Dieser Fall einer 45-jährigen Patientin präsentierte sich während der ambulanten Vorsorgeuntersuchung mit einem symptomlosen retrouterinen Tumor. Vor 10 Jahren war per Laparoskopie bereits ein Dermoid entfernt worden. Nun wird die erneute Laparoskopie mithilfe eines Uterusmanipulators zur Entfernung des retrouterinen Tumors geplant. Es zeigt sich medial kaudal des rechten Ovars breitbasig eine längsovale gekapselte zystische Raumforderung mit einer Größe von 35 × 25 mm, diese ist nach lateral, ventral und kaudal mit dem Peritoneum verwachsen und zeigt eine Nähe zum rechten Harnleiter. Daher wird hier die Inzision im Peritoneum notwendig und das Ligamentum sacrouterinum wird bei seinem proximalem Anteil durch bipolare Koagulation durchtrennt. Es erfolgen die Separierung des Tumors vom Peritonealblatt und die Bergung desselben über den Endobag mithilfe eines Bauchdeckenspreizers. Die liegende Mirena-Spirale wurde durch den Uterusmanipulatur nicht disloziert.
Background: AF ablation with the first generation duty-cycled non-irrigated radiofrequency catheter is associated with an increased incidence of asymptomatic cerebral embolism (ACE).A second generation catheter was designed to avoid this complication.Purpose: To compare the incidence and clinical implications of ACE between the PVAC Gold catheter and an irrigated-tip catheter.Methods: Seventy pts (6169 years, 43 male, CHADS2-VASc score 1.661.2) with paroxysmal AF were 1:1 randomized to pulmonary vein isolation (PVI) with PVAC Gold TM or Thermocool (TC) catheter.Cerebral MRI with diffusion-weighted, Fluid Attenuated Inversion Recovery and T2-weighted Turbo Spin sequences was performed on the day before and after ablation and 3 months thereafter if a new lesion developed.Continuous oral anticoagulation (INR2) and intravenous heparinization (ACT350s) were used.The PVAC catheter was submerged before introduction.During ablation, monitoring for detection of microembolic signals (MES) was performed by Transcranial Doppler Ultrasonography.Changes in coagulant state were determined with Prothrombin Time, Activated Partial Thromboplastin Time, INR, Von Willebrand antigen and fibrinogen before, during and after ablation.Neuropsychological tests and questionnaires tapping cognition and mood were applied 10 days before and 3 months after ablation.Results: No differences in baseline patient characteristics were found between groups, with a mean INR of 2.760.5 and ACT of 374624.Procedural duration was shorter in the PVAC group (140634 vs. 207644 min, p<0.001).The total amount and duration of MES was higher in the PVAC group 153861179 vs 8616557 (p¼0.005) and 66648 vs 45626s (p¼0.036).Seven pts (20%) in the PVAC group showed areas of restricted diffusion as an acute manifestation of ACE, compared to none of the pts in the TC group (p¼0.011).In 3 pts, the ACE remained detectable as a silent lesion on repeated MRI.There were no significant differences between groups in the pro-coagulant state and neuropsychological measures.Conclusion: PVI with the new PVAC Gold is associated with a higher incidence of cerebral emboli and longer duration of MES compared to ablation with an irrigated-tip catheter.
Abstract Background Cardiac resynchronization therapy (CRT) by implantation of an endocardial coronary sinus (CS) pacing lead is an established heart failure therapy. The recent European Society of Cardiology (ESC) guidelines on cardiac pacing and CRT recommend conduction system pacing (CSP) as a potential bail-out therapy in patients with previously unsuccessful CS-lead implantation. We present a case in which unsuccessful implantation of a CS pacing and ineffective QRS correction by His-bundle pacing (HBP) was overcome by left-bundle branch pacing (LBBP) to achieve cardiac resynchronization. Case summary The patient had to undergo revision of a CS lead for CRT due to rising pacing thresholds and pacing impedance. CS-lead implantation was omitted by a stenotic posterolateral CS branch. HBP did not lead to adequate QRS correction. The patient underwent successful LBB lead implantation as bail-out therapy. After LBBP lead implantation electrocardiographic and echocardiographic parameters were evident of effective CRT. Discussion Conduction system pacing may be an alternative to CS pacing for CRT in heart failure patients, which is endorsed by the current European guidelines. LBBP may overcome limitations of HBP and provide an alternative to other strategies such as surgical implantation of epicardial left-ventricular pacing leads. Further studies are needed to fully clarify the role of LBBP for heart failure treatment.
