[Practical guidance for the implantation of non-transvenous ICD systems]. / Praktische Anleitung zur Implantation nicht-transvenöser ICD-Systeme.

As an alternative to transvenous ICD systems, two non-transvenous ICD systems have been established in recent years: The subcutaneous ICD (S-ICD), which has been established for several years, has a presternal electrode that is implanted subcutaneously and offers a shock function and, to a limited extent, post-shock pacing. In addition, the extravascular ICD (EV-ICD) has been available in Europe since 2023 which does not require transvenous electrodes and offers the option of providing patients with antibradycardic and antitachycardic stimulation in combination with a conventional ICD function. The lead of this device is implanted substernally. Initial implantation results are promising in terms of safety and effectiveness. Both systems avoid possible complications of transvenous electrodes. This article provides practical guidance for the implantation technique and possible complications.

[Lead placement in cardiac implantable electronic devices]. / Elektrodenplatzierung in der kardialen Devicetherapie.

The implantation of electrodes for cardiac implantable electronic devices (CIED) requires profound technical understanding and precise execution. The positioning of electrodes in the right ventricle and atrium has significant implications for patient safety and the effectiveness of CIED therapy. Particular focus is given to the distinction between apical and septal stimulation in ventricular positioning. Based on current data, this article provides a practice-oriented guide that leads implanters through the individual steps of electrode positioning. The implantation of electrodes for physiological stimulation (cardiac resynchronization therapy, CRT, and conduction system pacing, CSP) is not addressed in this article.

[Perioperative management for cardiovascular implantable electronic devices]. / Perioperatives Management bei der Versorgung mit aktiven Rhythmusimplantaten.

Cardiovascular implantable electronic devices (CIED) are an important part of modern cardiology and careful perioperative planning of these procedures is necessary. All information relevant to the indication, the procedure, and the education of the patient must be available prior to surgery. This provides the basis for appropriate device selection. Preoperative antibiotic prophylaxis and perioperative anticoagulation management are essential to prevent infection. After surgery, postoperative monitoring, telemetric control, and device-based diagnostics are required before discharge. These processes need to be adapted to the increasing trend towards outpatient care. This review summarises perioperative management based on practical considerations.

Impact of Access Site on Periprocedural Bleeding and Cerebral and Coronary Events in High-Bleeding-Risk Percutaneous Coronary Intervention: Findings from the RIVA-PCI Trial.

INTRODUCTION: The preference for using transradial access (TRA) over transfemoral access (TFA) in patients requiring percutaneous coronary intervention (PCI) is based on evidence suggesting that TRA is associated with less bleeding and fewer vascular complications, shorter hospital stays, improved quality of life, and a potential beneficial effect on mortality. We have limited study data comparing the two access routes in a patient population with atrial fibrillation (AF) undergoing PCI, who have a particular increased risk of bleeding, while AF itself is associated with an increased risk of thromboembolism. METHODS: Using data from the RIVA-PCI registry, which includes patients with AF undergoing PCI, we analyzed a high-bleeding-risk (HBR) cohort. These patients were predominantly on oral anticoagulants (OAC) for AF, and the PCI was performed via radial or femoral access. Endpoints examined were in-hospital bleeding (BARC 2-5), cerebral events (TIA, hemorrhagic or ischemic stroke) and coronary events (stent thrombosis and myocardial infarction). RESULTS: Out of 1636 patients, 854 (52.2%) underwent TFA, while 782 (47.8%) underwent the procedure via TRA, including nine patients with brachial artery puncture. The mean age was 75.5 years. Groups were similar in terms of age, sex distribution, AF type, cardiovascular history, risk factors, and comorbidities, except for a higher incidence of previous bypass surgeries, heart failure, hyperlipidemia, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 60 ml/min in the TFA group. No clinically relevant differences in antithrombotic therapy and combinations were present at the time of PCI. However, upon discharge, transradial PCI patients had a higher rate of triple therapy, while dual therapy was preferred after transfemoral procedures. Radial access was more frequently chosen for non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP) cases (NSTEMI 26.6% vs. 17.0%, p < 0.0001; UAP 21.5% vs. 14.5%, p < 0.001), while femoral access was more common for elective PCI (60.3% vs. 44.1%, p < 0.0001). No differences were observed for ST-segment elevation myocardial infarction (STEMI). Both groups had similar rates of cerebral events (TFA 0.2% vs. TRA 0.3%, p = 0.93), but the TFA group had a higher incidence of bleeding (BARC 2-5) (4.2% vs. 1.5%, p < 0.01), mainly driven by BARC 3 bleeding (1.5% vs. 0.4%, p < 0.05). No significant differences were found for stent thrombosis and myocardial infarction (TFA 0.2% vs. TRA 0.3%, p = 0.93; TFA 0.4% vs. TRA 0.1%, p = 0.36). CONCLUSIONS: In HBR patients with AF undergoing PCI for acute or chronic coronary syndrome, the use of TRA might be associated with a decrease in in-hospital bleeding, while not increasing the risk of embolic or ischemic events compared to femoral access. Further studies are required to confirm these preliminary findings.

