[Development of catheter ablation of supraventricular tachycardias with special consideration of contributions from German engineers and electrophysiologists]

The development and clinical implementation of catheter ablation of supraventricular tachycardia is one of the outstanding achievements of modern cardiovascular treatment. Over a period of less than 40 years, a curative and safe treatment strategy for almost all forms of atrial arrhythmias has been developed and implemented. German electrophysiologists and engineers have made a significant contribution to this truly outstanding success story in modern medicine. Their contributions should be appropriately acknowledged because without them, the development of ablation technology and its worldwide dissemination would not have been possible. Both the technological contributions and the medical-electrophysiological contributions were at the absolute forefront of worldwide developments and have made a significant contribution to the fact that today more than 500,000 patients with symptomatic and/or threatening cardiac arrhythmias can be successfully treated every year by use of catheter ablation. We would like to thank them all for their achievements.

Incidence and patterns of atrial fibrillation after catheter ablation of typical atrial flutter-the FLUTFIB study

AIMS

In patients with atrial flutter (AFL), ablation of the cavotricuspid isthmus (CTI) is a highly effective procedure to prevent AFL recurrence, but atrial fibrillation (AF) may occur during follow-up. The presented FLUTFIB study was designed to identify the exact incidence, duration, timely occurrence, and associated symptoms of AF after CTI ablation using continuous cardiac monitoring via implantable loop recorders.

METHODS AND RESULTS

One hundred patients with AFL without prior AF diagnosis were included after CTI ablation (mean age 69.7 ± 9.7 years, 18% female) and received an implantable loop recorder for AF detection. After a median follow-up of 24 months 77 patients (77%) were diagnosed with AF episodes. Median time to first AF occurrence was 180 (43-298) days. Episodes lasted longer than 1 h in most patients (45/77, 58%). Forty patients (52%) had AF-associated symptoms.Patients with and without AF development showed similar baseline characteristics and neither HATCH- nor CHA2DS2-VASc scores were predictive of future AF episodes. Oral anticoagulation (OAC) was stopped during FU in 32 patients (32%) and was re-initiated after AF detection in 15 patients (15%). No strokes or transient ischaemic attack episodes were observed during follow-up.

CONCLUSION

This study represents the largest investigation using implantable loop recorders (ILRs) to detect AF after AFL ablation and shows a high incidence of AF episodes, most of them being asymptomatic and lasting longer than 1 h. In anticipation of trials determining the duration of AF episodes that should trigger OAC initiation, these results will help to guide anticoagulation management after CTI ablation.

Risk of occurrence of electromagnetic interference from the application of transcutaneous electrical nerve stimulation on the sensing function of implantable defibrillators

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is an established method for pain relief. But electrical TENS currents are also a source of electromagnetic interference (EMI). Thus, TENS is considered to be contraindicated in implantable cardioverter-defibrillator (ICD) patients. However, data might be outdated due to considerable advances in ICD and cardiac resynchronization therapy (CRT) filtering and noise protection algorithm technologies. The aim of this pilot safety study was to re-evaluate the safety of TENS in patients with modern ICDs.

METHODS AND RESULTS

One hundred and seven patients equipped with 55 different models of ICD/CRT with defibrillators from 4 manufacturers underwent a standardized test protocol including TENS at the cervical spine and the thorax, at 2 stimulation modes-high-frequency TENS (80 Hz) and burst-mode TENS (2 Hz). Potential interference monitoring included continuous documentation of ECG Lead II, intracardiac electrograms and the marker channel. Electromagnetic interference was detected in 17 of 107 patients (15.9%). Most frequent were: interpretations as a premature ventricular beats (VS/S) in 15 patients (14%), noise reversion in 5 (4.6%) which resulted in temporary asynchronous pacing in 3 (2.8%), interpretation as ventricular tachycardia/ventricular fibrillation in 2 (1.9%), and premature atrial beat in 2 (1.9%) patients. Electromagnetic interference occurrence was influenced by position (chest, P < 0.01), higher current intensity (P < 0.01), and manufacturer (P = 0.012).

CONCLUSION

Overall, only intermittent and minor EMI were detected. Prior to the use of TENS in patients with ICDs, they should undergo testing under the supervision of a cardiac device specialist.

Impact of cryoballoon application abortion due to phrenic nerve injury on reconnection rates: a YETI subgroup analysis

AIMS

Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). The most frequent complication during CB-based PVI is right-sided phrenic nerve injury (PNI) which is leading to premature abortion of the freeze cycle. Here, we analysed reconnection rates after CB-based PVI and PNI in a large-scale population during repeat procedures.

METHODS AND RESULTS

In the YETI registry, a total of 17 356 patients underwent CB-based PVI in 33 centres, and 731 (4.2%) patients experienced PNI. A total of 111/731 (15.2%) patients received a repeat procedure for treatment of recurrent AF. In 94/111 (84.7%) patients data on repeat procedures were available. A total of 89/94 (94.7%) index pulmonary veins (PVs) have been isolated during the initial PVI. During repeat procedures, 22 (24.7%) of initially isolated index PVs showed reconnection. The use of a double stop technique did non influence the PV reconnection rate (P = 0.464). The time to PNI was 140.5 ± 45.1 s in patients with persistent PVI and 133.5 ± 53.8 s in patients with reconnection (P = 0.559). No differences were noted between the two populations in terms of CB temperature at the time of PNI (P = 0.362). The only parameter associated with isolation durability was CB temperature after 30 s of freezing. The PV reconnection did not influence the time to AF recurrence.

