Impact of High-Intensity-NIV on the heart in stable COPD: a randomised cross-over pilot study.

BACKGROUND: Although high-intensity non-invasive ventilation has been shown to improve outcomes in stable COPD, it may adversely affect cardiac performance. Therefore, the aims of the present pilot study were to compare cardiac and pulmonary effects of 6 weeks of low-intensity non-invasive ventilation and 6 weeks of high-intensity non-invasive ventilation in stable COPD patients. METHODS: In a randomised crossover pilot feasibility study, the change in cardiac output after 6 weeks of each NIV mode compared to baseline was assessed with echocardiography in 14 severe stable COPD patients. Furthermore, CO during NIV, gas exchange, lung function, and health-related quality of life were investigated. RESULTS: Three patients dropped out: two deteriorated on low-intensity non-invasive ventilation, and one presented with decompensated heart failure while on high-intensity non-invasive ventilation. Eleven patients were included in the analysis. In general, cardiac output and NTproBNP did not change, although individual effects were noticed, depending on the pressures applied and/or the co-existence of heart failure. High-intensity non-invasive ventilation tended to be more effective in improving gas exchange, but both modes improved lung function and the health-related quality of life. CONCLUSIONS: Long-term non-invasive ventilation with adequate pressure to improve gas exchange and health-related quality of life did not have an overall adverse effect on cardiac performance. Nevertheless, in patients with pre-existing heart failure, the application of very high inspiratory pressures might reduce cardiac output. TRIAL REGISTRATION: The trial was registered in the Deutsches Register Klinischer Studien (DRKS-ID: DRKS00007977 ).

Effect of patient's age on the profitability of inpatient cardiac catheterization: a contribution margin analysis of frequently performed procedures over a 5-year period.

BACKGROUND: Due to a continuing age shift in the German society hospital providers are concerned about the additional costs associated with the treatment of elderly patients. It is not clear if cardiac catheterization in aged patients leads to higher resource utilization and if DRG-revenues do compensate for this factor. METHODS: Procedure-related and administrative data of all patients who underwent cardiac catheterization at a tertiary heart center between 2007 and 2011 were collected and analyzed. Then a profitability analysis was performed by comparing the case related variable costs with the Diagnosis-related group (DRG) per case revenues. A particular emphasis was placed on a comparative analysis of identical clusters of procedures. RESULTS: The most frequently performed catheterization procedure (n = 1800) was associated with significantly higher material expenditure in very old patients (178 ± 48 €) than in old (171 ± 28; p = 0.001) and young patients (172 ± 39; p = 0.046). Furthermore, radiation time and the length of hospital stay were increased in very old patients (3.5 ± 3.8 min and 6.2 ± 4.8 days) compared to old (2.7 ± 2.8 min and 4.6 ± 3.8 days; p < 0.001) and young patients (2.5 ± 2.5 min and 4.5 ± 3.9 days; p < 0.001). Due to higher DRG revenues very old patients achieved higher absolute contribution margins (2065 ± 1033 €) than old (1804 ± 1902 €; p < 0.001) and young patients (1771 ± 902 €; p < 0.001). However, the contribution margins per day were significantly smaller (440 ± 226 €) than those in old (488 ± 234 €; p = 0.001) and young patients (484 ± 206 €; p = 0.001). CONCLUSIONS: Catheterization of very old patients is related to lower contribution margins per day despite higher material and time expenditures. Since efforts to reduce the length of hospital stay of these patients are limited, this may result in a competitive disadvantage of hospitals which are more affected by the demographic change.

ECG-Guided Surveillance Technique in Cryoballoon Ablation for Paroxysmal and Persistent Atrial Fibrillation: A Strategy to Prevent From Phrenic Nerve Palsy.

