODS

A computed tomography scan showing the respiratory tract adjacent to the left atrial was obtained. Oral anticoagulation was interrupted on procedure day. Peri-procedurally, patients received heparin with an activated clotting time goal of >350 seconds. All pulmonary veins were individually isolated with a 13F steerable sheath and a pentaspline PFA catheter using either a straight-tip or J-tip guide wire. The J-tip guide wire patients were added to test the hypothesis that the straight-tip guidewire was associated with bleeding complications. One day afterward, bronchoscopy was performed. Serial hemoglobin levels were measured during 30-day follow-up.

RESULTS

In 2 series of 30 patients, PFA was performed, with all pulmonary veins acutely isolated. Clinical course was uneventful, no patient had chest discomfort, coughing, or hemoptysis. All patients underwent uncomplicated bronchoscopy, without thermal lesions or ulcers. In 12 out of 30 (40%) straight-tip guide wire patients, small amounts of old blood without active bleeding were seen in multiple segments. All hemoglobin levels remained clinically stable. At 30-day follow-up, all patients were asymptomatic.

CONCLUSIONS

Pulmonary vein isolation using PFA for paroxysmal atrial fibrillation does not cause thermal lesions in the bronchial system. Use of a straight-tip, extrastiff guide wire for the over-the-wire PFA catheter can lead to asymptomatic bleeding in the bronchial system without clinical relevance at 30-day follow-up, opposite to use of a J-tip guide wire.

Wide antral circumferential re-ablation in case of recurrent atrial fibrillation despite of prior pulmonary vein isolation increases freedom from atrial tachyarrhythmias

Funding Acknowledgements

Type of funding sources: None.

Background

Despite repeated pulmonary vein isolation (re-PVI) due to recurrent atrial fibrillation (AF) after PVI has been a standard procedure, the detailed ablation strategy in case of re-PVI remains disputable.

Objective

The aim of this study was to assess the efficacy of re-PVI using wide antral circumferential ablation (WACA) supported by high density mapping (HDM) for recurrent AF after PVI as compared to simple repeated PVI supported by circular mapping catheter.

Methods

Consecutive patients with recurrent AF after PVI were prospectively enrolled in this study, who underwent left atrial HDM and subsequently WACA antral (re-)isolation ("Re-WACA" group). The historical controls with re-PVI between 2016 and 2018 using circular mapping catheter, but without HDM were also enrolled ("control group"). These control patients underwent re-PVI with gap ablation at the pulmonary vein ostium. Primary endpoint was defined as any recurrence and ECG documentation of atrial tachyarrhythmias (AT) including AF or atrial tachycardias over 30 seconds. The patients were routinely followed up for 1 year with at least twice annual holter-monitoring.

Results

In total, 116 patients were enrolled in this study (Re-WACA group [N=56, 68±10 years], control group [N=58, 65±10 years]). There were no significant differences in clinical characteristics including the number of previous left atrial ablation procedures between two groups. In all 56 patients with Re-WACA, residual PV antral potentials were demonstrated (100%), whereas 7 patients (13%) showed no electrical potentials inside any PVs. During a mean follow-up period of 402±71 days, 6 out of 56 Re-WACA patients (11%) and 18 out of 58 controls (31%) experienced AT recurrences. Kaplan-Meier analysis demonstrated that the patients who underwent Re-WACA showed significantly lower AT recurrence after the index Re-PVI procedure as compared to the controls (log-rank, P = 0.010). Multivariate Cox regression showed that Re-WACA was an independent predictor of freedom from AT recurrence (hazard ratio = 0.39; 95% confidence-interval 0.16-0.93; P=0.034). The number of previous PVI procedures predicted AT recurrence during follow-up (hazard ratio = 2.35; 95% confidence-interval 1.20-4.46; P=0.010).

Conclusions

Residual pulmonary vein antral potential in patients with recurrent AF after previously performed PVI is a frequent finding. These antral potentials can be easily visualized by HDM. Repeated isolation of wide PV antrum (Re-WACA) is an effective strategy to reduce further AF recurrence as compared to conventional re-PVI without left atrial HDM.

Cryoballoon Ablation Strategy in Persistent Atrial Fibrillation

Background: Cryoballoon ablation is established for pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). The objective was to evaluate CBA strategy in consecutive patients with persistent AF in the initial AF ablation procedure.

Material and Methods: Prospectively, patients with symptomatic persistent AF scheduled for AF ablation all underwent cryoballoon PVI. Technical enhancements, laboratory management, safety, single-procedure outcome, predictors of recurrence, and durability of PVI were evaluated.

