Introduction: Catheter-based pulmonary vein isolation (PVI) is an established treatment option for atrial fibrillation (AF). Aim of this study was to quantify the extent of the ablation zone after wide area circumferential (WAC) PVI applying a novel high density mapping system (Rhythmia – Boston scientific). Methods: 20 consecutive pts underwent WAC-PVI for AF using the Rhythmia System in conjunction with the Orion mini-basket catheter, which was utilized to create a detailed 3-dimensional electroanatomic map of the LA and PVs during sinus rhythm, before and after the ablation procedure. Results: Mean pts age was 60 ± 4 years. 60 % had paroxysmal and 40% persistent AF. LA diameter was 45 ± 10 mm and LV ejection fraction was 55 ± 10%. PV anatomy was normal in all patients. A total of 9772 ± 3108 mapping points were taken for the initial map and 7910 ± 2344 points for the remap. Mapping time for the initial map was 19 ± 4.2 min and 10.8 ± 3.2 min for the remap. When comparing the initial voltage map with the remap after WAC – PVI, PVs and all PV antra, during remapping were isolated and displayed scar (<0.2mV), while the LA roof had scar in 10 out of 20 patients (50%), although intentionally no roof line was placed (Figure 1 showing left atrium voltage map performed before (A) and after ablation (B)). Posterior wall (PW) area during the initial map was 19,7 ± 3,5 cm2 and the ablated area at the PW during remapping was 7,8 ± 3,34 cm2 ( 40 ± 17%), although no additional lesions were intentionally placed. When the posterior wall was divided into four segments, there were no significant statistical differences regarding the location and extent of ablation zones at the PW after WAC-PVI (Table).
Introduction: Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging can be used to visualize regions of preexisting and ablation-induced scarring in the left atrium (LA) myocardium. The determination of preexisting fibrosis vs postablation scarring may be important for treatment stratification of patients with atrial fibrillation (AF) and affect future strategies for catheter ablation. This study aimed to define the characteristics of preexisting and ablation-induced LA wall LGE in patients who underwent pulmonary vein isolation (PVI) for AF. Methods: 20 patients underwent PVI for AF. LGE CMR was prospectively performed before and 3 months after catheter ablation. For every single ablation point, the intracardiac locations were projected onto an individual MRI-derived 3D LA shell. This allowed the LGE CMR signal intensities (SI) to be projected on to the LA anatomy from electroanatomical mapping. The image intensity ratio (IIR), defined as LA myocardial LGE CMR SI divided by the mean LA blood pool intensity, and LA myocardial wall thickness were calculated on pre- and postablation images. The ablation lesions could thus be directly analyzed as every vertex on the fused LA shell had an individual LGE label. Results: Data analysis was performed on a total of 894 ablation points and 346 pairs of pre- and postablation axial LGE CMR planes. A total number of 280250 vertices (11210/patient) were analyzed on the fused LA shells. Postablation LGE demonstrated a significant higher IIR as compared to preexisting LGE (1.40 +/- 0.21 vs 1.18 +/- 0.17 p = 0.001), indicating greater contrast uptake and denser scar. LA wall thickness was as well significantly reduced in postablation LGE regions (2.06 +/- 0.32mm vs 2.40 +/-0.44mm p = 0.001). Conclusion: CMR demonstrates that LA regions with postablation LGE have an increased contrast uptake and a thinner wall myocardium. This observation can assist in understanding LA remodeling processes and may allow a more informed assessment of the underlying atrial substrate.
Introduction: Catheter ablation is an established therapy for the treatment of symptomatic atrial fibrillation (AF). Current guidelines recommend catheter ablation for drug-refractory paroxysmal AF (PAF) in adults, and as first-line therapy in selected patients. However, long-term data on the efficacy and safety of catheter ablation for PAF in young adults is very limited. Methods: From 2005 to 2014, 52 consecutive young adults (32 men, 20 women) with symptomatic PAF underwent pulmonary vein isolation (PVI). The procedure end point was complete PVI (entrance block) verified by circular catheters placed within the PVs. Follow-up was based on regular outpatient clinic visits including 24h Holter-ECGs and telephone interviews at last follow-up. Recurrence was defined as any symptomatic and/or documented atrial tachyarrhythmia episode [30 s following a 3-month blanking period]. Results: Mean patient age at the time of the index procedure was 30 ± 4 years (range 19-35). Complete PVI by either radiofrequency current guided by 3-dimensional mapping (n = 50) or cryoballoon (n = 2) was achieved in 51/52 patients (98%). Six patients were lost to follow-up. During a mean follow-up period of 4.9 years (range 1.0-9.7 years) stable sinus rhythm was achieved in 65% after a single procedure, and in 83% after multiple procedures (mean 1.5; range 1-3). Success rate at last follow-up off anti-arrhythmic drugs was 74%. Eight patients (17%; 3 with stable sinus rhythm) were taking antiarrhythmic drugs (AAD; only class I) at last follow-up compared to 26 patients (57%, p < 0.01) before the index procedure. A second procedure was performed in 19, and a third procedure in 2 patients. PV reconduction was observed in 16 patients (84%) during the second, and in 1 patient (50%) during the third procedure. EHRA score significantly improved at last follow-up (mean 3.2 to 1.2, p < 0.001). Major periprocedural complications occurred in 3 patients (tamponade in 1, PV stenosis in 2). No patient progressed towards persistent AF. Conclusions: In the majority of very young adults ≤35 years of age, catheter ablation for PAF is effective during long-term follow-up and associated with a low complication rate. These findings support the concept of PVI in very young adults with symptomatic PAF.