AIMS: Phrenic nerve palsy (PNP) is still a cause for concern in Cryoballoon ablation (CBA) procedures. New surveillance techniques, such as invasive registration of the compound motor action potential (CMAP), have been thought to prevent the occurrence of PNP. The present study investigates the impact of CMAP surveillance via an alternative and non-invasive ECG-conduction technique during CBA. METHODS: PVI with CBA was performed in 166 patients suffering from AF. Diaphragmal contraction was monitored by abdominal hands-on observation in Observation Group I; Observation Group II was treated using additional ECG-conduction, as a means of modified CMAP surveillance method. During the ablation of the right superior and inferior pulmonary veins, the upper extremities lead I was newly adjusted between the inferior sternum and the right chest, thereby recording the maximum CMAP. The CMAP in the above-mentioned ECG leads was continuously observed in a semi-quantitative manner. RESULTS: PNP was observed in 10 (6%) patients in total. In Observation Group I, 6 out of 61 (9.8%) demonstrated PNP. In Observation Group II a significant decrease of PNP could be demonstrated (p <0,001) and occurred in 4 out of 105 patients (3.8%). While three patients from Observation Group I left the EP lap with an ongoing PNP, none of the patients in Observation Group II had persistent PNP outside of the EP lab. CONCLUSION: The present study demonstrates that additional ECG-conduction, used as modified CMAP surveillance, is an easy, effective and helpful additional safety measure to prevent PNP in CBA.

Impact of Cryoballoon Ablation in Hypertrophic Cardiomyopathy-related Heart Failure due to Paroxysmal Atrial Fibrillation. A Comparative Case Series.

BACKGROUND: Atrial fibrillation (AF) represents a turning point in hypertrophic cardiomyopathy (HCM). Pulmonary Vein Isolation (PVI) with Radiofrequency Catheter Ablation (RFCA) is accepted to be successful in restoring sinus rhythm (SR) in HCM patients. The efficacy of cryoballoon (CB) therapy in HCM patients has not been studied so far. METHODS: 166 patients with AF underwent PVI with CB technology in our single center between 1/2012 and 12/2015. To evaluate the efficacy of the CB therapy in HCM patients, we compared their clinical outcome with those in "Non-HCM" AF patients in a 3 and 6 months follow-up. RESULTS: Out of 166 AF patients (65.7% paroxysmal AF, PAF), 4 patients had HCM and PAF (young males < 50 years). During the blanking period, 26 patients (15.8%) suffered from AF recurrence (11.0% PAF), including all HCM patients. The 6 months follow up of "Non-HCM" AF patients showed acceptable results (80% stable SR), whereas the HCM patients remained AF. IN CONCLUSION: Even if the CB provides advantages, the single device cannot be recommended in HCM patients because of early AF recurrences. Anyway, because of the specific hemodynamic changes in HCM patients with AF, ablation should be sought in an early state of its occurrence, then, however, preferably with RFCA.

Clinical and Subclinical Femoral Vascular Complications after Deployment of two Different Vascular Closure Devices or Manual Compression in the Setting of Coronary Intervention.

BACKGROUND: In the past two decades vascular closure devices (VCD) have been increasingly utilized as an alternative to manual compression after percutaneous femoral artery access. However, there is a lack of data confirming a significant reduction of vascular complication in a routine interventional setting. Systematic assessment of puncture sites with ultrasound was hardly performed. METHODS: 620 consecutive patients undergoing elective or urgent percutaneous coronary intervention were randomly allocated to either Angioseal (AS; n = 210), or Starclose (SC; n = 196) or manual compression (MC; n = 214). As an adjunct to clinical evaluation vascular ultrasonography was used to assess the safety of each hemostatic method in terms of major and minor vascular complications. The efficacy of VCDs was assessed by achievement of puncture site hemostasis. RESULTS: No major complications needing transfusion or vascular surgery were observed. Furthermore, the overall incidence of clinical and subclinical minor complications was similar among the three groups. There was no differences in the occurrence of pseudoaneurysmata (AS = 10; SC = 6; MC = 10), arteriovenous fistula (AS = 1; SC = 4; MC = 2) and large hematoma (AS = 11; SC = 10; MC = 14). The choice of access site treatment had no impact in the duration of hospital stay (AS = 6.7; SC = 7.4; MS = 6.4 days). CONCLUSIONS: In the setting of routine coronary intervention AS and SC provide a similar efficacy and safety as manual compression. Subclinical vascular injuries are rare and not related to VCD use.

Pulmonary vein isolation in 2012: is it necessary to perform a time consuming electrophysical mapping or should we focus on rapid and safe therapies? A retrospective analysis of different ablation tools.

