Cephalic Vein Cutdown Is Superior to Subclavian Puncture as Venous Access for Patients with Cardiac Implantable Devices after Long-Term Follow-Up.

BACKGROUND: Cephalic vein cutdown (CVC) and subclavian vein puncture (SVP) are the most commonly used access sites for transvenous lead placement of cardiac implantable electronic devices (CIEDs). Limited knowledge exists about the long-term patency of the vascular lumen housing the leads. METHODS: Among the 2703 patients who underwent CIED procedures between 2005 and 2013, we evaluated the phlebographies of 162 patients scheduled for an elective CIED replacement (median of 6.4 years after the first operation). The phlebographies were divided into four stenosis types: Type I = 0%, Type II = 1-69%, Type III = 70-99%, and Type IV = occlusion. Due to the fact that no standardized stenosis categorization exists, experienced physicians in consensus with the involved team made the applied distribution. The primary endpoint was the occurrence of stenosis Type III or IV in the CVC group and in the SVP group. RESULTS: In total, 162 patients with venography were enrolled in this study. The prevalence of high-degree stenosis was significantly lower in the CVC group (7/89, 7.8%) than in the SVP group (15/73, 20.5%, p = 0.023). In the CVC group, venographies showed a lower median stenosis (33%) than in the SVP group (median 42%). CONCLUSIONS: The present study showed that the long-term patency of the subclavian vein is higher after CVC than after SVP for venous access in patients with CIED.

Incidence and prognostic significance of malignant arrhythmias during (repetitive) Holter electrocardiograms in patients with pulmonary hypertension.

Background: In patients with pulmonary hypertension (PH), increased pulmonary vascular resistance (PVR) may lead to increased right ventricular afterload and cardiac remodelling, potentially providing the substrate for ventricular arrhythmias. Studies dealing with long term monitoring of patients with PH are rare. The present study evaluated the incidence and the types of arrhythmias retrospectively recorded by Holter ECG in patients with newly detected PH during a long-term Holter ECG follow-up. Moreover, their impact on patient survival was evaluated. Patients and methods: Medical records were screened for demographic data, aetiology of PH, incidence of coronary heart disease, level of brain natriuretic peptide (BNP), results from Holter ECG monitoring, 6-minute walk test distance, echocardiographic data and hemodynamic data derived from right heart catheterization. Two subgroups were analyzed: 1. patients (n = 65) with PH (group 1 + 4) and derivation of at least 1 Holter ECG within 12 months from initial detection of PH and 2. patients (all PH etiologies, n = 59) with 3 follow-up Holter ECGs. The frequency and complexity of premature ventricular contractions (PVC) was classified into "lower" and "higher" (=non sustained ventricular tachycardia, nsVT) burden. Results: Holter ECG revealed sinus rhythm (SR) in most of the patients (n = 60). Incidence of atrial fibrillation (AFib) was low (n = 4). Patients with premature atrial contractions (PAC) tend to have a shorter period of survival (p = 0.098), PVC were not correlated with significant survival differences. During follow-up PAC and PVC were common in all PH groups. Holter ECG revealed non sustained ventricular tachycardia in 19/59 patients [(32.2%); n = 6 during first Holter-ECG, n = 13 during second/third Holter-ECG]. In all patients suffering from nsVT during follow-up previous Holter ECG revealed multiform/repetitive PVC. PVC burden was not linked to differences in systolic pulmonary arterial pressure, right atrial pressure, brain natriuretic peptide and results of six-minute walk test. Conclusion: Patients with PAC tend to have a shortened survival. None of the evaluated parameters (BNP, TAPSE, sPAP) was correlated with the development of arrhythmias. Patients with multiform/repetitive PVC seem to be at risk for ventricular arrhythmias.

Evaluation of the guideline-adherence of coronary angiography in patients with suspected chronic coronary syndrome - Results from the German prospective multicentre ENLIGHT-KHK project.