CONCLUSION

In patients with cryoballon application abortion due to PNI, a high rate of persistent PVI rate was found at repeat procedures. Our data may help to identify the optimal dosing protocol in CB-based PVI procedures.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT03645577?term=YETI&cntry=DE&draw=2&rank=1 ClinicalTrials.gov Identifier: NCT03645577.

Diagnostic yield of an insertable cardiac monitor in a large patient population

Background

Insertable cardiac monitors (ICMs) are increasingly used for cardiac rhythm diagnosis with expanding indications. Little has been reported about their use and efficacy.

Objective

The study sought to evaluate the clinical utility of a novel ICM (Biotronik BIOMONITOR III) including the time to diagnosis in unselected patients with different ICM indications.

Methods

Patients from 2 prospective clinical studies were included to determine the diagnostic yield of the ICM. The primary endpoint was time to clinical diagnosis per implant indication or to the first change in atrial fibrillation (AF) therapy.

Results

A total of 632 patients were included with a mean follow-up of 233 ± 168 days. Of 384 patients with (pre)syncope, 34.2% had a diagnosis at 1 year. The most frequent therapy was permanent pacemaker implantation. Of 133 patients with cryptogenic stroke, 16.6% had an AF diagnosis at 1 year, resulting in oral anticoagulation. Of 49 patients with an indication for AF monitoring, 41.0% had a relevant change in AF therapy based on ICM data at 1 year. Of 66 patients with other indications, 35.4% received a rhythm diagnosis at 1 year. Moreover, 6.5% of the cohort had additional diagnoses: 26 of 384 patients with syncope, 8 of 133 patients with cryptogenic stroke, and 7 of 49 patients with AF monitoring.

Conclusion

In a large unselected patient population with heterogeneous ICM indications, the primary endpoint of rhythm diagnosis was achieved in ∼1 in 4, and additional clinically relevant findings was achieved in 6.5% of patients at short-term follow-up.

Electrocardiographic changes after TAVR and their clinical impact according to new ESC Pacing Guidelines

 

Conduction disturbances after transcatheter aortic valve replacement (TAVR) remain one of the most frequent complications.

The aim of this study was to analyze ECG changes after TAVR using contemporary valves and to detect risk factors for the need of further clinical evaluation according to new ESC pacing guidelines to evaluate pacemaker implantation.

In this retrospective analysis we included 850 patients (mean age 80±9 years, 51% female), who underwent TAVR in our institution from January 2019 until December 2020. A mean follow-up of 8.9±8.4 months and 217 (25.5%) patients was performed.

55% of the implanted valves were self-expandable, 45% balloon-expandable. After TAVR, 77 (9.1%) patients developed new LBBB and QRS &gt;150ms, 26 (3.1%) new PR-time &gt;240ms. Prolongation of PR-time and prolongation of QRS duration &gt;20ms were seen in 20 (2.4%) and 90 (10.6%) patients with preexisting conduction disturbances. 152 (17.9%) patients needed pacemaker implantation post TAVR.

Developing a PR-prolongation of &gt;20ms was associated with calcification of the annulus (OR 1.2 CI 95% 1.004–1.4; p=0.04). New LBBB (OR 0.45; CI 95% 0.25–0.79; p=0.006) and pacemaker implantation (OR 0.4; CI 95% 0.2–0.8; p=0.009) were correlated with the implantation of a self-expandable valve. Coronary heart disease (OR 3, CI 95% 1.07–8.2; p=0.04) and peripheral arterial disease (OR 2.6 CI 95% 1.18–5.6; p=0.02) were associated with prolongation of QRS &gt;20ms. New LBBB with QRS &gt;150ms was seen more often after post-dilatation (OR 1.03, CI 95% 1.01–1.05; p=0.05). Pre-existing AV block I° (OR 2.8, CI 95% 1.4–5.6; p&lt;0.001), pre-existing RBBB (OR 20.5, CI 95% 7.5–56; p&lt;0.001), nicotine abuse (OR 2, CI 95% 1.05–3.8; p=0.04), prosthesis oversizing (OR 1.06, CI 95% 1.006–1.11; p=0.03) and implantation depth (OR 1.13, CI 95% 1.006–1.26; p=0.04) were independent risk factors for pacemaker implantation.

During the follow-up 161 patients (18.9%) were hospitalized in 270 inpatient stays [cardiac decompensation (n=36, 13%), pacemaker implantation (n=9, 3.3%), acute coronary syndrome (n=12, 4.4%)]. 8 patients (80%) received a pacemaker implantation because of AV Block III° and 1 (10%) patient because of sick-sinus-syndrome (SSS). Analyzing the post TAVR ECG 5 (50%) had a new LBBB (3 (30%) with QRS &gt;150ms) and 4 (40%) patients showed LBBB together with AV Block I°.