BACKGROUND: Pulmonary Vein Isolation (PVI) is evolving as an established treatment option in atrial fibrillation (AF). Different fluoroscopy-guided ablation devices exist either on the basis of expandable circumferential and mesh designs with mapping and ablation of pulmonary vein potentials, or of a balloon technology, a "single shot" device with a purely anatomical approach. Systematic comparisons between procedure duration (PD), fluoroscopy time (FT) and clinical outcome in using different ablation tools are lacking in the literature. METHODS: In a single center retrospective analysis, 119 PVI procedures were performed between August 2008 and March 2011 in paroxysmal AF (PAF, 59.7%) and persistent AF (persAF, 40.3%) patients with mean age of 59.4±10.3 years and history of AF since 8.1±9.7 months. The PVI procedures were evaluated by comparing PD and FT using I) the High Density Mesh Mapper (HDMM), II) the High Density Mesh Ablator (HDMA), and III) the Arctic Front® Cryoballoon. The primary endpoints were FT and PD, the secondary endpoint was procedural safety and efficacy in short- and longterm follow-up. RESULTS: The procedures performed for 119 patients (63.0 % male) included 42 PVIs with the HDMM (35.3 %), 47 with the HDMA (39.5 %) and 30 with the cryoballoon (25.2 %). Comparing the 30 first procedures in groups of 10 in the HDMM and HDMA group, PD and FT fell in the HDMM group (PD from 257.5 to 220.9 min and FT from 80.5 to 67.3 min, both p < 0.05) as well as in the HDMA group (PD from 182.9 to 147.2 min and FT from 41.02 to 29.1 min, both p < 0.05). In the cryoballoon group, there was a steep learning curve with a steady state after the first 10 procedures (PD and FT decreased significantly from 189.5 to 138.1 min and 36.9 to 27.3 min, p values 0.005 and 0.05 respectively). With respect to recurrence of AF in a 24 months follow up, the HDMM and cryoballoon group showed comparable results with ~72% of patients free of arrhythmias. None of the patients died due to severe complications, or suffered a hemodynamic relevant pericardial effusion and/or stroke. Impairment of the phrenic nerve was observed in three patients. CONCLUSION: Use of the cryoballoon technology was associated with a steep learning curve and a reduced PD and FT; the long-term outcome was similar compared with the HDMM group. The efficacy and safety of the devices but also PD and FT should be respected as the strongest indicators of the quality of ablation. Further studies with long time follow-ups will show if the time for correct mapping of the PV potentials is a price we should be willing to pay or if we should adopt a "wait-and-see" attitude referring the AF recurrence.

Segment-orientated analysis of two-dimensional strain and strain rate as assessed by velocity vector imaging in patients with acute myocardial infarction.

AIMS: Strain rate imaging techniques have been proposed for the detection of ischemic or viable myocardium in coronary artery disease, which is still a challenge in clinical cardiology. This retrospective comparative study analyzed regional left ventricular function and scaring with two-dimensional strain (2DS) in the first 4 to 10 days after acute anterior myocardial infarction (AMI). METHODS AND RESULTS: The study population consisted of 32 AMI patients with an LAD occlusion and successful reperfusion. The assessment of peak systolic 2DS and peak systolic strain rate (SR) was performed segment-oriented with the angle-independent speckle tracking algorithm Velocity Vector Imaging (VVI). The infarcted, adjacent and non-infarcted segments were revealed by late enhancement MRI (LE-MRI), which was used as reference for the comparison with 2DS. The infarcted segments showed a significant decrease of tissue velocities, 2DS and SR in comparison to the non-affected segments. CONCLUSION: 2DS and SR as assessed by VVI seem to be a suitable approach for echocardiographic quantification of global and regional myocardial function as well as a promising tool for multimodal risk stratification after anterior AMI.

First experiences for pulmonary vein isolation with the high-density mesh ablator (HDMA): a novel mesh electrode catheter for both mapping and radiofrequency delivery in a single unit.