Background: With 900'000 coronary angiographies (CA) per year, Germany has the highest annual per capita volume in Europe. Until now there are no prospective clinical data on the degree of guideline-adherence in the use of CA in patients with suspected chronic coronary syndrome (CCS) in Germany. Methods: Between January 2019 and August 2021, 458 patients with suspected CCS were recruited in nine German centres. Guideline-adherence was evaluated according to the current European Society of Cardiology and German guidelines. Pre-test probability (PTP) for CAD was determined using age, gender, and a standardized patient questionnaire to identify symptoms. Data on the diagnostic work-up were obtained from health records. Results: Patients were in mean 66.6 years old, male in 57.3 %, had known CAD in 48.4 % and presented with typical, atypical, non-anginal chest pain or dyspnoea in 35.7 %, 41.3 %, 23.0 % and 25.4 %, respectively. PTP according to the European guidelines was in mean 24.2 % (11.9 %-36.5 % 95 % CI). 20.9 % of the patients received guideline-recommended preceding non-invasive image guided testing. The use of CA was adherent to the European and German guideline recommendations in 20.4 % and 25.4 %, respectively. In multivariate-analysis, arterial hypertension and prior revascularization were predictors of guideline non-adherence. Conclusion: These are the first prospective clinical data which demonstrated an overall low degree of guideline-adherence in the use of CA in patients with suspected CCS in the German health care setting. To improve adherence rates, the availability of and access to non-invasive image guided testing needs to be strengthened. (German Clinical Trials Registry DRKS00015638 - Registration Date: 19.02.2019).

Analysis of the effect of cortisone on the QT interval.

BACKGROUND: Cardiac death caused by malignant arrhythmias is very prevalent. Prolongation of the QT interval is a relevant aspect in arrhythmia mechanisms. Prior studies have revealed that the QTc interval could be shortened by cortisone. Moreover, in an animal model of long QT syndrome, cortisone treatment shortens the ventricular action potential duration. The present study investigated the effect of methylprednisolone (MPS) on the QTc interval in cardiovascularly healthy humans. METHODS: Patients who had just been diagnosed with multiple sclerosis receiving MPS therapy were analysed prospectively. Demographic data, laboratory values, anti-arrhythmic medication and baseline and follow-up ECGs were extracted from the patients' medical records. RESULTS: Seventy-eight patients were included. The mean ± standard deviation age was 47 ± 15 years. The values of the electrolytes were normal. All patients were treated with MPS for 3 or 5 days. The heart rate increased at the beginning of MPS therapy and decreased during the subsequent period. ECG measurements showed that the QTc interval was prolonged at the beginning of MPS therapy and shortened over the course of treatment. The longest QTc intervals were obtained by calculation with Bazett's formula. CONCLUSIONS: In humans, cortisone shortens the QTc interval over time. The analysis indicates a cumulative effect of cortisone that lasts longer. The results of our pilot study reveal that cortisone might be added to therapeutic strategies in patients with long QT syndromes. Further clinical studies have to be carried out to analyze potential clinical options.

Perioperative complications after pacemaker implantation: higher complication rates with subclavian vein puncture than with cephalic vein cutdown.

PURPOSE: The cephalic vein cutdown (CVC) and the subclavian puncture (SP) is the most common access for pacemaker implantation. The purpose of this study was to compare the peri-/postoperative complications of these approaches. METHODS: A retrospective analysis of the quality assurance data of the state of North Rhine-Westphalia was performed to evaluate the peri-/postoperative complications of first pacemaker implantation according to the venous access. The primary endpoint was defined as the occurrence of one of the following: asystole, ventricular fibrillation, pneumothorax, hemothorax, pericardial effusion, pocket hematoma, lead dislocation, lead dysfunction, postoperative wound infection or other complication requiring intervention. Descriptive analysis was done via absolute, relative frequencies and Odds Ratio. Fisher's exact test was used for comparison of the both study groups. RESULTS: From 139,176 pacemaker implantations from 2010 to 2014, 15,483 cases were excluded due to other/double access. The median age was 78 years and the access used was CVC for 75,251 cases (60.8%) and SP for 48,442 cases (39.2%). The implanted devices were mainly dual-chamber pacemakers (73.9% in the CVC group and 78.4% in the SP group), followed by single-chamber pacemakers VVI (24.9% and 19.9% in the CVC and SP group respectively). There were significantly fewer peri/postoperative complications in the CVC group compared to the SP group (2.49% vs. 3.64%, p = 0.0001, OR 1.47; 95% CI 1.38-1.57). CONCLUSIONS: CVC as venous access for pacemaker implantation has significantly fewer peri/postoperative complications than SP and appears to be an advantageous technique.

Long-term prognosis of successful left ventricular substrate modification of electrical storm.