According to new guidelines 213 (25.1%) patients would have needed further clinical evaluation (EP study or ECG monitoring) after TAVR. AV-conduction abnormalities were associated with annulus calcification. Self-expandable valves were associated with new LBBB and pacemaker implantation. There seems to be a correlation between arteriosclerotic diseases and QRS width post TAVR. Pre-existing RBBB, AV block I°, implantation depth and prosthesis oversizing are important risk factors for pacemaker implantation post TAVR. New LBBB after TAVR is associated with a higher risk for pacemaker implantation in the long-term analysis.

Funding Acknowledgement

Type of funding sources: None.

Phrenic Nerve Injury During Cryoballoon-Based Pulmonary Vein Isolation: Results of the Worldwide YETI Registry

Supplemental Digital Content is available in the text.

Background:

Cryoballoon-based pulmonary vein isolation (PVI) has emerged as an effective treatment for atrial fibrillation. The most frequent complication during cryoballoon-based PVI is phrenic nerve injury (PNI). However, data on PNI are scarce.

Methods:

The YETI registry is a retrospective, multicenter, and multinational registry evaluating the incidence, characteristics, prognostic factors for PNI recovery and follow-up data of patients with PNI during cryoballoon-based PVI. Experienced electrophysiological centers were invited to participate. All patients with PNI during CB2 or third (CB3) and fourth-generation cryoballoon (CB4)-based PVI were eligible.

Results:

A total of 17 356 patients underwent cryoballoon-based PVI in 33 centers from 10 countries. A total of 731 (4.2%) patients experienced PNI. The mean time to PNI was 127.7±50.4 seconds, and the mean temperature at the time of PNI was −49±8°C. At the end of the procedure, PNI recovered in 394/731 patients (53.9%). Recovery of PNI at 12 months of follow-up was found in 97.0% of patients (682/703, with 28 patients lost to follow-up). A total of 16/703 (2.3%) reported symptomatic PNI. Only 0.06% of the overall population showed symptomatic and permanent PNI. Prognostic factors improving PNI recovery are immediate stop at PNI by double-stop technique and utilization of a bonus-freeze protocol. Age, cryoballoon temperature at PNI, and compound motor action potential amplitude loss >30% were identified as factors decreasing PNI recovery. Based on these parameters, a score was calculated. The YETI score has a numerical value that will directly represent the probability of a specific patient of recovering from PNI within 12 months.

Conclusions:

The incidence of PNI during cryoballoon-based PVI was 4.2%. Overall 97% of PNI recovered within 12 months. Symptomatic and permanent PNI is exceedingly rare in patients after cryoballoon-based PVI. The YETI score estimates the prognosis after iatrogenic cryoballoon-derived PNI.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03645577.

Graphic Abstract:

A graphic abstract is available for this article.

Results from a real-time dosimetry study during left atrial ablations performed with ultra-low dose radiation settings

Background

Three-dimensional mapping systems and the use of ultra-low dose radiation protocols have supported minimization of radiation dose during left atrial ablation procedures. By using optimal shielding, scattered radiation reaching the operator can be further reduced. This prospective study was designed to determine the remaining operator radiation exposure during left atrial catheter ablations using real-time dosimetry.

Methods

Radiation dose was recorded using real-time digital dosimetry badges outside the lead apron during 201 consecutive left atrial fibrillation ablation procedures. All procedures were performed using the same X‑ray system (Siemens Healthineers Artis dBc; Siemens Healthcare AG, Erlangen, Germany) programmed with ultra-low dose radiation settings including a low frame rate (two frames per second), maximum copper filtration, and an optimized detector dose. To reduce scattered radiation to the operators, table-suspended lead curtains, ceiling-suspended leaded plastic shields, and radiation-absorbing shields on the patient were positioned in an overlapping configuration.

Results

The 201 procedures included 139 (69%) pulmonary vein isolations (PVI) (20 cryoballoon ablations, 119 radiofrequency ablations, with 35 cases receiving additional ablation of the cavotricuspid isthmus) and 62 (31%) PVI plus further left atrial substrate ablation.

Mean radiation dose measured as dose area product for all procedures was 128.09 ± 187.87 cGy ∙ cm² with a mean fluoroscopy duration of 9.4 ± 8.7 min. Real-time dosimetry showed very low average operator doses of 0.52 ± 0.10 µSv. A subanalysis of 51 (25%) procedures showed that the radiation burden for the operator was highest during pulmonary vein angiography.

Conclusion

The use of ultra-low dose radiation protocols in combination with optimized shielding results in extremely low scattered radiation reaching the operator.

Benefit of a wearable cardioverter defibrillator for detection and therapy of arrhythmias in patients with myocarditis

Aims

Myocarditis may lead to malignant arrhythmias and sudden cardiac death. As of today, there are no reliable predictors to identify individuals at risk for these catastrophic events. The aim of this study was to evaluate if a wearable cardioverter defibrillator (WCD) may detect and treat such arrhythmias adequately in the peracute setting of myocarditis.