The second-generation cryoballoon (CB2) has demonstrated high procedural efficacy and convincing clinical success rates for pulmonary vein isolation (PVI). Nevertheless, data on the impact of different ablations protocols on durability are limited. The aim was to comparing the durability of PVI following 3 different ablation strategies in patients with recurrence of atrial fibrillation or atrial tachycardia undergoing repeat procedures.
Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging can be used to evaluate characteristics of atrial fibrosis. The novel noninvasive epicardial and endocardial electrophysiology system (NEEES) allows for the identification of sources with rotor activity. This study describes a new technique to examine the relationship between rotors and LGE signal intensity in patients with persistent atrial fibrillation (PERS) scheduled for ablation.Ten consecutive patients underwent pulmonary vein isolation for persistent atrial fibrillation. LGE CMR of both atria was performed, and NEEES-based analysis was conducted to identify rotors. For each mapping point, the intracardiac locations were transferred onto an individual CMR-derived 3-dimensional shell. This allowed the LGE signal intensity to be projected onto the anatomy from the NEEES analysis. NEEES analysis identified a total number of 410 electric rotors, 47.8% were located in the left atrium and 52.2% in the right atrium. Magnetic resonance imaging analysis was performed from 10 right atria and 10 left atria data sets, including 86 axial LGE CMR planes per atrium. The mean LGE burden for left atrium and right atrium was 23.9±1.6% and 15.9±1.8%, respectively. Statistical analysis demonstrated a lack of regional association between the extent of LGE signal intensity and the presence of rotors.This is the first study demonstrating that the presence of rotors based on NEEES analysis is not directly associated with the extent and anatomic location of LGE signal intensity from CMR. Further studies evaluating the relationship between rotors and fibrosis in patients with persistent atrial fibrillation are mandatory and may inform strategies to improve ablation outcome.
Abstract Funding Acknowledgements Type of funding sources: None. Background Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). Recently, a novel balloon-guided cryothermal single shot device (POLARx) was introduced. Purpose This observational study aimed to evaluate ablation efficacy and outcome using the novel POLARx CB system compared to the established one and to access the impact of individual PV characteristics on freedom from arrhythmia recurrence in paroxysmal (PAF) and persistent (PERS) AF. Methods 666 patients undergoing CB-guided ablation for AF were included. 601 patients treated with the AFA ablation system (Arctic Front Advance Pro, AFA) were compared to 65 consecutive patients who underwent PVI using the POLARx. Individual anatomical characteristics of the left atrium and PVs were assessed using pre-procedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional orifice area (CSOA) was determined. Follow-up examinations were scheduled after 3 and 6 months. Results Acute PVI was achieved in all patients (100%). 6-months AF-free survival was significantly higher in the POLARx cohort (POLARx: n=45, 69%; AFA: n=359, 60%; Log-rank p=0.037*). This applies to PAF (n=42, 65%, p=0.033*), PERS (n=23, 35%, p<0.001*) and normal PV anatomy (2 left- and two right-sided PVs; n=57, 88%, p< 0.001*). MRI found a comparable percentage of patients with normal PV anatomy (POLARx: n=57, 88%; AFA: n=512, 85%, p=0.126). A higher amount of variant PV anatomy was revealed in patients with PERS AF (p=0.043*), but this factor was not predictive for AF-recurrence (PAF: p=0.610; PERS: p=0.096). PAF patients with AF-recurrence presented with significantly larger CSOA of the left sided PVs and the right superior PVs (LSPV: 224.8 ± 98.1 mm2 vs. 220.6 ± 64.8 mm2, p<0.001*; LIPV: 145.9 ± 63.2 mm2 vs. 140.4 ± 52.8 mm2, p<0.001*; RSPV 268.9 ± 79.3 mm2 vs. 262.3 ± 75.6 mm2, p<0.001*). In patients with PERS AF no association between CSOA and ablation outcome was observed. Multivariate Cox regression analyses identified the AFA ablation system (p=0.022*, hazard ratio (HR) 1.776, confidence interval (CI) 0.240-9.281) and PERS AF (p<0.001*, HR 6.608, CI 0.220-73.839) as independent predictors for AF-recurrence. Conclusion PVI using the POLARx system improves freedom from AF recurrence independent of individual anatomical considerations and PV occlusion rates. For PAF patients, a significant association between CSOA and the outcome after CB- guided PVI was demonstrated.