[Lead extraction in cardiac implantable electronic devices]. / Sondenextraktionen bei implantierbaren kardialen Devices.

Lead extraction due to infection or lead dysfunction has become more important in recent years. Patients with high risk of severe and life-threatening complications should only undergo surgery in experienced centers where appropriate personnel and equipment are available. In this review, different techniques and methods to safely and successfully perform transvenous lead extraction are summarized.

[Venous access routes for cardiac implantable electronic devices]. / Venöse Zugangswege in der kardialen Devicetherapie.

Various venous access routes in the region of the clavicle are available for cardiac device treatment. After many years of choosing access via the subclavian vein, current data explicitly show that lateral approaches such as preparation of the cephalic vein or puncture of the axillary vein are clearly superior in terms of probe durability and risk of complications. This article describes the preparation and performance of the various access techniques and is intended to provide a practical guide for the work in cardiac pacemaker operations. This work continues a series of articles designed for advanced training in specialized rhythmology.

A worldwide survey on incidence, management, and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: the POTTER-AF study.

AIMS: Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse. METHODS AND RESULTS: This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001]. CONCLUSION: Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.

[Mentorship in electrophysiology : What does it take? What's the advantage?] / Mentorship in der Rhythmologie : Was braucht es? Was bringt es?

Mentoring has long been a fundamental part of medical education. In this article, the term mentoring is defined and the requirements, advantages, and methods of structuring are discussed. Further, the use of mentoring in the context of education in electrophysiology will be highlighted. In this setting, requirements on the personal level of mentors and mentees as well as on the institutional level are outlined, and different phases and types of mentoring are discussed.

[Focal atrial tachycardias: diagnostics and therapy]. / Fokale atriale Tachykardien: Diagnostik und Therapie.

In this article, typical characteristics of focal atrial tachycardias are described and a systematic approach regarding diagnostics and treatment options in the field of invasive cardiac electrophysiology (EP) is presented. Subjects of this article include the definition of focal atrial tachycardias, knowledge about localizing the origin of such, and guidance on how to approach an invasive EP study (e.g., administration of medication during the EP study to provoke tachycardias). Further, descriptions will be found on how to localize the origin of focal atrial tachycardias with the help of the 12-lead ECG and invasive three-dimensional mapping to successfully treat focal atrial tachycardias with catheter ablation.

[Atypical atrial fibrillation : Diagnostics and therapy]. / Atypisches Vorhofflattern : Diagnostik und Therapie.

In contrast to typical atrial flutter, atypical atrial flutter is a heterogeneous group of right and left atrial macro- or localized reentry tachycardias whose critical component for maintaining tachycardia is not the cavotricuspid isthmus. Atypical atrial flutter occurs more frequently after previous catheter ablation and after cardiac surgery. The intraprocedural success rate during ablation is high, although the recurrence rate depends on structural changes in the atria as well as the underlying mechanism. This article provides an overview of the mechanisms as well as mapping and ablation strategies of the most common forms of right and left atrial atypical atrial flutter. This article is part of the "EP Basics" series for targeted continuing education in invasive electrophysiology. Basics, clinic and therapy of atypical atrial flutter are presented with focus on clinically relevant aspects. Procedures and findings of invasive electrophysiological diagnostics and ablation treatment are the focus of this article.