Methods and results

In this observational, retrospective, single centre study, we reviewed patients presenting to the Charité Hospital from 2009 to 2017, who were provided with a WCD for the diagnosis of myocarditis with reduced ejection fraction (<50%) and/or arrhythmias. Amongst 259 patients receiving a WCD, 59 patients (23%) were diagnosed with myocarditis by histology. The mean age was 46 ± 14 years, and 11 patients were women (19%). The mean WCD wearing time was 86 ± 63 days, and the mean daily use was 20 ± 5 h. During that time, two patients (3%) had episodes of sustained ventricular tachycardia (VT; four total) corresponding to a rate of 28 sustained VT episodes per 100 patient‐years. Consequently, one of these patients underwent rhythm stabilization through intravenous amiodarone, while the other patient received an implantable cardioverter defibrillator. Two patients (3.4%) were found to have non‐sustained VT.

Conclusions

Using a WCD after acute myocarditis led to the detection of sustained VT in 2/59 patients (3%). While a WCD may prevent sudden cardiac death after myocarditis, our data suggest that WCD may have impact on clinical management through monitoring and arrhythmia detection.

Cardiac arrhythmias in patients with COVID-19: Lessons from 2300 telemetric monitoring days on the intensive care unit

BACKGROUND

Patients with COVID-19 seem to be prone to the development of arrhythmias. The objective of this trial was to determine the characteristics, clinical significance and therapeutic consequences of these arrhythmias in COVID-19 patients requiring intensive care unit (ICU) treatment.

METHODS AND RESULTS

A total of 113 consecutive patients (mean age 64.1 ± 14.3 years, 30 (26.5%) female) with positive PCR testing for SARS-CoV2 as well as radiographically confirmed pulmonary involvement admitted to the ICU from March to May 2020 were included and observed for a cumulative time of 2321 days. Fifty episodes of sustained atrial tachycardias, five episodes of sustained ventricular arrhythmias and thirty bradycardic events were documented. Sustained new onset atrial arrhythmias were associated with hemodynamic deterioration in 13 cases (35.1%). Patients with new onset atrial arrhythmias were older, showed higher levels of Hs-Troponin and NT-proBNP, and a more severe course of disease. The 5 ventricular arrhythmias (two ventricular tachycardias, two episodes of ventricular fibrillation, and one torsade de pointes tachycardia) were observed in 4 patients. All episodes could be terminated by immediate defibrillation/cardioversion. Five bradycardic events were associated with hemodynamic deterioration. Precipitating factors could be identified in 19 of 30 episodes (63.3%), no patient required cardiac pacing. Baseline characteristics were not significantly different between patients with or without bradycardic events.

CONCLUSION

Relevant arrhythmias are common in severely ill ICU patients with COVID-19. They are associated with worse courses of disease and require specific treatment. This makes daily close monitoring of telemetric data mandatory in this patient group.

The use of a high-power (50 W), ablation index-guided protocol for ablation of the cavotricuspid isthmus

BACKGROUND

High-power (HP) ablation protocols are increasingly used for ablation procedures to shorten procedural times and improve short- and long-term success. The ablation index (AI) combines contact force, power settings, and ablation time. It can be used in combination with HP protocols to guide operators toward standardized lesions. The purpose of this study was to evaluate both a HP and AI-guided strategy for ablation of the cavotricuspid isthmus (CTI) in patients with typical atrial flutter (AFL).

METHODS

In this single-center study, consecutive patients with typical AFL (n = 52, mean age 68.7 ± 8.3 years, 21/52 [40.4%] female) underwent AI-guided HP radiofrequency (RF) ablation of the CTI. Ablation was performed with 50 W and AI target values of 550 with a maximum ablation duration of 25 seconds per lesion. Target interlesion distance was ≤6 mm. Ablation was performed with a 3.5 mm porous tip Smarttouch SF catheter.

RESULTS

Acute CTI block was achieved in 52 of 52 patients (100%), and first-pass conduction block was achieved in 41 of 52 patients (80.4%). Spontaneous reconduction after 30 minutes waiting time occurred in 1 of 52 (1.9%) patient. Average ablation time until CTI block was 3:51 ± 1:40; 2:33 ± 1:01 minutes of bonus ablation pulses were applied after CTI block. An audible steam pop was noted in one patient (1.9%). No major complications occurred. After a mean follow-up of 193.7 ± 152.2 days, no patient showed recurrence of typical AFL.

CONCLUSION

In this pilot study, AI-guided HP ablation of the CTI was fast, safe, and effective.

Reduction of mapping time in pulmonary vein isolation using atrial pacing during left atrial voltage map acquisition

INTRODUCTION

3D mapping systems are used during radiofrequency (RF) pulmonary vein isolation (PVI) to facilitate catheter navigation and to provide additional electroanatomical information as a surrogate marker for the presence and location of fibrotic atrial myocardium. Electric voltage information can only be measured when the myocardium is depolarized. Low heart rates or frequent premature atrial beats can significantly prolong creation of detailed left atrial voltage maps. This study was designed to evaluate the potential advantage of voltage information collection during atrial pacing instead of acquisition during sinus rhythm.

METHODS AND RESULTS

A total of 40 patients were included in the study, in 20 consecutive patients voltage mapping was performed during sinus rhythm, and in the following 20 patients during atrial pacing. The average age of the included patients was 69.5 ± 9.4, 17 of 40 patients (43%) were male. All procedures were performed using the Carto 3D Mapping system. For LA voltage mapping, a multipolar circular mapping catheter was used. The atrium was paced via the proximal coronary sinus catheter electrodes with a fixed cycle length of 600 ms. By mapping during atrial pacing mapping time was reduced by 35% (441 s. (±141) vs. 683 s. (±203) p = 0.029) while a higher number of total mapping points were acquired (908 ± 560 vs. 581 ± 150, p = 0.008).