The telemonitoring of heart failure (HF) patients is becoming increasingly important. This study aimed to evaluate the benefit of telemonitoring in end-stage HF patients with a ventricular-assistance device (VAD). A total of 26 HF-patients (66 ± 11 years, 88% male) on VAD therapy with an implantable cardioverter-defibrillator (ICD) or a cardiac resynchronization defibrillator (CRT-D) including telemonitoring function were enrolled. The long-term follow-up data (4.10 ± 2.58 years) were assessed. All the patients (n = 26, 100%) received daily ICD/CRT-D telemonitoring. In most of the patients (73%, n = 19), the telemedical center had to take action for a mean of three times. An acute alert due to sustained ventricular arrhythmias (VAs) occurred in 12 patients (63%) with 50% of them (n = 6) requiring ICD shock delivery. Eight patients (67%) were hospitalized due to symptomatic VAs. In 11 patients (92%), immediate medication adjustments were recommended. Relevant lead issues were revealed in thirteen patients (50%), with six patients (46%) undergoing consecutive lead revisions. Most of the events (83%) were detected within 24 h. Daily telemonitoring significantly reduced the number of in-hospital device controls by 44% (p < 0.01). The telemonitoring ensured that cardiac arrhythmias and device/lead problems were identified early, allowing pre-emptive and prompt interventions. In addition, the telemonitoring significantly reduced the number of in-hospital device controls in this cohort of HF patients.
Proton pump inhibitors (PPI), e.g. pantoprazole (PP), esomeprazole (EP) and omeprazole (OP), work as anti-ulcer/gastrointestinal reflux drugs. Also, they are widely used in postoperative care of patients in cardiac surgery to prevent upper gastrointestinal bleeding. Therefore, in western industrial countries they play a major economic role, representing one of the most important drugs in open heart cardiac surgery.Intact muscle strips (n=32) were isolated from the right ventricle wall of failing human hearts. In four different groups (PP, EP, OP, control group, each n=8), force amplitudes were recorded at a frequency of 60 beats per minute (bpm) with increasing PPI concentrations (0 to 320 µm/mL).In isometrically contracting muscle strips, significant negative inotropic effects were observed in the presence of all three PPI-groups (PP, EP and OP) with doses of 2.5 µg/mL and higher compared to the control group (p < 0.05 each). With high doses (320 µm/mL), force amplitudes could be almost completely depressed. The half maximal inhibitory concentration (IC50) for EP was 35.7 (confidence interval: 17.3-73.6) vs. OP 29.3 (6.8-126.6) vs. PP 25.1 (14.6-43.1) µg/mL (n.s.). No significant differences were found between the different proton pump inhibitors (PP, EP, OP) throughout the range of all concentrations. Relaxation was impaired in all PPI subgroups with prolonged time to 90% relaxation (RT90%) and maximum relaxation velocity (‑df/dt) was reduced, too. These effects were partially reversible after wash-out of the drugs.We conclude that proton pump inhibitors show significant negative inotropic effects on isolated human failing myocardium. There is no apparent difference seen in the magnitude of the effects of each PPI-group. Further, in-vivo investigations are necessary to reveal the clinical evidence of PPI's negative inotropic effects, e.g. in cardio-surgical patients with heart failure.
Only limited comparative data exist on the benefits of fluid monitoring (FM) combined with remote monitoring (RM) regarding morbidity and mortality of heart failure (HF) patients. This prospective single-centre randomized pilot study aimed to estimate the influence of RM in combination with FM on HF hospitalizations as well as ventricular tachyarrhythmias and mortality.Patients with standard indication for implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy and defibrillator were implanted with devices capable of RM and FM, and were followed for 15 months. Subjects were randomly allocated to RM including OptiVol and predefined management of alerts (remote group), or standard in-office visits every 3 months (control group). A total of 176 patients (77% male; 66 ± 12 years; left ventricular ejection fraction (LVEF) 32 ± 11%; ischemic cardiomyopathy 50%; CRT device 50%; primary prevention 85%) were analysed. Cox proportional hazard analysis on the time to first HF-related hospitalization showed a hazard ratio of 1.23 [0.62-2.44] (P = 0.551) favouring the control group. In the remote group, 13 patients (15%) experienced ICD shocks vs. 10 patients (11%) in the control group (P = 0.512). The average time to first ICD shock was 212 ± 173 days in the remote arm and 212 ± 143 days in the control arm (P = 0.994). The Kaplan-Meier estimate of mortality after 1 year was 8.6% (eight deaths) in the remote group vs. 4.6% in the control group (six deaths; P = 0.502).In a single-centre randomized pilot study of RM in combination with FM, no significant influence on HF-related hospitalizations, ICD shocks, or mortality was found.