BACKGROUND: Interventional therapy of atrial fibrillation (AF) is often associated with long examination and fluoroscopy times. The use of mapping catheters in addition to the ablation catheter requires multiple transseptal sheaths for left atrial access. OBJECTIVES: The purpose of this prospective study was to evaluate feasibility and safety of pulmonary vein (PV) isolation using the high-density mesh ablator (HDMA), a novel single, expandable electrode catheter for both mapping and radiofrequency (RF) delivery at the left atrium/PV junctions. METHODS: Twenty-six patients with highly symptomatic paroxysmal AF (14, 53.8%) and persistent AF (12, 46.2%) were studied. Segmental PV isolation via the HDMA was performed using a customized pulsed RF energy delivery program (target temperature 55-60 degrees C, power 70-100 W, 600-900 seconds RF application time/PV). RESULTS: All 104 PVs in 26 patients could be ablated by the HDMA. Segmental PV isolation was achieved with a mean of 3.25 +/- 1.4 RF applications for a mean of 603 +/- 185 seconds. Entrance conduction block was obtained in 94.2% of all PV. The mean total procedure and fluoroscopy time was 159.0 +/- 32 minutes and 33.5 +/- 8.6 minutes, respectively. None of the patients experienced severe acute complications. After 3 months no PV stenosis was observed, and 85.6% and 41.6% of the patients with PAF and persistent AF, respectively, did not report symptomatic AF. CONCLUSIONS: In this first study of PV isolation using the HDMA, our findings suggest that this method is safe and yields good primary success rates. The HDMA simplifies AF ablation, favorably impacting procedure and fluoroscopy times.

Sustained high quality of life in a 5-year long term follow-up after successful ablation for supra-ventricular tachycardia. results from a large retrospective patient cohort.

INTRODUCTION: The ablation of supraventricular tachycardias (SVT) using radiofrequency energy (RF) is a procedure with a high primary success rate. However, there is a scarcity of data regarding the long term outcome, particularly with respect to quality of life (QoL). METHODS AND RESULTS: In this retrospective single-center study, 454 patients who underwent ablation of SVT between 2002 and 2007 received a detailed questionnaire addressing matters of QoL. The questionnaire was a modified version of the SF-36 Health Survey questionnaire and the Symptom Checklist--Frequency and Severity Scale.After a mean follow up of 4.5+/-1.3 years, 309 (68.1%) of the contacted 454 patients (269 female, 59.2%, mean age 58+/-6.5) completed the questionnaire. Despite of 27% of relapses in the study group, 91.7% considered the procedure a long-term success. The remainder of patients experienced no change in (3.7%) or worsening of (4.7%) symptoms. There were no significant differences between the various types of SVT (p=1). QoL in patients with Atrio-Ventricular Nodal Reentry Tachycardia (AVNRT) and Atrio-Ventricular Reentry Tachycardia (AVRT) improved significantly (p<0.0005 respectively p<0.043), whereas QoL in patients with Ectopic Atrial Tachycardia (EAT) showed a non-significant trend towards improvement. Main symptoms before ablation, such as tachycardia (91.5%), increased incidence of tachycardia episodes over time (78.1%), anxiety (55.5%) and reduced physical capacity in daily life (52%) were significantly improved after ablation (p<0.0001). CONCLUSION: The high acute ablation success of SVT persists for years in long term follow up and translates into a significant improvement of QoL in most patients.

Acute simultaneous proximal occlusion of two major coronary arteries in acute myocardial infarction: successful treatment with percutaneous coronary intervention.

BACKGROUND: Acute myocardial infarction (AMI) due to acute simultaneous proximal occlusion of two major coronary arteries (ASOMC) is a rare but life-threatening situation. Most patients die suddenly or go into cardiogenic shock (CS). In patients with AMI due to ASOMC identified by coronary angiography (CA), percutaneous coronary intervention (PCI) performed in both infarct-related arteries (IRAs) at the same time as diagnostic CA is the fastest option to complete revascularization. However, no prospective studies regarding the outcome of such procedures have been published so far. METHODS: In this prospective single-center study, between October 2004 and March 2007, consecutive patients with acute coronary syndrome (ACS) reporting to our university hospital and regional referral center were evaluated for ASOMC by means of emergent CA. When diagnosed with ASOMC, PCI of the IRAs was performed. Clinical data were obtained at baseline, discharge, after 6 months, and after 1 year. RESULTS: Out of 417 patients with ACS, 379 patients (90.9%) suffered an AMI. In 5 patients CA revealed an ASOMC. PCI was performed in 4 patients. One patient with severe triple-vessel disease was referred for emergent coronary artery bypass graft (CABG) surgery after conventional PCI of one IRA. One patient died in-hospital due to early in-stent thrombosis after PCI. At 6-month follow-up and at 1-year follow-up, 4 patients were alive. CONCLUSION: In spite of the complex interventions, PCI patients had low in-hospital mortality and good clinical results at 1-year follow-up. Our observations are important in the clinical decision-making process of AMI due to ASOMC.