CONCLUSION

Acquiring left atrial low voltage maps during atrial pacing significantly reduces mapping time. As pacing also improves comparability of left atrial electroanatomical maps we suggest that this approach may be considered as a standard during these procedures.

[Update on radiation exposure in catheter ablation of atrial fibrillation]

The rising number of catheter ablations of atrial fibrillation increases radiation exposure for both patients and surgeons. Fortunately, this trend is counteracted by the development of measures to reduce total fluoroscopy time using non-fluoroscopic catheter visualization. Since even low-dose radiation can cause serious injury, all options to reduce radiation burden must be utilized (ALARA, "as low as reasonably achievable"). Dose reduction protocols with low-dose settings, which include reduced framerates, pulse duration, detector entrance dose and increased beam hardening, play a decisive role in this regard. This review provides a state-of-the-art summary of non-fluoroscopic catheter visualization and dose reduction protocols for catheter ablation of atrial fibrillation.

Early NT-proBNP and MR-proANP associated with QoL 1 year after acutely decompensated heart failure: secondary analysis from the MOLITOR trial

Aim: Heart failure negatively impacts quality of life (QoL), which in turn contributes to an adverse long-term prognosis. We aimed at identifying biomarker trajectories after an episode of acutely decompensated heart failure (ADHF) that differ between patients showing average versus impaired QoL 1 year later, thus allowing to predict impaired QoL. Methods: Biomarkers were repeatedly measured throughout the year in 104 ADHF patients. QoL was assessed at discharge and 1 year after ADHF. Logistic regression and receiver operating characteristic analyses were used to identify predictors of impaired QoL while controlling psychosocial confounders. Results: MR-proANP predicted impaired physical and mental QoL. NT-proBNP measurements were important predictors for poor physical QoL. Conclusion: MR-proANP and NT-proBNP predict poor QoL after an epidode of ADHF. The trial is registered at http://clinicaltrials.gov as MOLITOR (IMpact of therapy optimisation On the Level of biomarkers in paTients with Acute and Decompensated ChrOnic HeaRt Failure) with unique identifier: NCT01501981.

Correlation of P-wave properties with the size of left atrial low voltage areas in patients with atrial fibrillation

BACKGROUND

Left atrial low voltage areas (LVA) are associated with increased recurrence rates of atrial fibrillation (AF) after catheter ablation and can be a potential ablation target during the procedure. Therefore, noninvasive prediction of the presence and the distribution of LVA may help physicians to predict ablation outcomes and to guide antiarrhythmic management.

MATERIAL AND METHODS

Seventy-three consecutive patients with atrial fibrillation undergoing first time left atrial ablation for paroxysmal or persistent AF were enrolled. P-wave properties (amplitude and duration) were measured in all limb and precordial leads in pre-interventional sinus rhythm surface ECGs and correlated with total LVA size. LVA were detected via high density low voltage maps of the left atrium in sinus rhythm. LVA were then manually encircled, their total size was calculated and given as a percentage of the total LA surface area.

RESULTS

A significant, inverse correlation with LVA size was shown for P-wave amplitude for leads I, II, aVR, aVF, V1, V4, V5 and V6. Additionally, a significant positive correlation between LVA size and P-wave duration was shown for leads V1, V2 and V3. As the strongest correlation was shown for the amplitude in lead I (R = -0.578), this lead was used to find a potential cutoff for LVA prediction. The best cut-off for a P-wave amplitude in lead I to predict severe scarring (defined as LVA size >35%, according to UTAH stadium IV) was 0.062 mV with an area-under-the receiver-operating-characteristic curve of 0.935, a sensitivity of 85% and a specificity of 88%.

CONCLUSIONS

P-wave duration and amplitude show significant correlations with LVA size and may be used as a noninvasive tool to predict severe scarring. Amplitudes in lead I smaller than 0.062 mV were found to be predictive of LVA >35%.

Velocity characteristics of atrial fibrillation sources determined by electrographic flow mapping before and after catheter ablation

BACKGROUND

Electrographic-Flow-(EGF)-Mapping is a novel method to identify Atrial Fibrillation (AF) drivers. Sources of excitation during AF can be characterized and monitored.

OBJECTIVE

The aim of this study was to evaluate the correlation between velocity of EGF around a respective AF source and its spatial variability (SV) and stability (SST).

METHODS

25 patients with AF were included in this study (persistent: n = 24, long-standing persistent: n = 1; mean age 70 ± 8.3 years, male: n = 17). Focal impulse and Rotor-Mapping (FIRM) was performed in addition to pulmonary vein isolation. One-minute epochs of unipolar electrograms recorded via a 64-pole basket catheter in both atria were re-analyzed with EGF-Mapping. SST was calculated as the percentage of time in which a source was detected.

RESULTS

AF sources identified with EGF-Mapping show a wide range of SV during 1 min covering between 0.12% and 38% of the recorded basket-catheter surface. The 12 atria where the sources showed highest temporal stability (TS; between 34% and 97% of 1 min recorded) and those 12 with the lowest TS (between 11 and 20%) differed significantly in their velocities (17.8 el/s vs 12.2 el/s; p < 0.01). In 11 atria ablation caused an average decrease of TS by 47% and of velocity by 27% while SV more than doubled.

