[Impact of cardiovascular diseases on fitness to drive: mobility limitations in the elderly]. / Einfluss kardiovaskulärer Erkrankungen auf die Fahreignung: Mobilitätseinschränkungen im Alter.

The prevalence of cardiovascular diseases increases with age. Common symptoms such as dyspnea, chest pain, dizziness, or syncope can impact driving fitness. Due to a growing number of private drivers aged 65 and older and an increasing prevalence of cardiovascular diseases, questions regarding driving fitness restrictions for cardiological patients are gaining prominence in clinical settings. This article aims to summarize current recommendations for driving fitness in the context of cardiovascular diseases. The basis for the guidelines includes the Driving License Ordinance, the expert assessment guidelines of the Federal Highway Research Institute, and the guidelines of the German Society of Cardiology on driving fitness. Original literature on this topic is limited.Emphasizing an individualized assessment, clear guidelines for driving fitness in cardiac diseases or their symptoms and treatments are formulated. Regardless of the cardiac condition, the symptoms and likelihood of sudden loss of consciousness play a leading role in driving fitness assessment. Resulting impairments can range from a few weeks to a complete revocation of driving fitness. Regular examinations and differentiated assessments by medical professionals are prerequisites for maintaining driving fitness.The driving fitness of older private drivers is a significant and practical topic in cardiology. Current guidelines support the treating physicians in providing appropriate recommendations.

3 Tesla magnetic resonance imaging in patients with cardiac implantable electronic devices: a single centre experience.

AIMS: Three Tesla (T) magnetic resonance imaging (MRI) provides critical imaging information for many conditions. Owing to potential interactions of the magnetic field, it is largely withheld from patients with cardiac implantable electronic devices (CIEDs). Therefore, we assessed the safety of 3T MRI in patients with '3T MRI-conditional' and 'non-3T MRI-conditional' CIEDs. METHODS AND RESULTS: We performed a retrospective single-centre analysis of clinically indicated 3T MRI examinations in patients with conventional pacemakers, cardiac resynchronization devices, and implanted defibrillators from April 2020 to May 2022. All CIEDs were interrogated and programmed before and after scanning. Adverse events included all-cause death, arrhythmias, loss of capture, inappropriate anti-tachycardia therapies, electrical reset, and lead or generator failure during or shortly after MRI. Changes in signal amplitude and lead impedance were systematically assessed. Statistics included median and interquartile range. A total of 132 MRI examinations were performed on a 3T scanner in 97 patients. Thirty-five examinations were performed in patients with 'non-3T MRI-conditional' CIEDs. Twenty-six scans were performed in pacemaker-dependent patients. No adverse events occurred during or shortly after MRI. P-wave or R-wave reductions ≥ 50 and ≥ 25%, respectively, were noted after three (2.3%) scans, all in patients with '3T MRI-conditional' CIEDs. Pacing and shock impedance changed by ± 30% in one case (0.7%). Battery voltage and stimulation thresholds did not relevantly change after MRI. CONCLUSION: Pending verification in independent series, our data suggest that clinically indicated MRI scans at 3T field strength should not be withheld from patients with cardiac pacemakers or defibrillators.

Hybrid transvenous lead extraction during cardiac surgery for valvular endocarditis.

INTRODUCTION: In patients with endocarditis and cardiac implantable electronic devices (CIED), lead extraction is recommended according to current guidelines. In patients with short lead implant duration, lead extraction by manual traction might be sufficient for intraoperative lead removal. However, in patients with long implant duration, specialized extraction tools like laser or mechanical rotational sheaths are necessary. We report our experience with transvenous lead extraction during concomitant cardiac surgery for valvular endocarditis using mechanical rotational sheaths. METHODS AND RESULTS: Between December 2018 and April 2020, 12 patients were treated with transvenous lead extraction during open-heart surgery using mechanical rotational sheaths. Cardiac surgery was performed due to mitral, aortic, or tricuspid valve endocarditis. All patient-related and procedural data were collected, and in-hospital outcome was analyzed retrospectively. Mean patients' age was 65.2 ± 16.4 years, and 75.0% were male. Nine atrial, 15 ventricular, and 2 coronary sinus leads had to be extracted. The mean time from initial lead implantation was 94.3 ± 39.7 months. Complete procedural success was achieved in all patients with no major but one minor complication (pocket hematoma) occurring during lead extraction. Four patients with pacemaker dependency received epicardial leads, seven patients were treated in a two-step approach with endocardial leads, whereas one patient had no further CIED indication. No procedure-related mortality was seen. In-hospital survival was 91.7%. CONCLUSIONS: Valvular endocarditis surgery in combination with lead extraction using mechanical rotational sheaths is safe and feasible. It results in a high procedural success rate with prompt infection control by immediate removal of all infected lead materials.