Das Lungenkarzinom ist mit jährlich über 40 000 Sterbefällen in der Bundesrepublik Deutschland die vierthäufigste Todesursache und die häufigste Krebstodesursache [1]. Trotz der Fortschritte in der Diagnostik und Therapie liegt die 5-Jahres-Überlebensrate der Patienten mit Lungenkarzinom in europäischen und nordamerikanischen Ländern nur in einem Bereich von 5,5 – 15,7 % [2] [3]. Ziel der vorliegenden Leitlinie ist die Verbesserung der Prognose und der Lebensqualität von Patienten mit Lungenkarzinomen durch Optimierung des Einsatzes der derzeitigen diagnostischen und therapeutischen Möglichkeiten in einem interdisziplinären Ansatz. Außerdem soll durch die Empfehlung präventiver Maßnahmen die Häufigkeit des Lungenkarzinoms reduziert werden.
Abstract Pulsed field ablation (PFA) is an emerging technology for the treatment of atrial fibrillation (AF), for which pre-clinical and early-stage clinical data are suggestive of some degree of preferentiality to myocardial tissue ablation without damage to adjacent structures. Here in the MANIFEST-17K study we assessed the safety of PFA by studying the post-approval use of this treatment modality. Of the 116 centers performing post-approval PFA with a pentaspline catheter, data were received from 106 centers (91.4% participation) regarding 17,642 patients undergoing PFA (mean age 64, 34.7% female, 57.8% paroxysmal AF and 35.2% persistent AF). No esophageal complications, pulmonary vein stenosis or persistent phrenic palsy was reported (transient palsy was reported in 0.06% of patients; 11 of 17,642). Major complications, reported for ~1% of patients (173 of 17,642), were pericardial tamponade (0.36%; 63 of 17,642) and vascular events (0.30%; 53 of 17,642). Stroke was rare (0.12%; 22 of 17,642) and death was even rarer (0.03%; 5 of 17,642). Unexpected complications of PFA were coronary arterial spasm in 0.14% of patients (25 of 17,642) and hemolysis-related acute renal failure necessitating hemodialysis in 0.03% of patients (5 of 17,642). Taken together, these data indicate that PFA demonstrates a favorable safety profile by avoiding much of the collateral damage seen with conventional thermal ablation. PFA has the potential to be transformative for the management of patients with AF.
Abstract Objective. To characterize the complementary DNA (cDNA) and protein sequences of autoantigens recognized by anti–Mi‐2 antibodies, using recombinant Mi‐2 proteins for improved autoantibody detection. Methods. A cDNA expression library was immunoscreened, and cDNA isolation, alignment, and sequence analysis were performed. Northern blotting and in situ hybridization techniques were used. A recombinant protein (rMi‐2) was synthesized. Immunoprecipitation of 35 S‐methionine–labeled HEp‐2 cell proteins and immunoblotting of rMi‐2 and natural nuclear proteins were performed. Immunofluorescence studies were done with anti–Mi‐2 positive sera of dermatomyositis (DM) patients, and with human or rabbit antibodies specific for rMi‐2. Antibody screening of systemic lupus erythematosus, rheumatoid arthritis, DM, and antinuclear antibody–positive human sera was performed using an rMi‐2 protein enzyme‐linked immunosorbent assay (ELISA). Results. A major antigen recognized by anti–Mi‐2 positive sera of DM patients was found to constitute a 218‐kd nuclear protein (218‐kd Mi‐2) encoded on chromosome 12 and to belong to the SNF2/RAD 54 helicase family. Human and rabbit antibodies that were affinity purified using the recombinant protein reacted with and precipitated a nuclear protein of similar size, which was also recognized by anti–Mi‐2 sera. Anti–218‐kd Mi‐2 antibodies detected by rMi‐2 protein ELISA seemed to be mainly restricted to sera from patients with DM. Conclusion. The molecular characterization of the 218‐kd Mi‐2 antigen may contribute to our understanding of autoimmune phenomena in DM. The use of immunoreactive recombinant proteins allows structural and functional studies of the helicase and the development of sensitive and accurate antibody screening tests.