CONCLUSION

Less stable AF-sources with high spatial variability showed reduced excitation propagation velocity while stable AF sources displayed a high average velocity in their vicinity. Importantly, catheter ablation reduced stability of sources and velocity suggesting a role of these parameters in guidance of ablation.

CONDENSED ABSTRACT

Electrographic Flow (EGF)-Mapping is a novel method to identify Atrial Fibrillation (AF) drivers based on modeling of an electrical potential surface and subsequent flow analysis. Sources of excitation during AF can be characterized and monitored. The aim of this study was to evaluate the correlation between velocity of EGF around a respective AF source and its spatial variability and stability. Less stable AF sources with high spatial variability showed reduced excitation propagation velocity while very stable AF sources displayed a high average velocity in their vicinity. Catheter ablation reduced stability of sources and velocity.

Cryoballoon ablation in the elderly: one year outcome and safety of the second-generation 28mm cryoballoon in patients over 75 years old

Aims

The efficacy of the second-generation cryoballoon (CB) ablation in patients with atrial fibrillation (AF) has been demonstrated previously. Data on the efficacy of CB ablation in elderly patients is missing. The aim of this study was to evaluate the long-term success rate of pulmonary vein isolation (PVI) in patients ≥75 years vs. <75 years using the second-generation 28mm CB.

Methods and results

Eighty patients [n = 40 ≥75 years (Group 1); n = 40 <75 years (Group 2)] with paroxysmal [n = 37 (46%) or persistent (n = 43 (54%)] AF were included. Median follow-up was 12 [6;18] months (Group 1 vs. 13 [6;27]) months (Group 2; P = 0.8). PVI was performed in all patients using cryoablation. Follow-up was obtained using 24h-Holter monitoring or via an implanted loop recorder or pacemaker. CHA2DS2VASc-Score (Group 1: 4 [4;5] vs. Group 2: 2 [1;3], P < 0.001) and HASBLED-Score (Group 1: 2 [2;3] and Group 2: 2 [1;3], (P = 0.009)) differed significantly between the two groups. Mean fluoroscopy time was 22.9 [16.3;31.9] in Group 1 and 24.5 [19.1;30.6] in Group 2 (P = 0.75), and mean procedure time was 125 min [105;151] in Group 1 and 130.5 min [117.5;147.3] in Group 2 (P = 0.66). Arrhythmia recurrence was similar in Group 1 and Group 2 (12/40 (30%) vs. 10/40 (25%) (P = 0.62). One transient ischaemic attack occurred in Group 2. No further major complications were documented in this patients cohort.

Conclusion

CB ablation in patients ≥75 years has favourable success rates and similar complication rates compared with patients <75 years.

Left atrial appendage angiography is associated with the incidence and number of magnetic resonance imaging-detected brain lesions after percutaneous catheter-based left atrial appendage closure

BACKGROUND

Percutaneous catheter-based left atrial appendage closure (LAAC) is a procedure being increasingly performed in patients with atrial fibrillation and high bleeding risk.

OBJECTIVE

The purpose of this study was to evaluate the incidence of magnetic resonance imaging (MRI)-detected acute brain lesions (ABLs) as well as potential changes in neurocognitive function after percutaneous LAAC in patients with atrial fibrillation.

METHODS

Brain MRI at 3 T was performed within 24 hours before and after LAAC along with neurologic (National Institutes of Health Stroke Scale [NIHSS] score) and cognitive (Montreal Cognitive Assessment [MoCA] test) assessment. Acquired MRI sequences included high-resolution diffusion-weighted imaging as well as fluid-attenuated inversion recovery.

RESULTS

Successful device implantation was achieved in all 23 patients (age 74.1 ± 10.5 years; 16 male) using the Amulet (n = 18), Occlutech (n = 3), or LAmbre (n = 2) device. Thirty-seven ABLs were detected by MRI in 12 of 23 patients (52%) after LAAC. The number of periprocedural LAA angiographies was significantly higher in patients with ABL than in those without ABL (1.67 ± 0.65 vs 1.18 ± 0.41; P = .048) and was associated with a higher number of ABL (ρ = 0.615; P = .033). Compared to pre-LAAC assessment, post-LAAC MoCA and NIHSS scores revealed similar results. After LAAC, MoCA test (mean 24.1 ± 4.6 vs 23.2 ± 4.6; P = .09) and NIHSS score (mean 1.0 ± 1.7 vs 1.2 ± 1.8; P = .1) were similar between patients with and those without ABL, respectively.

CONCLUSION

MRI-detected ABLs are commonly observed after percutaneous LAAC. The number of LAA angiographies is significantly associated with the number of ABLs; however, the clinical implications of ABL have yet to be determined.

Long-term follow up of 3 T MRI-detected brain lesions after percutaneous catheter-based left atrial appendage closure

BACKGROUND

Left atrial appendage closure (LAAC) for stroke prevention is an increasingly performed intervention.

AIMS

This prospective study aims to evaluate the incidence of long-term magnetic resonance imaging (MRI)-detected brain lesions as well as potential changes of neurocognitive function after percutaneous LAAC.