Introduction: The Electrical storm (ES) subsumes a state of electrical instability of the heart, which manifests itself in repeated and potentially fatal ventricular arrhythmias (VA). We examine the long-term effects of substrate modification with regards to mortality, ventricular tachycardia (VT) recurrences and hospitalization depending on age, gender, heart function, scare location, VT documentation, postprocedural electrical stimulation (PES) and induced VTs. Methods: From 08/2008 and 09/2019 160 consecutive patients admitted for ES ablation via electroanatomical mapping were followed up until 04/2021. Results: 50/160 patients showed VT recurrences after 13.8 ± 21.7 (0.0-80.3) months, with a characteristic steep curve directly after ES and then a rapid decline leading to a plateau (first month 10/50 (20%), first year 35/50 VT recurrences (70%) Mortality rates followed a similar pattern also the initial decline was not as steep. 42 patients died during the observation period (26%) after 16.6 ± 16.1 (0.0-67.9) months after ablation day (first month (n = 7, 16.7%) first year (n = 21, 50%). Gender, age, scare localization, missing VT documentation did not worsen outcome. Induction of >3 VTs and lack of PES due to hemodynamic instability significantly decreased effectiveness. Finding the entry significantly increased long-term effects. Conclusion: Ablation of ES is safe and feasible independent of a variety of factors. Employing more sophisticated tools to understand the reentry mechanism will further improve the long-term outcome.

Catheter ablation of short-coupled variant of torsade de pointes.

BACKGROUND: The short-coupled variant of torsade de pointes (sc-TdP) is a malignant arrhythmia that frequently presents with ventricular fibrillation (VF) electrical storm. Verapamil is considered the first-line therapy of sc-TdP while catheter ablation is not widely adopted. The aim of this study was to determine the origin of sc-TdP and to assess the outcome of catheter ablation using 3D-mapping. METHODS AND RESULTS: We retrospectively analyzed five patients with sc-TdP who underwent 3D-mapping and ablation of sc-TdP at five different institutions. Four patients initially presented with sudden cardiac arrest, one patient experienced recurrent syncope as the first manifestation. All patients demonstrated a monomorphic premature ventricular contraction (PVC) with late transition left bundle branch block pattern, superior axis, and a coupling interval of less than 300 ms. triggering recurrent TdP and VF. In four patients, the culprit PVC was mapped to the free wall insertion of the moderator band (MB) with a preceding Purkinje potential in two patients. Catheter ablation using 3D-mapping and intracardiac echocardiography eliminated sc-TdP in all patients, with no recurrence at mean 2.7 years (range 6 months to 8 years) of follow-up. CONCLUSION: 3D-mapping and intracardiac echocardiography demonstrate that sc-TdP predominantly originates from the MB free wall insertion and its Purkinje network. Catheter ablation of the culprit PVC at the MB free wall junction leads to excellent short- and long-term results and should be considered as first-line therapy in recurrent sc-TdP or electrical storm.

Improvement of electrical synchrony in cardiac resynchronization therapy using dynamic atrioventricular delay programming and multipoint pacing.

BACKGROUND: Optimization of cardiac resynchronization therapy (CRT) is often time-consuming and therefore underused in a clinical setting. Novel device-based algorithms aiming to simplify optimization include a dynamic atrioventricular delay (AVD) algorithm (SyncAV, Abbott) and multipoint pacing (MPP, Abbott). This study examines the acute effect of SyncAV and MPP on electrical synchrony in patients with newly and chronically implanted CRT devices. METHODS: Patients with SyncAV and MPP enabled devices were prospectively enrolled during implant or scheduled follow-up. Blinded 12-lead electrocardiographic acute measurements of QRS duration (QRSd) were performed for intrinsic QRSd (Intrinsic), bi-ventricular pacing (BiV), MPP, BiV with SyncAV at default offset 50 ms (BiVSyncAVdef ), BiV with SyncAV at patient-specific optimised offset (BiVSyncAVopt ), MPP with SyncAV at default offset 50 ms (MPPSyncAVdef ), and MPP with SyncAV at patient-specific optimised offset (MPPSyncAVopt ). RESULTS: Thirty-three patients were enrolled. QRSd for Intrinsic, BiV, MPP, BiVSyncAVdef , BiVSyncAVopt , MPPSyncAVdef , MPPSyncAVopt were 160.4 ± 20.6 ms, 141.0 ± 20.5 ms, 130.2 ± 17.2 ms, 121.7 ± 20.9 ms, 117.0 ± 19.0 ms, 121.2 ± 17.1 ms, 108.7 ± 16.5 ms respectively. MPPSyncAVopt led to greatest reduction of QRSd relative to Intrinsic (-31.6 ± 11.1%; p < .001), showed significantly shorter QRSd compared to all other pacing configurations (p < .001) and shortest QRSd in every patient. Shortening of QRSd was not significantly different between newly and chronically implanted devices (-51.6 ± 14.7 ms vs. -52.7 ± 21.9 ms; p = .99). CONCLUSION: SyncAV and MPP improved acute electrical synchrony in CRT. Combining both technologies with patient-specific optimization resulted in greatest improvement, regardless of time since implantation. Whats new Novel device-based algorithms like a dynamic AVD algorithm (SyncAV, Abbott) and multipoint pacing (MPP, Abbott) aim to simplify CRT optimization. Our data show that a combination of patient tailored SyncAV optimization and MPP results in greatest improvement of electrical synchrony in CRT measured by QRS duration, regardless if programmed in newly or chronically implanted devices. This is the first study to our knowledge to examine a combination of these device-based algorithms. The results help understanding the ideal ventricular excitation in heart failure.