[Heart Failure Despite Low BNP-Level: Paradoxon or Pathfinder? - - A Case of Pericarditis constrictiva]. / Herzinsuffizienz bei niedrigem BNP-Wert: Paradoxon oder Wegweiser?

HISTORY AND CLINICIAL FINDINGS: We elaborate a case of a 48-year old patient of indian descent who presented with shortness of breath, lower extremity edema and ascites in our emergency unit.One year beforehand tuberculous pleuritis was diagnosed and treated in accordance with guidelines. INVESTIGATIONS: CT-Scan of the heart revealed a pericardial thickening with calcifications. Echocardiographic examination and invasive pressure measurement did not provide any clear evidence of pericarditis constrictiva. Coronary artery disease was ruled out. In laboratory tests, the BNP-level was noticeably low despite severe cardiac decompensation. DIAGNOSIS: Due to a typically low BNP-level, pericarditis constrictiva was our suspected diagnosis TREATMENT AND COURSE: After an intraoperative diagnosis confirmation by our cardiosurgery colleagues, a complete pericardiectomy was performed. In the follow up, the patient presented symptom-free and with normal capacity. CONCLUSION: In case of incongruent findings, the BNP-level seems to be a useful additional diagnostic tool in the diagnosis of pericarditis constrictiva.

Point-by-point versus multisite electrode mapping in VT ablation: does freedom from VT recurrences depend on mapping catheter? An observational study.

PURPOSE: This study was conducted with the purpose of determining whether or not the potential technical advantages of multi-electrode mapping catheters in catheter ablation (CA) of ventricular tachycardia (VT) result in any relevant clinical benefit for VT patients. METHODS: A single-center VT study, having taken place from 2012 to 2014 using a standard 3.5-mm catheter (Thermocool SF® group 1) and from 2014 to 2016 using a 1-mm multi-electrode-mapping catheter (PentaRay® group 2), was conducted. The endpoint was the complete elimination of late potentials (LPs), local abnormal ventricular activities (LAVA), and VT non-inducibility. Follow-up consisted of device interrogation to monitor for VT recurrence. RESULTS: Out of 74 VT patients aged 64.5 ± 12.0 years (66 male [89.2%], 56 with ICM [75.7%], and 18 with NICM [24.3%)]), 48 patients (64.9%) were investigated in group 1 and 26 (35.1%) in group 2. Using the multi-point acquisition approach, a tendency to require less mapping time (group 1 65.2 ± 37.6 min, group 2 55.6 ± 34.4 min, p ns) was determined. During 12-month follow-up, 57 patients had freedom from VT recurrences (79.2%). The result was insignificant between the groups (38 patients (79.2%) in group 1 and 19 patients (73.1%) in group 2). CONCLUSIONS: In a single-center observational study, both conventional and high-density mapping approaches in VT patients are comparable in terms of procedure duration and outcome. Mapping time when using a multi-electrode catheter seems to have the tendency of being shorter. We should be encouraged to recruit more patients comparing the benefit of different catheter types.

Pulmonary vein potential mapping in atrial fibrillation with high density and standard spiral (lasso) catheters: A comparative study.

