Computed tomography-derived left atrial volume index, sex, and age to predict the presence and the extent of left atrial low-voltage zones in patients with atrial fibrillation: The ZAQ score.

BACKGROUND: Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low-voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single-shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. OBJECTIVE: We hypothesized that computed tomography (CT)-derived left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. METHODS: In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electroanatomic voltage maps were created. LVZs were defined as areas ≥1 cm2 with bipolar peak-to-peak voltage amplitudes ≤0.5 mV. RESULTS: In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the Zentralklinik Bad Berka and University of L'Aquila (ZAQ) score (age ≥65 years; female sex; and CT-LAVI ≥57 mL/m2 ). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (area under the curve [AUC], 0.809; 95% confidence interval [CI], 0.758-0.861; P < .001 and 3 [interquartile range, IQR, 1.5-4.5] vs 7 cm2 [IQR 4-9]; P = .001). In a validation cohort of 103 patients, the predictive value of the score was confirmed (AUC, 0.793; 95% CI, 0.709-0.878; P < .001 and 4 [IQR, 2-7] vs 11.5 cm2 [IQR, 8-16.5]; P = .001). CONCLUSIONS: The ZAQ score identifies LVZs and may be useful for planning the ablation strategy ahead of time.

Electrocardiographic and Electrophysiological Characteristics of Atrial Tachycardia With Early Activation Close to the His-Bundle.

INTRODUCTION: Radiofrequency (RF) ablation of atrial tachycardia (AT) with earliest activation at the His-bundle may be associated with the risk of AV block, and detection of this AT origin using the electrocardiogram (ECG) would be helpful in planning ablation. Aim of this study was to characterize the P-wave morphology and intracardiac electrograms at the successful ablation site for this group of ATs. METHODS: All consecutive patients undergoing ablation for AT with earliest activation at the His-bundle were included. Twelve-lead ECG and intracardiac electrograms were analyzed. RESULTS: A total of 33 patients underwent successful ablation. The P-wave and the PR interval during AT (cycle length 460 ± 88, range 360-670 milliseconds) were significantly shorter compared to sinus rhythm 87 ± 18 vs. 117 ± 23 and 131 ± 37 vs. 170 ± 47 milliseconds, respectively, P < 0.01. In 28 patients (85%), the P-wave was biphasic (-/+) or triphasic (+/-/+) in the precordial leads, especially V4 -V6 , and in 25 patients (76%) it was biphasic (-/+) or triphasic (+/-/+) in the inferior leads. RF was delivered at the following locations: noncoronary aortic cusp (NCC) in 24 patients, antero-septal left atrium in 4, supero-septal right atrium in 3, left coronary cusp in 1, and between the right coronary cusp and the NCC in 1. Atrial bipolar electrograms at the successful ablation site preceded the P-wave by 38 ± 11 (range 10-60) milliseconds, and AT termination was obtained after a mean RF energy time of 10 ± 8 (range 2-31) seconds. CONCLUSION: A characteristic narrow and biphasic (-/+) or triphasic (+/-/+) P-wave in the inferior and precordial leads reliably identifies the group of AT arising from the para-Hisian region.

Isolated Disruption of the Right Coronary Artery Following a Steam Pop during Cavotricuspid Linear Ablation with a Contact Force Catheter.

A 70-year-old woman with persistent atrial fibrillation underwent pulmonary vein isolation and linear ablation with a contact sensor catheter. During cavotricuspid isthmus ablation, a steam pop resulted in cardiac tamponade, and the patient developed severe hypotension despite successful pericardial puncture and minimal residual pericardial effusion. Right coronary artery angiography revealed extravasal contrast medium accumulation posterior of the Crux Cordis. Emergent cardiac surgery confirmed isolated disruption of the artery in the absence of additional heart perforation. Although contact sensor catheters may reduce complications, steam pops can still occur and result in dramatic complications.

Mental health and patterns of work-related coping behaviour in a German sample of student teachers: a cross-sectional study.

PURPOSE: The aim of this cross-sectional study was to evaluate the mental health of student teachers, to analyse the extent to which they feel prepared for their profession by the university curriculum and to investigate patterns of coping with occupational stress. METHODS: A sample of 481 German student teachers was investigated using two standardised instruments: GHQ-12 (General Health Questionnaire) and AVEM (Arbeitsbezogenes Verhaltens- und Erlebensmuster), an occupational stress and coping questionnaire describing four patterns of work-related coping behaviour. In addition, we asked how well the student teachers felt that the curriculum prepared them for their profession. RESULTS: Forty-four per cent of the student teachers report impaired mental health in the second teacher training period, indicated by a GHQ value equal to or over the cut-off of four. The AVEM responses revealed more than 40% showing risk patterns (A or B) compared to only 26.3% displaying a healthy coping style (G), while 32.8% demonstrate an unambitious style (S). These GHQ values are inversely correlated with the extent to which student teachers feel prepared for their work by the university curriculum. CONCLUSIONS: Our data indicate a problematic stress level for student teachers in the second training phase (high exposure to health risks and unfavourable coping styles). Since teaching is clearly an extremely demanding job, it is vital that teacher training systems contribute towards protecting the health of teachers by focusing on fostering healthy personal attitudes and equipping young teachers with coping styles and skills that will better prepare them for the challenges facing them in their daily work. Self-care health management should also be part of the teacher training curriculum.

Catheter ablation of ventricular ectopy with para-hisian origin: importance of mapping both sides of the interventricular septum and understanding when to stop ablating.

Catheter ablation of para-Hisian premature ventricular contractions (PVCs) still represents a challenge and is a compromise between success and inadvertent AV block. We describe a possible strategy to address PVCs from this location with high-amplitude His-bundle potentials at the site of earliest activation.