Minimally invasive epicardial left-ventricular lead implantation and simultaneous left atrial appendage closure.

Background: Atrial fibrillation (AF) is common in patients with heart failure resulting in a high prevalence of AF in patients receiving Cardiac Resynchronization Therapy (CRT) implantation. In patients, unsuitable for transvenous left ventricular (LV)-lead implantation, epicardial LV-lead implantation represents a valuable alternative. Epicardial LV-lead placement can be achieved totally thoracoscopical or via minimally invasive left lateral thoracotomy. In patients with atrial fibrillation, concomitant left atrial appendage (LAA) clipping is feasible via the same access. Therefore, the aim of our study was the analysis of safety and efficacy of epicardial LV lead implantation and concomitant LAA clipping via minimally invasive left-lateral thoracotomy. Methods: Between December 2019 and March 2022, 8 patients received minimally invasive left atrial LV-lead implantation with concomitant LAA closure using the AtriClip. Transesophageal echocardiography (TEE) was performed to intraoperatively guide and control LAA closure. Results: Mean patients age was 64 ± 11.2 years, 67% were male patients. Minimally invasive left-lateral thoracotomy was used in 6 patients while a totally thoracoscopic approach was performed in 2 cases. Epicardial lead implantation was successfully performed in all patients with good pacing threshold (mean 0.8 ± 0.2 V) and sensing values (10.1 ± 2.3 mV). Posterolateral position of the LV lead was achieved in all patients. Furthermore, successful LAA closure was confirmed during TEE in all patients. No procedure-related complications occurred in any of the patients. Two patients additionally received simultaneous laser lead extraction during the same procedure. Complete lead extraction was achieved in both patients. All patients were extubated in the OR and had an uneventful postoperative course. Conclusion: Our study highlights a novel treatment approach for patients with atrial fibrillation and the necessity of epicardial LV leads. Placement of a posterolateral LV lead position with concomitant occlusion of the left atrial appendage via a minimally-invasive left-lateral thoracotomy or even a totally thoracoscopic approach is safe and feasible with superior cosmetic result and complete occlusion of the left atrial appendage.

Prognostic impact of implantable cardioverter defibrillators and associated adverse events in patients with continuous flow left ventricular assist devices.

Objectives: Implantation of implantable cardioverter defibrillators (ICD) reduces the risk of all-cause mortality in symptomatic heart failure (HF) patients with severe left ventricular (LV) dysfunction. Nevertheless, the prognostic impact of ICD therapy in continuous flow left ventricular assist device (LVAD) recipients remains controversial. Methods: 162 consecutive HF patients, who underwent LVAD implantation at our institution between 2010 and 2019, were categorized according to the presence (n = 94, ICD-group) or absence (n = 68, Control-group) of ICDs. Apart from clinical baseline and follow-up parameters, adverse events (AEs) related to ICD therapy and overall survival rates were retrospectively analyzed. Results: Out of 162 consecutive LVAD recipients 79 patients (48.8%) were preoperatively categorized as Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile ≤2. The prevalence of severe HF symptoms and preoperative use of short-term circulatory support devices (54.4% vs. 13.8%, p < 0.001) was higher within the Control-group, although baseline severity of LV and RV dysfunction was similar. Apart from an increased prevalence of perioperative right heart failure (RHF) within the Control-group (45.6% vs. 17.0%; p < 0.001), procedural characteristics and perioperative outcome were similar. Overall-survival during a median follow-up of 14 (3.0-36.5) months was similar within both groups (p = 0.46). During the first 2 years after LVAD implantation 53 ICD-related AEs occurred within the ICD-group. Thereof, lead-dysfunction occurred in 19 patients and unplanned ICD-reintervention in 11 patients. Furthermore, in 18 patients appropriate shocks without loss of consciousness occurred, whereas inappropriate shocks occurred in 5 patients. Conclusion: ICD therapy in LVAD recipients was not associated with a survival benefit or reduced morbidity after LVAD implantation. Conservative ICD-programming seems to be justified to avoid ICD-related complications and "awake shocks" after LVAD implantation.