BACKGROUND: The dominant single-shot procedure for Pulmonary Vein Isolation (PVI) is the Cryoballoon Ablation (CBA) technique using a spiral catheter (Achieve™, AC) for mapping and monitoring purposes. We hypothesized that Basket Catheters, such as the High Density Mesh Mapper (HDMM), with its high-density mapping properties, could detect Pulmonary Vein Potentials (PVPs) that the octapolar AC would not be able to identify. METHODS: Twenty-four patients (average age 61.8±10 years) with either paroxysmal or persistent atrial fibrillation (AF) (Paroxysmal AF or Persistent AF) were enrolled in the study. While the patients were in sinus rhythm, all pulmonary veins (PVs) were prospectively mapped both prior and subsequent to CBA with a 32-pole HDMM and an 8-pole AC. PVPs were recorded using both catheters, and their location was allocated to one of four PV quadrants. Then, the quadrant findings of the mapping catheters were compared. RESULTS: Mapping using the HDMM allowed for more precise identification of PVPs both before and after CBA compared to AC mapping. We identified an average of 83.6±4.8 PVPs in all four PVs (this means 20.9±10.5 PVPs /per single PV per patient [HDMM], 14.5±1.3 PVPs/in all four PVs and 3.6±2.7 PVPs /per single PV per patient [AC]) before ablation, thereby leading to a significant difference in the identification of PVPs per PV quadrant. Of 384 PV quadrants/24 patients analyzed, the HDMM identified PVPs in 279 and AC in only 192 quadrants (P<0.05). CONCLUSION: High-density mapping with a Basket Catheter, such as the HDMM, detects PVPs that remain undetected when using the standard AC catheter in CBA procedures.

High-Density Mapping in Ventricular Tachycardia Ablation: A PentaRay® Study.

BACKGROUND: High-density mapping of ventricular tachycardia (VT) with PentaRay® (Biosense-Webster) provides high resolution with discrimination of local abnormal electrograms and slow conducting channels. We evaluate the feasibility of PentaRay® to characterize the anatomical substrate and assume an influence of the outcome despite limitations. METHODS: Over a 24-month period, 26 endocardial and four epicardial maps were obtained of 26 VT patients (18 ischemic cardiomyopathy (ICM, 69.2%) and 8 non-ischemic cardiomyopathy (NICM, 30.8%), age 65 ± 9 years). Catheter ablation (CA) was performed with the aim of transecting the isthmus. The endpoint was non-inducibility of any VT. Manual review of the maps was performed and focused on evaluating scarring, bipolar electrograms, and procedure times. RESULTS: In 55.6 ± 34.4 min, 1,085.9 ± 726.2 points were created. The mean ablation time was 50.8 ± 30.1 min. The endpoint was achieved in 12 patients (46.2%). The mean dense scar area and the mean patchy scar area were 49.4 ± 51.8 cm2 (range 0 - 190 cm2) and 14.7 ± 14.9 cm2 (range 0 - 110 cm2), respectively. Analyzing the learning curve, we found a tendency in decreasing procedure times. During the course of follow-up treatment averaging a 14-month period, device interrogation showed that 17 patients (65.4%) had remained free of any arrhythmia recurrence. CONCLUSION: The high-density maps with PentaRay® were safely created in a short period of time. Our manual review of the maps reveals limitations of current annotation criteria; nevertheless, medium-term outcomes were encouraging. Further prospective studies are required to validate our findings in a larger cohort of patients.

Is it time to rebalance the case mix? A portfolio analysis of direct catheterization laboratory costs over a 5-year period.

BACKGROUND: Cardiac catheterization laboratories (CLL) have continued to function as profit centers for hospitals. Due to a high percentage of material and labor costs, they are natural targets for process improvement. Our study applied a contribution margin (CBM) concept to evaluate costs and cost dynamics over a 5-year period. METHODS: We retrospectively analyzed all procedures performed at a tertiary heart center between 2007 and 2011. Total variable costs, including labor time, material, and maintenance-expenses, were allocated at a global as well as a procedural level. CBM and CBM ratios were calculated by integration of individual DRG revenues. RESULTS: Annual case volume increased from 1288 to 1545. In parallel, overall profitability improved as indicated by a 2% increase in CBM ratio and a higher CBM generated per hour of CLL working time (4325 vs. 5892 €, p < 0.001). Coronary angiography generated higher average CBMs per hour than coronary or electrophysiological interventions (5831 vs. 3458 vs. 1495 €; p < 0.001). The latter are characterized by relatively high per case material expenditures. On a procedural level, DRG-specific trends as a steady improvement of examination time or an increase in material costs were detectable. CONCLUSIONS: The CBM concept allows a comprehensive analysis of CLL costs and cost dynamics. From a health service providers view, its range of application includes global profitability analysis, portfolio evaluation, and a detailed cost analysis of specific service lines. From a healthcare payers perspective, it may help to monitor hospital activities and to provide a solid data basis in cases where inappropriate developments are suspected. The calculation principle is simple which may increase user acceptance and thus the motivation of team members.