Results: From 2007 to 2020, a total of 1,140 patients with persistent AF, median age 68 years, underwent cryoballoon ablation (CBA). Median left atrial (LA) diameter was 45 mm (interquantile range, IQR, 8), and Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled), Vascular disease, Age 65 to 74 years, Sex category (CHA₂DS₂-VASc) score was 3. Acute isolation was achieved in 99.6% of the pulmonary veins by CBA. Median LA time and median dose area product decreased significantly over time (p < 0.001). Major complications occurred in 17 (1.5%) patients including 2 (0.2%) stroke/transitory ischemic attack (TIA), 1 (0.1%) tamponade, relevant groin complications, 1 (0.1%) significant ASD, and 4 (0.4%) persistent phrenic nerve palsy (PNP). Transient PNP occurred in 66 (5.5%) patients. No atrio-esophageal fistula was documented. Five deaths (0.4%), unrelated to the procedure, occurred very late during follow-up. After initial CBA, arrhythmia recurrences occurred in 46.6% of the patients. Freedom from atrial arrhythmias at 1-, and 2-year was 81.8 and 61.7%, respectively. Independent predictors of recurrence were LA diameter, female sex, and use of the first cryoballoon generation. Repeat ablations due to recurrences were performed in 268 (23.5%) of the 1,140 patients. No pulmonary vein (PV) reconduction was found in 49.6% of the patients and 73.5% of PVs. This rate increased to 66.4% of the patients and 88% of PVs if an advanced cryoballoon was used in the first AF ablation procedure.

Conclusion: Cryoballoon ablation for symptomatic persistent AF is a reasonable strategy in the initial AF ablation procedure.

Cardiac computed tomography angiography-derived analysis of left atrial appendage morphology and left atrial dimensions for the prediction of atrial fibrillation recurrence after pulmonary vein isolation

Background

Left atrial appendage (LAA) is a potential source of atrial fibrillation (AF) triggers.

Hypothesis

LAA morphology and dimensions are associated with AF recurrence after pulmonary vein isolation (PVI).

Methods

From cardiac computed tomography angiography (CCTA), left atrial (LA), pulmonary vein (PV), and LAA anatomy were assessed in cryoballoon ablation (CBA) patients.

Results

Among 1103 patients undergoing second‐generation CBA, 725 (65.7%) received CCTA with 473 (42.9%) qualifying for detailed LAA analysis (66.3 ± 9.5 years). Symptomatic AF reoccurred in 166 (35.1%) patients during a median follow‐up of 19 months. Independent predictors of recurrence were LA volume, female sex, and mitral regurgitation ≥°II. LAA volume and AF‐type were dependent predictors of recurrence due to their strong correlations with LA volume. LA volumes ≥122.7 ml (sensitivity 0.53, specificity 0.69, area under the curve [AUC] 0.63) and LAA volumes ≥11.25 ml (sensitivity 0.39, specificity 0.79, AUC 0.59) were associated with recurrence. LA volume was significantly smaller in females. LAA volumes showed no sex‐specific difference. LAA morphology, classified as windsock (51.4%), chicken‐wing (20.7%), cactus (12.5%), and cauliflower‐type (15.2%), did not predict successful PVI (log‐rank; p = 0.596).

Conclusions

LAA volume was strongly correlated to LA volume and was a dependent predictor of recurrence after CBA. Main independent predictors were LA volume, female sex, and mitral regurgitation ≥°II. Gender differences in LA volumes were observed. Individual LAA morphology was not associated with AF recurrence after cryo‐PVI. Our results indicate that preprocedural CCTA might be a useful imaging modality to evaluate ablation strategies for patients with recurrences despite successful PVI.

Benefit of ultra-high-density mapping-guided radiofrequency reablation in pulmonary vein isolation non-responders after initial cryoballoon procedure

AIMS

Symptomatic atrial arrhythmias despite complete pulmonary vein isolation (PVI) are common. The purpose was to evaluate ultra-high-density multi-electrode electroanatomical mapping-guided radiofrequency ablation (RFA) in PVI non-responders.