METHODS

Brain MRI at 3 T was performed within 24 hr before and after LAAC. A follow-up MRI was carried out after three months. Neuro-cognitive examination using the National Institutes of Health Stroke Scale (NIHSS) score and the Montreal Cognitive Assessment (MoCA) Test was performed.

RESULTS

Successful device implantation was achieved in all 25 patients (age 74.6 ± 10.2 years, male = 17) using the Amulet (n = 20), Occlutech (n = 3), or a Lambre (n = 2) device. In 12/25 (48%) patients, acute brain lesions (ABL) were detected after LAAC. A three-month follow-up MRI was performed in seven patients, and no new ABLs were seen. In 5/7 (71%) patients, there were no residual changes from the ABLs detectable. However, the FLAIR sequence was still positive in two patients. After LAAC, there were no significant differences in the MoCA-test (mean 24.3 ± 4.5 vs. 23.5 ± 4.5; P = 0.1) and the NIHSS-score (mean 0.9 ± 1.6 vs. 1.2 ± 1.8; P = 0.1). This was the same at the three-month follow-up (MoCA-test 23.5 ± 4.5 vs. 23.8 ± 2.7; P = 0.3; NIHSS-score 1.2 ± 1.8 vs. 1.0 ± 0.8; P = 0.4).

CONCLUSION

While new MRI-detected brain lesions are commonly observed after percutaneous LAAC, ABLs were no longer detectable in 71% of the patients at the three-month follow-up. There were no significant changes in neurocognitive function after LAAC and at the three-month follow-up.

Prognostic performance of serial in-hospital measurements of copeptin and multiple novel biomarkers among patients with worsening heart failure: results from the MOLITOR study

Aims

In heart failure, various biomarkers are established for diagnosis and risk stratification; however, little is known about the relevance of serial measurements during an episode worsening heart failure (WHF). This study sought to investigate the trajectory of natriuretic peptides and multiple novel biomarkers during hospitalization for WHF and to determine the best time point to predict outcome.

Methods and results

MOLITOR (Impact of Therapy Optimisation on the Level of Biomarkers in Patients with Acute and Decompensated Chronic Heart Failure) was an eight‐centre prospective study of 164 patients hospitalized with a primary diagnosis of WHF. C‐terminal fragment of pre‐pro‐vasopressin (copeptin), N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP), mid‐regional pro‐atrial natriuretic peptide (MR‐proANP), mid‐regional pro‐adrenomedullin (MR‐proADM), and C‐terminal pro‐endothelin‐1 (CT‐proET1) were measured on admission, after 24, 48, and 72 h, and every 72 h thereafter, at discharge and follow‐up visits. Their performance to predict all‐cause mortality and rehospitalization at 90 days was compared. All biomarkers decreased during recompensation (P < 0.05) except MR‐proADM. Copeptin at admission was the best predictor of 90 day mortality or rehospitalization (χ² = 16.63, C‐index = 0.724, P < 0.001), followed by NT‐proBNP (χ² = 10.53, C‐index = 0.646, P = 0.001), MR‐proADM (χ² = 9.29, C‐index = 0.686, P = 0.002), MR‐proANP (χ² = 8.75, C‐index = 0.631, P = 0.003), and CT‐proET1 (χ² = 6.60, C‐index = 0.64, P = 0.010). Re‐measurement of copeptin at 72 h and of NT‐proBNP at 48 h increased prognostic value (χ² = 23.48, C‐index = 0.718, P = 0.00001; χ² = 14.23, C‐index = 0.650, P = 0.00081, respectively).

Conclusions

This largest sample of serial measurements of multiple biomarkers in WHF found copeptin at admission with re‐measurement at 72 h to be the best predictor of 90 day mortality and rehospitalization.

Apixaban, rivaroxaban, and dabigatran use in patients undergoing catheter ablation for atrial fibrillation using the second-generation cryoballoon

BACKGROUND

Data are limited on the safety of periprocedural anticoagulation with novel oral anticoagulants (NOACs) in patients undergoing pulmonary vein isolation (PVI) using the second-generation cryoballoon (CB) for the treatment of atrial fibrillation.

HYPOTHESIS

We hypothesized that the incidence of acute periprocedural complications in patients undergoing PVI do not differ between patients treated with VKA compared to NOACs.

METHODS

In 200 consecutive patients (mean age, 64.3 _ 10.6 years; female, n = 83) with symptomatic atrial fibrillation, PVI using the second-generation 28-mm CB was performed. In patients treated with NOACs, the medication was stopped the day of the procedure and continued the evening after the procedure with a reduced dosage. Patients treated with phenprocoumon were continued on uninterrupted phenprocoumon with a target INR of 2 to 3. If INR was <2, bridging with low-molecular-weight heparin was performed.

RESULTS

Forty-seven of 200 patients (23.5%) were treated with a vitamin K antagonist (VKA) and 55 (27.5%) were treated with apixaban, 67 (33.5%) with rivaroxaban, and 31 (15.5%) with dabigatran. Seven (3.5%) major complications occurred in the overall population. Major bleeding complications did not differ significantly between the 2 groups (P = 0.23). One patient taking VKA had a pericardial tamponade at the end of the procedure; 2 patients treated with apixaban developed a groin hematoma requiring surgical intervention. Transient ischemic attack occurred in 1 patient of the apixaban and rivaroxaban group.