Ablation of typical atrial flutter as therapeutic component in carcinoid heart disease: a case report.

BACKGROUND: Carcinoid heart disease is the cardiac manifestation of carcinoid syndrome. There is limited research on rhythm management in patients with carcinoid heart disease. The association of typical atrial flutter and carcinoid heart disease in particular is poorly described. CASE PRESENTATION: Here we present a case of a 77-year-old German woman with carcinoid heart disease and recurrent typical atrial flutter complicating the postoperative course after tricuspid valve replacement and its successful long-term rhythm control by ablation therapy. CONCLUSION: There is limited evidence on rhythm management in patients with the rare diagnosis of carcinoid heart disease. Typical atrial flutter repeatedly complicated the postoperative course of our patient with carcinoid heart disease and could finally be treated curatively by ablation. Radiofrequency ablation should be considered as a valuable therapeutic component in the challenging therapy of this disease.

[Catheter ablation of ventricular tachycardias in patients with ischemic cardiomyopathy]. / Katheterablation ventrikulärer Tachykardien bei Patienten mit ischämischer Kardiomyopathie.

Radiofrequency (RF) ablation is an effective treatment option of scar-related ventricular tachycardias (VT) in patients with ischemic cardiomyopathy. Several studies proved the benefit of VT catheter ablation, which has become routine in most electrophysiology laboratories. This article provides practical instructions to perform a VT catheter ablation. The authors describe conventional and substrate-based mapping and ablation strategies as well as concepts for image integration. This article continues a series of publications created for education in advanced electrophysiology.

Catheter ablation of supraventricular tachycardia in patients with and without structural heart disease: insights from the German ablation registry.

AIM: To compare patient characteristics, safety and efficacy of catheter ablation of supraventricular tachycardia (SVT) in patients with and without structural heart disease (SHD) enrolled in the German ablation registry. METHODS AND RESULTS: From January 2007 until January 2010, a total of 12,536 patients (37.2% with known SHD) were enrolled and followed for at least one year. Patients with SHD more often underwent ablation for atrial flutter (45.8% vs. 20.9%, p < 0.001), whereas patients without SHD more often underwent ablation for atrioventricular nodal reentrant tachycardia (30.2% vs. 11.8%, p < 0.001) or atrioventricular reentrant tachycardia (9.1% vs. 1.6%, p < 0.001). Atrial fibrillation catheter ablation procedures were performed in a similar proportion of patients with and without SHD (38.1% vs. 36.9%, p = 0.21). Overall, periprocedural success rate was high in both groups. Death, myocardial infarction or stroke occurred in 0.2% and 0.1% of patients with and without SHD (p = 0.066). Major non-fatal complications prior to discharge were rare and did not differ significantly between patients with and without SHD (0.5% vs. 0.4%, p = 0.34). Kaplan-Meier mortality estimate at 1 year demonstrated a significant mortality increase in patients with SHD (2.6% versus 0.7%; p < 0.001). CONCLUSION: Patients with and without SHD undergoing SVT ablation exhibit similar success rates and low major complication rates, despite disadvantageous baseline characteristics in SHD patients. These data highlight the safety and efficacy of SVT ablation in patients with and without SHD. Nevertheless Kaplan-Meier mortality estimates at 1 year demonstrate a significant mortality increase in patients with SHD, highlighting the importance of treating the underlying condition and reliable anticoagulation if indicated.

[Practical guide for safe and efficient cryoballoon ablation for atrial fibrillation : Practical procedure, tips and tricks]. / Leitfaden zur sicheren und effizienten Kryoballon-Vorhofflimmerablation : Praktisches Vorgehen, Tipps und Tricks.

In the current guidelines on treatment of atrial fibrillation, cryoballoon-based catheter ablation of atrial fibrillation is recommended in addition to radiofrequency ablation and has become established as a standard procedure in the clinical routine of many centers for index pulmonary vein isolation. A safe, simplified and often durable pulmonary vein isolation can be achieved by a systematic approach. This review article provides a practical guide for all steps of cryoballoon-based pulmonary vein isolation, including preprocedural preparation and postinterventional follow-up. Both cryoballoon systems currently available on the market are considered.