Transradial versus transfemoral approach in coronary angiography: a matched pair analysis of cath lab equipment costs.

INTRODUCTION: There is an ongoing struggle to understand the potential economic benefits that radial access may offer. Cost savings are thought to primarily occur after the procedure. The aim of our study was to analyze cath lab expenses resulting from transradial (TRA) and transfemoral approaches (TFA). METHODS: A total of n = 1890 matched pairs of patients were analyzed. A traditional Judkins catheter strategy was pursued for coronary angiography. Three large databases were merged to collect and compare procedural data as material, medication costs and fluoroscopy time. RESULTS: Compared to TFA diagnostic catheterization from TRA was associated with significantly lower procedural costs (€181.0 versus €167.5; p<0.001). Extra costs in TFA were primarily produced by frequent use of vascular closure devices (VCDs) in 86% of patients. However, the potential saving amount related to VCD use was only partly realized due to the higher number of extra catheters (0.53 ± 0.9 versus 0.23 ± 0.6; p<0.001) and hydrophilic guidewires (0.088 ± 0.3 versus 0.014 ± 0.1; p<0.001) used in TRA. Weak correlations were observed between the total number of cases and fluoroscopy time (r = -0.13; p<0.001) as well as material costs (r = 0.31; p<0.001). CONCLUSIONS: Significant cost savings can be realized by TRA at the procedural level even when adhering to a conventional Judkins catheter strategy. Hydrophilic guidewires and additional catheters are the main cost drivers in TRA. In contrast to fluoroscopy time material costs steadily increase during the early stage of the TRA learning curve.

New-onset versus chronic atrial fibrillation in acute myocardial infarction: differences in short- and long-term follow-up.

AIMS: Atrial fibrillation (AF) occurs commonly in patients with acute myocardial infarction (AMI) and has been established as a marker of adverse prognosis. There are only few clinical trials that investigate differences between new-onset and chronic AF in AMI. We hypothesize that chronic AF is associated with an increased rate of adverse short- and long-term outcomes. METHODS AND RESULTS: In a single center study, over a period of 28 months, 375 consecutive patients with AMI were included [337 patients without AF (89.9%) and 38 with AF (10.1%)]. As much as 16 patients had new-onset AF (42.1%) and 22 had chronic AF (57.9%). Patients with severe coronary artery disease develop AF more often in AMI, and the existence of AF was associated with a poor prognosis. Compared to patients with new-onset AF, chronic AF was more frequently associated with advanced age (75 vs. 70 years, p not significant), reduced left ventricular ejection fraction (44.8 vs. 54.0%, p < 0.05) and NSTEMI (63.6 vs. 36.4%, p < 0.05). Only chronic AF resulted in increased in-hospital death (18.2 vs. 0.0%; p < 0.005) at the 2-year follow-up, 14 patients with AF died (63.6%), predominantly due to cardiovascular reasons. CONCLUSION: Our results indicate that patients with chronic AF had a higher incidence of in-hospital death than those with new-onset AF or without. Chronic AF includes a group of older and sicker patients than their counterparts with new-onset AF. Understanding these findings may ultimately lead to better care of patients with this arrhythmia to prevent the development of the underlying atrial substrate in chronic AF patients and to improve their otherwise worse prognosis.

Eighteen months follow-up of the clinical efficacy of the high density mesh ablator (HDMA) in patients with atrial fibrillation after pulmonary vein isolation.