CONCLUSIONS

Apixaban, rivaroxaban, and dabigatran, compared with uninterrupted VKA, did not show a higher risk for major bleeding or ischemic complications in patients undergoing PVI using the second-generation CB.

[Recurrent microdislocation of pacemaker leads due to an aortic aneurysm of the aorta ascendens]

We report about a 79 years old female patient which was admitted due to a symptomatic AV block 3rd degree. The coronary angiography excluded a coronary artery disease and the echocardiography revealed a normal left ventricular systolic function. Therefore a dual-chamber pacemaker was implanted. Following two micro-dislocations of the right ventricular lead, which required operative revisions, a computed tomography of the heart was performed. This detected an aneurysm of the ascending aorta (5 cm maximum diameter) with compression of the superior caval vein. This case shows that a possible cause of recurrent micro-dislocations could be a pathological anatomy of the heart.

Validation of the FEW16 questionnaire for the assessment of physical well-being in patients with heart failure with reduced ejection fraction: results from the CIBIS-ELD study

Aims

Patients with heart failure (HF) commonly suffer from severe impairment of quality of life (QoL). One main goal of HF treatment is improvement of QoL. Physical well‐being is an essential component of QoL. To enable assessment of physical well‐being in HF patients, we validated the FEW16 questionnaire in a prospective study with patients from the Cardiac Insufficiency Bisoprolol Study in ELDerly.

Methods and results

In 127 HF patients (age 73 ± 5.5 years, 72% male, 60% New York Heart Association class II, left ventricular ejection fraction 37 ± 8.5%), we measured physical well‐being (FEW16), QoL [36‐Item Short‐Form Health Survey (SF36)], and depressive symptoms [PRIME MD Patient Health Questionnaire German short version for depression (PHQ‐D)] at baseline and two follow‐up visits, and correlated FEW16 scores with QoL data and clinical parameters. FEW16 mean scores are 3.04 ± 1.04 at baseline, 3.19 ± 0.94 after 3 months, and 2.77 ± 0.94 after 2–4 years. We assessed data quality, scale assumptions, and construct validity and reliability. Cronbach's alpha for subscales resilience: 0.84; ability to enjoy: 0.80; vitality: 0.88; inner peace: 0.87; total score: 0.95. Intraclass correlation coefficient (ICC) is 0.87 (95% CI 0.84–0.89, ICC (1.4). Pearson's correlations of FEW16 with SF36 and PHQ‐D were significant. Six minutes walking distance and heart rate correlated significantly with the FEW16 total score.

Conclusions

The FEW16 showed good reliability, internal consistency, and intraclass correlation. FEW16 scores correlated well with psychological and physical well‐being (SF36) and clinical markers of exercise tolerance (6 min walk test and heart rate). Our results indicate a strong correlation of self‐reported physical well‐being with psychological factors. FEW16 values at baseline predicted the development of several aspects of QoL during beta‐blocker up‐titration.

Should procalcitonin be measured routinely in acute decompensated heart failure?

Aim: To elucidate the prognostic role of procalcitonin (PCT) in patients with acute decompensated heart failure (ADHF) without clinical signs of infection at admission. Materials & Methods: Serial measurements of PCT and NT-proBNP were performed in 168 patients, aged 68 ± 10 years with ADHF followed by 3-month outcome evaluation. Results: Cox regression analysis demonstrated significant predictive value of baseline PCT for all-cause death/hospitalization (area under the curve: 0.67; p = 0.013) at 90th day. The patients with persistently elevated PCT or with an increase during the first 72 h of hospitalization had the worst prognosis (p = 0.0002). Conclusion: Baseline and serial in-hospital measurements of PCT have significant prognostic properties for 3-month all-cause mortality/hospitalization in patients with ADHF without clinical signs of infection at admission.

[Right ventricular outflow tract tachycardia 30 years after surgical correction of tetralogy of Fallot]

This case report describes a 31-year-old man with a sustained wide complex tachycardia with left bundle brunch block morphology after surgical repair of a tetralogy of Fallot. The tachycardia was inducible after orciprenaline administration after ventricular stimulation with one extra beat. In combination with the three-dimensional electroanatomic mapping system and pace mapping technique the origin of the tachycardia was identified at the lateral free wall of the right ventricular outflow tract tachycardia (RVOT) inferior of the pulmonary valve. Successful radiofrequency ablation was performed and the patient is still free from ventricular tachycardia.

[Cardiac resynchronisation with atrial sensing: Is it feasible?]

In this article the cases of two female patients with heart failure (functional class III) and an intrinsic complete left bundle branch block are reported. Both patients have had an implanted cardioverter defibrillator (ICD) connected to a VDD lead for primary prevention of sudden cardiac death. Atrial sensing was good/acceptable with a physiological frequency histogram and normal PQ time. A system upgrade to cardiac resynchronization therapy device (CRT) was planned. The VDD lead was directly connected to the Bivent ICD. The follow up showed stable measurements and a high biventricular pacing rate. Thus, usage of VDD leads for atrial sensing in CRT seems to be possible in a selected patient population.