METHODS AND RESULTS

Ultra-high-density multi-electrode electroanatomical mapping-guided RFA in consecutive symptomatic atrial fibrillation (AF) patients after initial cryoballoon PVI was performed. Patients were included if all pulmonary veins (PVs) were still isolated. Radiofrequency targets were atrial tachycardia (AT), extra-PV trigger, and/or substrate. Procedural results and outcome were evaluated. Of 95 patients, 67 (70.5%) with complete PVI were included (70 years, CHA2DS2Vasc 2.9, left atrium 45 mm, persistent AF 45%, AT 45%). The median time to reablation was 26 months. One hundred and seven maps (1.6/patient) and 11.890 ± 9.018 electrograms were acquired in 33 ± 12 min. Twenty-eight percent of the left atrial (LA) wall showed pathological voltage signals, predominantly at the anterior (37%) and septal wall (26%). Atrial tachycardia (49 left, 4 right) were ablated in 35 patients (52%), extra-PV trigger in two patients (3%). One atrioventricular nodal re-entry tachycardia and seven right atrial isthmus ablation (10%) were performed. In 32 patients (48%), no AT was present and substrate-based ablation was performed. Mean LA area ablated was 7 ± 6 cm2 (7%). No major complication occurred. The mean follow-up time was 772 ± 317 days. Freedom from atrial arrhythmia recurrence off antiarrhythmic drugs was 49% at 12 months.

CONCLUSION

Pulmonary vein isolation non-responders are older, mainly suffering from complex atrial arrhythmias. Left atrial substrate is predominantly located at the anterior and septal wall. Ultra-high-density multi-electrode electroanatomical mapping-guided RFA is safe and effective. At 1 year, 5 out of 10 patients were in stable sinus rhythm off antiarrhythmic drugs.

Impact of age on the outcome of cryoballoon ablation as the primary approach in the interventional treatment of atrial fibrillation: Insights from a large all-comer study

INTRODUCTION

The objective was to analyze the impact of patient age on clinical characteristics, procedural results, safety, and outcome of cryoballoon ablation (CBA) as the primary approach in the interventional treatment of symptomatic atrial fibrillation (AF).

METHODS AND RESULTS

The single-center prospective observational study investigated consecutive patients who underwent initial left atrial ablation for symptomatic paroxysmal (PAF) or persistent AF (persAF). Age groups (A-F) of less than 40, 40-49, 50-59, 60-69, 70-79 and more than or equal to 80 years were evaluated. Follow-up (FU) included ECG, Holter monitoring and assessment of AF-symptoms. From 2012 to 2016, a total of 786 patients (64 ± 11 years, range 21-85) underwent CBA. With advancing age, more cardiovascular comorbidities and larger LA diameter were observed, more females were included (each p < .001). PAF (57%) and persAF (43%, p = .320) were equally distributed over all age groups. Age was neither related to procedural parameters, nor to the complication rate (3.9%, p = .233). Median FU was 38 months. Two non-procedure related noncardiac deaths occurred late during FU. Freedom from arrhythmia was independent of age at 18 months (p = .210) but decreased for patients more than or equal to 70 years at 24 months (p = .02). At 36 months, freedom from arrhythmia was 66%-74% (groups A-D), 54% (E) and 49% (F), respectively (p = .002). LA diameter and persAF were independent predictors, whereas age was a dependent predictor of recurrence.

CONCLUSION

CBA as the primary approach in the initial ablation procedure is safe and highly effective in the young, middle aged, and elderly population. LA diameter and persAF, but not ageing, were independent predictors for arrhythmia recurrence.

Comprehensive investigation of saliva replacement liquids for the treatment of xerostomia

The sensation of dry mouth also referred to as xerostomia is becoming increasingly common worldwide. Current treatment strategies include topical agents, sialagogues and saliva substitutes. The latter have been reported to be ineffective as special physicochemical features of natural saliva have so far been ignored (e.g., buffer capacity, osmolality, etc.). The aim of this study was to comprehensively investigate the most relevant physicochemical properties of three products frequently used in the clinics and compare them to unstimulated whole saliva (UWS). Sialin-Sigma®, Glandomed® and Xylitol CVS Health^TM Dry Mouth Spray were characterized regarding their pH, osmolality, electrical conductivity, buffer capacity, rheological behaviour, microstructure, surface tension and wettability and compared to UWS. The influence of residual saliva was examined under consideration of the conditions of xerostomia to assess whether the quantity given in the instruction for use is appropriate. All three products showed significant differences to UWS regarding the values received. Only Xylitol CVS Health^TM Dry Mouth Spray showed a comparable wettability. It could be further determined that the recommended doses were too low. These data can not only be used for an improved understanding of saliva, but also for the development of a replacement fluid to successfully alleviate xerostomia.