Incidence of premature battery depletion in subcutaneous cardioverter-defibrillator patients: insights from a multicenter registry.

BACKGROUND: The subcutaneous ICD established its role in the prevention of sudden cardiac death in recent years. The occurrence of premature battery depletion in a large subset of potentially affected devices has been a cause of concern. The incidence of premature battery depletion has not been studied systematically beyond manufacturer-reported data. METHODS: Retrospective data and the most recent follow-up data on S-ICD devices from fourteen centers in Europe, the US, and Canada was studied. The incidence of generator removal or failure was reported to investigate the incidence of premature S-ICD battery depletion, defined as battery failure within 60 months or less. RESULTS: Data from 1054 devices was analyzed. Premature battery depletion occurred in 3.5% of potentially affected devices over an observation period of 49 months. CONCLUSIONS: The incidence of premature battery depletion of S-ICD potentially affected by a battery advisory was around 3.5% after 4 years in this study. Premature depletion occurred exclusively in devices under advisory. This is in line with the most recently published reports from the manufacturer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04767516 .

Two versus one repeat freeze-thaw cycle(s) after cryoballoon pulmonary vein isolation: the alster extra pilot study.

BACKGROUND: Repeated freezing (bonus applications) during cryoballoon pulmonary vein isolation (PVI) has been suggested to improve lesion durability. However, the long-term clinical effects of repeated freezing have not been investigated. METHODS AND RESULTS: A total of 51 patients (pts) with paroxysmal atrial fibrillation (AF) underwent PVI using the single big (28 mm) cryoballoon technique. One (27 pts, group I) or 2 bonus applications (24 pts, group II) were performed at all PVs subsequent to PVI. Clinical follow-up consisted of continuous rhythm monitoring by an implantable cardiac monitor (ICM, 24 pts) and serial 7-day Holter-ECG recording (7DH, 27 pts). The primary endpoint was defined as recurrent AF or atrial tachycardia. Acute PVI of all PVs was obtained in 50/51 pts (98%). The median (Q1;Q3) follow-up duration in this study was 384 (213;638) days. The primary endpoint occurred in 48% (group I, 15 pts ICM, 12 pts 7DH) and 46% (group II, 9 pts ICM, 15 pts 7DH), P = 0.84. Procedure- and fluoroscopy-time for group I versus group II was 193 ± 56 minutes versus 207 ± 27 and 33 ± 13 minutes versus 34 ± 11 minutes, respectively. Right phrenic nerve palsy (PNP) occurred in 3 pts (all group II, time to resolution: 128 ± 112 days). In 2 of these pts, PNP occurred during the second bonus application. CONCLUSION: Application of 2 when compared to 1 freeze-thaw cycle(s) following cryoballoon PVI did not result in improved clinical success but was associated with a higher complication rate.

Laser Lead Extraction During Venoarterial ECMO support.

The treatment of valvular endocarditis in patients with cardiac implantable electrophysiological device (CIED) includes valvular surgery and lead extraction. This can be challenging in patients with severely reduced left ventricular ejection fraction (LVEF). Reduced LVEF in combination with sepsis and cardioplegic cardiac arrest can make weaning from cardiopulmonary bypass difficult. Some of these patients require venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy syndrome. Lead extraction by manual traction is often not possible in cases with a long lead dwell time. Therefore, a lead extraction procedure with powered sheaths is required during the VA-ECMO support. We describe our technique for laser lead extraction during VA-ECMO support in a 64-year-old patient with triple valve endocarditis and lead vegetations.