PURPOSE: The high density mesh ablator (HDMA), a mesh electrode catheter using radiofrequency delivery for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF), has been shown to have a high acute ablation success rate. The primary endpoint of our study was the efficacy of HDMA to maintain sinus rhythm (SR), and the secondary endpoint is its efficacy to reduce AF burden in an 18-month follow-up. METHODS: Forty-two patients with AF [25 patients with paroxysmal AF (PAF, 59.5%), 17 patients with persistent AF (persAF, 40.5%)], were followed up with 7-day Holter monitoring and anamnestic survey at 6 and 12 months after PVI. To evaluate symptomatic AF episodes after 12 months, we used data from further hospital stays or information given by phone. RESULTS: In 42 patients at intervals of 6 and 12 months, stable SR was documented in 7-day Holter monitoring in 18 patients (42.9%, 10/25 and 9/25 for PAF and 8/17 and 9/17 for persAF, respectively). Symptomatic episodes of AF were reported in 31 patients (73.8%, 18/25 for PAF and 13/17 for persAF). Re-ablation was performed in seven patients (3/25 for PAF and 4/17 for persAF) not yielding to stable SR. At an 18-month follow-up (12-29 months), AF recurrence persisted in all 42 patients; in four patients, a permanent pacemaker was implanted (9.5%). No complications attributable to the HDMA occurred in this series. CONCLUSIONS: Our findings suggest that the PVI using the HDMA is a safe method but yields to a high AF recurrence rate at long-term follow-up even after a second procedure with the same tool.

The first three-dimensional visualization of a thrombus in transit trapped between the leads of a permanent dual-chamber pacemaker: a case report.

INTRODUCTION: Two-dimensional echocardiography is a useful tool in diagnosing cardiac masses. However, the three-dimensional offline reconstruction technique of transesophageal echocardiography might be superior to two-dimensional transesophageal echocardiography in providing additional information of structural details. CASE PRESENTATION: We report the case of a 76-year-old Caucasian man with a permanent dual-chamber pacemaker and a worm-like right-heart thrombus in transit. Two-dimensional transthoracic echocardiography and two-dimensional transesophageal echocardiography showed that it was debatable as to whether "the worm" was originating from the leads. Offline three-dimensional transesophageal echocardiography reconstruction technique proved superior in identifying the cardiac mass as a thrombus trapped between the leads of the pacemaker. The thrombus was successfully dissolved by systemic heparin therapy. CONCLUSIONS: The three-dimensional transesophageal echocardiography is useful and effective in patients with implanted pacemakers or defibrillators when other closely competing imaging modalities are contraindicated, such as magnetic resonance imaging. In patients with pacemakers and trapped thrombus in transit for whom surgical therapy might be a high risk, medical therapy seems to offer a safer and convincing alternative. Whether the management of right-heart thrombi has to be modified due to the presence of pacemaker leads is controversial.

Segmental pulmonary vein isolation in atrial fibrillation: new insights from the high density mesh mapper technique in an electrophysiologically guided approach.

OBJECTIVE: As opposed to fundamental investigations into the nature of atrial fibrillation (AF) current clinical studies of AF ablation techniques sometimes only contain sparse information about the underlying electrophysiological properties. The purpose of this prospective, pilot study was to evaluate acute therapeutic success and clinical outcome after 6 month of segmental ostial ablation (SOA) using the High Density Mesh Mapper catheter (HDMM, BARD Electrophysiology, Lowell, MA, USA) for an electrophysiological guided approach. The HDMM is a novel, single expandable basket electrode catheter for high resolution recordings at the left atrium/pulmonary vein (PV) junction. METHODS: SOA was performed by irrigated radiofrequency (RF) application around the HDMM. Entry- and exit conduction block, as well as decreased local electrode amplitude, were endpoints for short-term successful ablation. RESULTS: Seventy-two patients with highly symptomatic paroxysmal AF (PAF; 47, 65.2%), persistent AF (12, 16.7%) and permanent AF (13, 18.1%) were studied. Entrance conduction block was obtained in 93%, exit conduction block in 81% of all PV. After 6 month no PV stenosis was observed, 62 patients (86.1%) improved clinically, whereas 52 patients (72.2%) were free from arrhythmias and sinus rhythm was present favoring patients with PAF. CONCLUSIONS: In this first prospective study of PV isolation using the HDMM, our findings suggest, that this method is safe and yields good primary success rates and favourable clinical outcome at 6 month. The new technology based on high resolution recordings, offers beside good anatomical orientation a direct electrophysiological control for monitoring of bidirectional conduction block.