The fourth cryoballoon generation with a shorter tip to facilitate real-time pulmonary vein potential recording: Feasibility and safety results

INTRODUCTION

Time-to-isolation (TTI) guided ablation protocols have been developed to ensure durable pulmonary vein isolation (PVI) in cryoballoon ablation (CBA). The aim was to determine the feasibility and safety of the fourth generation cryoballoon (CBG4) with a shortened tip.

METHODS AND RESULTS

Consecutive patients scheduled for initial atrial fibrillation (AF) ablation were prospectively included. PVI with the 28 mm CBG4 and the latest 20 mm spiral-mapping catheter (SMC) was performed. A total of 302 pulmonary veins (PVs) in 76 patients (64.8 ± 10.4 years, paroxysmal AF 49%) were treated with 617 applications. Left atrium (LA) time, fluoroscopy time, and dose-area product were 65.5 ± 19.2 minutes, 14.6 ± 5.6 minutes, and 1094 (738; 2097) cGy·cm² , respectively. PVI in cryoballoon technique was achieved in 302 of 302 (100%) PVs. TTI was determined in 256 (84.8%) of PVs. The mean TTI was 45.3 ± 26.4 seconds. Single-shot isolation was achieved in 247 (82%) PVs. In 6 of 302 (2.0%) PV the SMC was changed to a stiff wire to isolate the PV because of instability, and in 17 of 302 (5.6%) of PVs, the 23 mm CB was used to isolate. No radiofrequency touch-up applications were applied. The mean nadir balloon temperature was -44.8°C ± 6.6°C. Balloon dislodgement during positioning occurred in 3 of 617 (0.5%) applications without complications. One PN palsy occurred which resolved until discharge. One patient suffered from the inflammatory syndrome.

CONCLUSION

The CBG4 with a shorter distal tip seems to be safe and effective, and allows determining the TTI in 84.8% of PVs. In case of balloon instability, the exchange of the SMC to a stiff wire or, in small PV, the 23 mm cryoballoon facilitate PVI.

[Guideline for the Diagnosis and Treatment of COPD Patients - Issued by the German Respiratory Society and the German Atemwegsliga in Cooperation with the Austrian Society of Pneumology]

This document is a revision of the guideline for diagnosis and treatment of COPD that replaces the version from 2007. A multitude of recent reports regarding risk factors, diagnosis, assessment, prevention and pharmacological as well as non-pharmacological treatment options made a major revision mandatory. The new guideline is based on the GOLD document taking into account specifics in Germany and Austria.

[The Austrian LEAD (Lung hEart sociAL boDy) Study: Background of the Austrian Longitudinal Cohort Study]

More research is needed to elucidate natural history and underlying pathomechanisms of the most common airway diseases, Asthma and COPD. In the last decade risk factors affecting the natural history of lung function, defined by the decline of lung function over time, have been evaluated. Moreover, scientific methods have been extended and novel biomarkers, genetics, metabolomics, and epidemiology are dominant tools for investigating the natural history of lung function and potential risk factors. Evidence shows that lung function in childhood is a predictor for lung function in adulthood and risk factors starting in utero contribute to lung function decline during life. Therefore, recently it has been hypothesized that COPD begins in childhood. Thus, prospective investigation of lung function changes including novel scientific methodology has been advocated. The Austrian LEAD  study has been initiated in the general population 2012 to investigate the natural history of obstructive airway diseases.

Incidence and outcome of weaning from mechanical ventilation according to new categories

Weaning from mechanical ventilation was categorised as simple, difficult or prolonged by an international task force of the American Thoracic Society/European Respiratory Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine/Sociéte de Réanimation de Langue Française in 2007. This new classification has not been tested in clinical practice. The objective of the present study was to determine the incidence and outcome of weaning according to the new categories. We included medical and surgical patients who required mechanical ventilation in a prospective, multicentre, 6-month cohort study. From an initial cohort of 510 patients, 257 intubated patients started weaning. Of these patients, the cumulative incidences of simple, difficult, and prolonged weaning were 152 (59%), 68 (26%) and 37 (14%), respectively. Hospital mortality was increased in patients with prolonged (32%) but not difficult (9%) weaning in comparison with those with simple weaning (13%), overall p = 0.0205. In a multivariate logistic regression model, prolonged but not difficult weaning was associated with an increased risk of death. Ventilator-free days and intensive care unit (ICU)-free days were decreased in both difficult and prolonged weaning. In conclusion, the new weaning category prolonged weaning is associated with increased mortality and morbidity in the ICU. The new category difficult to wean was associated with increased morbidity, but not mortality.