Transseptal use of high-density grid catheter for VT mapping and retrograde hemodynamic support with Impella pump in presence of Mitraclips.

PURPOSE: We sought to establish the technical feasibility of VT-mapping with high-density catheters in patients with Mitraclips, requiring a hemodynamic support. METHODS: A 73-year-old man with ischemic cardiomyopathy and reduced left ventricular ejection fraction (LVEF ~ 20%) was presented due to syncope and adequate shock of his ICD. Due to severe mitral valve regurgitation (MR), two Mitraclips were implanted earlier. The decision for catheter ablation was made in line with current guidelines. Given the increased PAAINESD score, the use of hemodynamic support was required. To employ an Impella pump via the retrograde transaortic approach, LV-mapping and VT-ablation were necessary to be performed via the transseptal approach, which was challenging due to the presence of Mitraclips. The MV passage with the steerable sheath was guided by a quadripolar catheter and 3D transoesophageal echo (TEE). After the 12F steerable sheath had passed the MV, the quadripolar catheter was exchanged by a high-density (HD) Grid® catheter. Hereafter, the Impella pump was placed retrogradely in the LV, and voltage-mapping of the LV and ablation was performed. RESULTS: At the end of the procedure, the Impella pump could be removed in stable hemodynamic conditions. The follow-up after 3, 6, and 12 months showed no new VT episodes. CONCLUSIONS: This case demonstrates the feasibility of the transseptal approach of VT mapping used HD Grid catheter and retrograde hemodynamic support with Impella Pump for VT treatment in patients after Mitraclips implantation. To avoid a damage of the MV and Mitraclips, 3D-TEE is advisable.

QTc evaluation in patients with bundle branch block.

Proper measurement of the QT interval on the 12-lead body-surface ECG is challenging in daily practice. Even more difficult is its correct estimation in the presence of repolarization abnormalities, arrhythmias or bundle-branch blocks (BBB). The QT interval results from two parts of the ECG: (1) the QRS complex, describing the excitation of the ventricles and (2) the JT interval, describing the repolarisation of the ventricles. Prolongation of the QRS width - like in the presence of BBB - entails prolongation of the QT interval, making the estimation of the true repolarisation time challenging. The US recommendations for the standardization and interpretation of the ECG suggest focusing on the JT interval in presence of BBB. However, in clinical practice physicians have become more familiar with the interpretation of QT-interval measurements than with the interpretation of the JT Interval. In the last decade, a simple formula for the estimation of the "modified QT interval" in the presence of left or right BBB has been developed and evaluated. In this formula, the modified QT interval is calculated by subtracting 50% of the length of the BBB-QRS from the measured QT interval (QTm = QTBBB - 50% QRSBBB). Subsequently, rate-correction formula should be applied as usual. In this review, we discuss the determination of the QT-interval in the presence of BBB and summarize the origin and application of the modified QT-interval formula.

[Electrical storm : Recognition and management]. / Elektrischer Sturm : Erkennung und Beherrschung.

The electrical storm (ES) defined as ≥3 sustained episodes of ventricular tachycardia within a 24 h period comprises a wide spectrum of clinical entities. Mostly patients suffer from severe heart insufficiency and comorbidities making an immediate transfer into a heart center with multidisciplinary expertise in the treatment of ES mandatory. As these patients are often traumatized by ongoing tachycardia despite multiple cardioversions, early deep sedation and ß­blockade to break the vicious circle of sympathico-adrenergic hyperactivation is very effective. Multiple ICD discharges suggesting the diagnosis of ES are inadequate in one third of cases. Pharmacological suppression, frequency control or ablation of supraventricular tachycardias (SVT) help in most cases. In some cases "oversensing" demands optimization of ICD programming. Even so not all adequate ICD discharges, however, are necessary. Since every ICD discharge worsens the patient's prognosis, any kind of ICD discharge should be prevented as far as hemodynamically feasible. After clinical stabilization of the patient with simultaneous acquisition of ECG and testing for reversible causes of ES, ES should be terminated by external or internal cardioversion followed by urgent but elective therapy. Some cases of ES, however, may require immediate escalation of therapy with emergency ablation or revascularization sometimes with circulatory support systems. If ES still persists, a further step in escalation may be taken by cardiac sympathetic denervation. Due to the poor prognosis of patients after ES, close monitoring of the patient, preferably with telemedicine, is indicated.