Catheter Ablation of Atrial Fibrillation: State of the Art and Future Perspectives.

PURPOSE OF REVIEW: Atrial fibrillation (AF), the most common sustained arrhythmia, is associated with high rates of morbidity and mortality. Maintenance of stable sinus rhythm (SR) is the intended treatment target in symptomatic patients, and catheter ablation aimed at isolating the pulmonary veins provides the most effective treatment option, supported by encouraging clinical outcome data. A variety of energy sources and devices have been developed and evaluated. In this review, we summarize the current state of the art of catheter ablation of AF and describe future perspectives. RECENT FINDINGS: Catheter ablation is a well-established treatment option for patients with symptomatic AF and is more successful at maintaining SR than antiarrhythmic drugs. Antral pulmonary vein isolation (PVI) as a stand-alone ablation strategy results in beneficial clinical outcomes and is therefore recommended as first-line strategy for both paroxysmal and persistent AF. While radiofrequency-based PVI in conjunction with a three-dimensional mapping system was for many years considered to be the "gold standard", the cryoballoon has emerged as the most commonly used alternative AF ablation tool, especially in patients with paroxysmal AF. Patients with persistent or long-standing persistent AF and with arrhythmia recurrence after previous PVI may benefit from additional ablation strategies, such as substrate modification of various forms or left atrial appendage isolation. New technologies and techniques, such as identification of the AF sources and magnetic resonance imaging-guided substrate modification, are on the way to further improve the success rates of catheter ablation for selected patients and might help to further reduce arrhythmia recurrence. CONCLUSIONS: Pulmonary vein isolation is the treatment of choice for symptomatic patients with paroxysmal and persistent drug-refractory AF. The reconnection of previously isolated pulmonary veins remains the major cause of AF recurrence. Novel ablation tools, such as balloon technologies or alternative energy sources, might help to overcome this limitation. Patients with non-paroxysmal AF and with AF recurrence might benefit from alternative ablation strategies. However, further studies are warranted to further improve our knowledge of the underlying mechanisms of AF and to obtain long-term clinical outcomes on new ablation techniques.

[Limitations and possibilities of noninvasive risk stratification for sudden cardiac death]. / Grenzen und Möglichkeiten der nichtinvasiven Risikostratifikation für den plötzlichen Herztod.

Therapy of sudden cardiac death is dominated by the implantable cardioverter defibrillator (ICD), which is highly efficient, but also has side effects. Therefore, the adequate selection of patients who could benefit from this therapy is crucial. For risk stratification, left ventricular ejection fraction is basically used. It has, however, neither a high sensitivity nor a high specificity. Yet, its benefit has been proven in large randomized trials. Numerous noninvasive risk stratification parameters are available and still object of research to achieve a better prediction of sudden cardiac death than actually possible. This article gives an overview of the possibilities of noninvasive risk stratification and shows the concepts and the potential benefit.

Positive impact of pulmonary vein isolation on biventricular pacing in nonresponders to cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) is less effective in patients with atrial fibrillation (AF) because of impaired ventricular CRT capture. OBJECTIVE: We investigated the effects of catheter ablation in patients with AF and previous nonresponse to CRT. METHODS: Consecutive patients with AF and CRT nonresponse who underwent catheter ablation for AF were analyzed. CRT nonresponse was defined as one of the following: (1) reduced biventricular capture <95% due to rapidly conducted AF, (2) <1 point improvement in New York Heart Association (NYHA) class after CRT implantation, or (3) insufficient increase in left ventricular ejection fraction (LVEF; ≤5%) after CRT implantation. RESULTS: Thirty-eight patients (8 women [21%]; mean age 68 ± 10 years; LVEF 30% ± 7%, biventricular capture 88.0% [25th, 75th percentile 75.3%, 98.5%]) underwent catheter ablation. One major and 1 minor complication occurred (1 lethal atrioesophageal fistula and 1 hemodynamically nonrelevant pericardial effusion). The Kaplan-Meier estimates for arrhythmia-free survival after single and multiple ablation procedures were 29% (95% confidence interval 16%-51%) and 67% (95% confidence interval 53%-86%) after 24 months. After a median follow-up of 817 days (25th, 75th percentile 179, 1741 days), biventricular capture and LVEF were significantly higher (median [25th, 75th percentile] 99% [96%, 99%], difference 8% [0.2%, 3.75%], P < .0001; mean 32.1% ± 9.1%, difference 2.2% ± 7.1%, P = .0225) and patients had a significantly lower functional NYHA class (28 of 37 patients with improvement of at least 1 point; P < .0001). CONCLUSION: Catheter ablation of AF significantly improves CRT response in patients with heart failure and concomitant AF in terms of increased biventricular capture and LVEF and improved functional NYHA class.