Measuring FEV(6) for detecting early airway obstruction in the primary care setting. Quality and utility of the new PiKo-6 device

BACKGROUND

The prevalence of asthma and chronic obstructive pulmonary disease (COPD) is high ( approximately 7.4-18%) in the general population, but less than half are diagnosed. Several studies have shown FEV(6) as a good surrogate marker for forced vital capacity (FVC) to detect airflow limitations.

OBJECTIVES

The aim of this study was to evaluate if it is possible to simplify and improve the diagnosis of so far undiagnosed asthma or COPD in the primary care setting by measuring FEV(6) with a new simple screening device (PiKo-6).

METHODS

507 patients were recruited from three general practices from May to June 2005. Patients with any known pulmonary disease were excluded by questionnaire. FEV(1), FEV(6) and FEV(1)/FEV(6) were determined using a PiKo-6 device. Patients with an FEV(1)/FEV(6) <80% (PiKo positive) were invited to a standardized pulmonary function test to confirm or rule out airflow limitation.

RESULTS

401 (79.1%) patients showed FEV(1)/FEV(6) > or =80% (PiKo negative), and 106 (20.9%) patients were PiKo positive. Of the 106 PiKo-positive patients, 74 patients (14.7% of total) agreed to further studies and 18 patients (3.6%) of them suffered from COPD [COPD 0: 5 (1.0%); COPD I: 9 (1.8%); COPD II: 4 (0.8%), and none with COPD III or IV] and 14 patients (2.8%) suffered from bronchial hyperresponsiveness or asthma. In 42 patients (8.3%), the pulmonary function test was normal.

CONCLUSIONS

Measurement of FEV(6) using a new simple screening device (PiKo-6) may improve the detection rate of undiagnosed airflow limitation in the primary care setting. However, patients should be carefully selected.

Multicentric Adenocarcinomas in a Long-Segment of Barrett's Esophagus

This report describes a complicated course of a 58-year-old patient with multicentric Barrett's carcinoma within a long-segment of Barrett metaplasia. After abdominal-thoracic resection of the cancer, with incomplete removal of the long-segment metaplastic lesion, invasive carcinoma was diagnosed in the remnant Barrett's segment. Endoscopic mucosal resection was done, but Barrett's mucosa was left in situ again. Recurrent tumor growth was diagnosed only few months later. Finally, transthoracic complete resection on the remnant Barrett's segment was performed. Thus, our case demonstrates impressively the appearance of multicentric adenocarcinomas in Barrett's esophagus and underlines the necessity of resection of the complete Barrett mucosa.

End-of-life decision-making in respiratory intermediate care units: a European survey

A survey was performed on behalf of the European Respiratory Society to assess end-of-life practices in patients admitted to European respiratory intermediate care units and high dependency units over a 6-month period. A 33-item questionnaire was sent by e-mail to physicians throughout Europe and the response rate was 28 (29.5%) out of 95. A total of 6,008 patients were admitted and an end-of-life decision was taken in 1,292 (21.5%). The mortality rate in these patients was 68% (884 out of 1,292). The patients received similar proportions of withholding of treatment (298 (23%) out of 1292), do-not-resuscitate or do-not-intubate orders (442 (34%) out of 1,292) and noninvasive mechanical ventilation as the ceiling of ventilatory care (402 (31%) out of 1,292). Withdrawal of therapy was employed in 149 (11%) out of 1,292 patients and euthanasia in one. Do-not-intubate/do-not-resuscitate orders were more frequently used in North compared with South Europe. All of the 473 competent patients directly participated in the decision, whereas, in 722 (56%) out of 1,292 cases, decision-making was reported to be shared with the nurses. In European respiratory intermediate care units and high dependency units, an end-of-life decision is taken for 21.5% of patients admitted. Withholding of treatment, do-not-intubate/do-not-resuscitate orders and noninvasive mechanical ventilation as the ventilatory care ceiling are the most common procedures. Competent patients are often involved, together with nurses.

Successful lung transplantation in a long-term ventilator-dependent patient

Ventilator dependence has been postulated to be a major contraindication for successful lung transplantation. We describe the case of a 44-year-old female patient mechanically ventilated for 10 months after adult respiratory distress syndrome. After a program of physical training the patient underwent successful bilateral sequential lung transplantation. Six months postoperatively she is in good physical condition and is able to carry out the activities of normal daily living. We conclude that in selected patients long-term mechanical ventilatory support is not a contraindication for lung transplantation.