Residual conduction after pulmonary vein isolation with a circular multielectrode radiofrequency ablation catheter: the role of adenosine and orciprenalin during a prolonged observation time.

INTRODUCTION: Recurrences after pulmonary vein isolation (PVI) in patients (pts) with paroxysmal atrial fibrillation (AF) are mostly due to PV reconnection. The effect of adenosine, orciprenalin and their combination on left atrial PV conduction after PVI with a phased radiofrequency (RF) circular multielectrode ablation catheter (Pulmonary Vein Ablation Catheter, PVAC) was prospectively evaluated during a prolonged waiting time. In addition, it was assessed whether pharmacological reconnection characterizes veins requiring use of an irrigated catheter. METHODS AND RESULTS: In 116 consecutive pts [age 62 (IQR:52,68) years, 46% female], PVI was achieved with the PVAC alone in 114/116 (98%) pts and 461/464 (99%) veins after a median of 26 (IQR:22,32) applications delivering 1782 s (IQR:1518,2197) of RF. Mostly transient PV reconnections were observed in 40/116 (34%) pts and 57/464 (12%) PVs, a median of 44 (IQR:30,58) min after initial isolation. Adenosine, alone (43/57, 75%) or during orciprenalin infusion (7/57, 12%), unmasked residual conduction in the majority of veins (50/57, 88%). Additional PVAC applications less frequently achieved permanent isolation in veins showing reconnection compared to those that didn't (52/57, 91% vs. 404/407, 99%; P < .001). All PVs that could not be isolated with the PVAC were successfully treated with a standard irrigated catheter. CONCLUSIONS: After apparent PVI with the PVAC, drug-challenge after prolonged observation unmasked residual PV conduction in a significant number of pts, and adenosine was the most effective strategy. Drug-induced PV reconnection was difficult to treat with the PVAC. Whether this strategy improves clinical outcome of PVI with phased RF needs to be investigated.

A case of Prinzmetal angina diagnosed by Holter monitoring who survived a sudden cardiac death: Case report.

A 47-year-old female patient was admitted to our hospital after a syncope. She reported episodes of angina in previous weeks. On admission, there were no electrocardiographic changes but elevated troponin. Coronary angiogram showed minimal arteriosclerosis and normal left ventricle. Holter monitoring showed severe ST-segment changes during an anginal episode.With calcium antagonists, the patient experienced no further episodes of angina or ST changes during telemetry.Six weeks later, calcium antagonist was stopped for unknown reason. After that, the patient experienced a second prolonged syncope with cardiopulmonary resuscitation and defibrillation of ventricular fibrillation. DISCUSSION: "A variant form of angina pectoris" was first described by Myron Prinzmetal. He postulated coronary vasospasm as the underlying cause, however, after 50 years the exact pathophysiology is still not known.Patients with "variant angina" usually present with "spontaneous" attacks of typical retrosternal anginal pain during rest or normal activities, but not with physical exercise.Sudden cardiac deaths were reported in patients with Prinzmetal angina in only a few case reports. CONCLUSION: In cases of variant angina accompanied by syncope, a provocation test and an electrophysiological study should be considered.

Working conditions, adverse events and mental health problems in a sample of 949 German teachers.

OBJECTIVES: The aim of this study was (1) to explore in detail the working load of teachers, (2) to analyse the extent of negative or threatening school-related events teachers are confronted with, and (3) to evaluate mental health strain by applying the general health questionnaire (GHQ). METHODS: A sample of 949 teachers in 10 grammar schools (German: Gymnasien) and 79 secondary modern schools (German: Hauptschulen) was investigated applying (1) a questionnaire covering different aspects of the occupational burden and threatening school-associated events and (2) the general health questionnaire (GHQ-12). RESULTS: Based on what teachers indicated in the questionnaire, full-time teachers work more than 51 h weekly. More than 42% of our sample indicated verbal insults, almost 7% deliberate damage of personal belongings, and 4.4% threat of violence by pupils during the past 12 months. When applying the GHQ-12, we found that 29.8% of the sample report significant mental health problems. With respect to school types, teachers in secondary modern schools indicated more of such problems, while no effects regarding age, gender, or full/part-time teaching were observed. CONCLUSIONS: To be a teacher is a hard work and requires coping of considerable amount of adverse events. Based on the GHQ, nearly 30% of teachers suffer from significant mental health problems.

Burnout and effort-reward-imbalance in a sample of 949 German teachers.

OBJECTIVES: High rates of teachers' premature retirement initiated a research investigating their occupational burden. The aim of this study was to elaborate on and extend previous investigations exploring (1) teacher burnout and (2) the relationship between teachers' efforts and their rewards. METHODS: A sample of 949 German teachers in 10 Gymnasien (grammar schools) and 79 Hauptschulen (secondary modern schools) was investigated applying the Maslach Burnout Inventory (MBI-D) and the Effort Reward Imbalance Inventory (ERI). RESULTS: Compared with other studies investigating burnout in employees, we found high rates of burnout symptoms such as emotional exhaustion, depersonalisation, and low personal accomplishment. Male teachers showed significantly lower personal accomplishment and more depersonalization than female teachers. With respect to school types, teachers in Hauptschulen were more often affected by emotional exhaustion and showed more depersonalization. Part-time teachers felt less personal accomplishment than full-time teachers. The ERI cut off was exceeded by 21.6% of all teachers indicating that this subgroup is affected by an imbalance between too much effort and too little reward. With respect to the ERI, significant differences were found for school types, with a higher proportion of Hauptschulen teachers being above this cut off. CONCLUSIONS: At present, the working situation of teachers appears to be characterized by a perceived imbalance of effort and reward and is associated with a high risk of developing burnout symptoms.