Laser Lead Extraction During Venoarterial ECMO support

Abstract The treatment of valvular endocarditis in patients with cardiac implantable electrophysiological device (CIED) includes valvular surgery and lead extraction. This can be challenging in patients with severely reduced left ventricular ejection fraction (LVEF). Reduced LVEF in combination with sepsis and cardioplegic cardiac arrest can make weaning from cardiopulmonary bypass difficult. Some of these patients require venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy syndrome. Lead extraction by manual traction is often not possible in cases with a long lead dwell time. Therefore, a lead extraction procedure with powered sheaths is required during the VA-ECMO support. We describe our technique for laser lead extraction during VA-ECMO support in a 64-year-old patient with triple valve endocarditis and lead vegetations.

Ventricular arrhythmias arising from the left ventricular outflow tract below the aortic sinus cusps: mapping and catheter ablation via transseptal approach and electrocardiographic characteristics.

BACKGROUND: Ventricular arrhythmias (VAs) originating from the anterosuperior left ventricular outflow tract (LVOT) represent a challenging location for catheter ablation. This study investigates mapping and ablation of VA from anterosuperior LVOT via a transseptal approach. METHODS AND RESULTS: This study included 27 patients with symptomatic VA, of which 13 patients had previous failed ablations. LVOT endocardial 3-dimensional mapping via retrograde transaortic and antegrade transseptal approaches was performed. Previous ECG markers for procedure failure were analyzed. In all patients, earliest activation with low-amplitude potentials was identified at the anterosuperior LVOT 5.1±2.8 mm below the aortic cusp and preceded the QRS onset by 39.5±7.7 ms only via an antegrade transseptal approach using a reversed S curve. In all patients, pace mapping failed to demonstrate perfect QRS morphology match. The anatomic location was below the left coronary cusp in 16, below the left coronary cusp/right coronary cusp junction in 8, and below the right coronary cusp in 3 patients. Radiofrequency energy resulted in rapid disappearance of VAs in all patients. ECG analysis showed aVL/aVR Q-wave amplitude ratio >1.4 in 7, lead III/II R-wave amplitude ratio >1.1 in 10, and peak deflection index >0.6 in 11 patients. There were no complications or clinical VA recurrence during a mean follow-up of 8.4±2.5 months. CONCLUSIONS: The anterosuperior LVOT can be reached via a transseptal approach with a reversed S curve of the ablation catheter. The rapid effect from radiofrequency energy indicates that the VA is most likely located under the endocardium. Also, previous ECG markers for procedure failure need further investigation.

[How many leads are needed for an ICD?]. / Wie viele Elektroden braucht der ICD?

In addition to secondary prevention of sudden cardiac death (SCD), the number of cardioverter defibrillator implantations (ICD) for primary prevention is increasing. An indication for primary prevention of SCD is supported by results of the MADIT II, Companion and SCD-HeFT trials. The main risk factor for SCD is the reduced left ventricular function (LVEF < or = 35%). For selecting the appropriate ICD device and the number of leads, several clinical parameters are important. For the primary prevention of SCD a single-lead VVI ICD is usually sufficient. In case of AV conduction delay and symptomatic heart failure with a prolonged QRS duration a biventricular ICD device is preferred in favor of a ventricular resynchronization. The use of a dual-chamber device should be limited to sinus nodal disease and better discrimination capabilities for slow ventricular tachycardias.