[Pulmonary vein isolation using radiofrequency ablation]. / Pulmonalvenenisolation mittels Radiofrequenzablation.

Catheter ablation represents the primary treatment for most arrhythmias. The effectiveness of catheter ablation for the treatment of atrial fibrillation is superior to drug therapy. Therefore, catheter ablation has been established as an increasingly common procedure in clinical routine. In this context, the electrical isolation of the pulmonary veins (PVI) constitutes the cornerstone of the interventional therapy of paroxysmal and persistent atrial fibrillation. This article describes the procedure of pulmonary vein isolation utilizing radiofrequency point-by-point ablation. It shall be a practical guide for the staff in the electrophysiological laboratory. This article continues a series of manuscripts focusing on interventional electrophysiology topics in the course of EP (electrophysiology) training.This article describes the procedure of pulmonary vein isolation utilizing radiofrequency point-by-point ablation. It shall be a practical guide for the staff in the electrophysiological laboratory. This article continues a series of manuscripts dealing with topics of interventional electrophysiology in the course of EP training.

Ablation Therapy as Management of Typical Atrial Flutter in the Early Period After Cardiac Surgery.

INTRODUCTION: Available data on management of atrial flutter in the early postoperative setting after cardiac surgery are scarce. We aimed to investigate the safety and efficacy (profile) of flutter ablation in the early postoperative phase (30 days after cardiac surgery) in a cohort of 47 consecutive patients. METHODS: Between 2007 and 2016, 47 patients who underwent ablation for postoperative typical atrial flutter were retrospectively identified and analyzed. Follow-up data were acquired from patients' records in case of rehospitalization and via follow-up calls. RESULTS: The median age of patients was 69 years, 89% male and with a median LV-EF of 55%. CAD was present in 80.8% of patients. The predominant conduction of atrial flutter was 2:1 (76.6%); 85.1% of patients had either undergone CABG, SAVR, or a combination of these two. Acute procedural success could be achieved in 100% of patients with one vascular pseudoaneurysm that was managed conservatively. No other complications occurred. After a median follow-up of 5.7 years, follow-up information regarding heart rhythm was available in 87.2% of patients. One patient (2.1%) had undergone repeat ablation for typical flutter. Two patients (4.2%) had developed atrial fibrillation, while 87.2% of patients were in sinus rhythm. CONCLUSIONS: In this small cohort, early postoperative ablation of typical flutter was associated with a favorable short- and long-term safety and efficacy profile and can be considered part of heart rhythm management options in this setting.

[Puncture techniques in invasive cardiac electrophysiology]. / Punktionstechniken in der invasiven Elektrophysiologie.

Due to good results, increasing standardization and lack of equivalent alternatives, catheter ablation has been established as an increasingly common procedure in clinical routine. This article describes common and necessary puncture techniques in catheter ablation (puncture of the groin vessels, transseptal puncture, pericardial puncture) and represents a practical instruction for the catheter laboratory. This article is part of a series of manuscripts presenting topics of interventional electrophysiology in the course of electrophysiology training.

Typical atrial flutter but not fibrillation predicts coronary artery disease in formerly healthy patients.

AIMS: Long-term mortality after ablation of typical atrial flutter has been found to be increased two-fold in comparison to atrial fibrillation ablations through a period of 5 years with unclear mechanism. METHODS AND RESULTS: We analysed 189 consecutive patients who underwent ablation for typical atrial flutter (AFL), in which the incidence of AF was the first manifestation of cardiac disease. According to the clinical standards of our centre, the routine recommendation was to evaluate for coronary artery disease (CAD) by invasive angiogram or computed tomography scan. We compared the AFL patients to 141 patients with paroxysmal atrial fibrillation (AFIB) without known structural heart disease who underwent ablation in the same period and who had routine coronary angiograms performed. Out of 189 patients who presented with AFL, coronary status was available in 152 patients (80.4%). Both groups were balanced for mean age (64.9 years in AFL vs. 63.2 years in AFIB; P = 0.15), body mass index (BMI; 28.8 vs. 28.5 kg/m2; P = 0.15), CHA2DS2-VASc-Score (2.20 vs. 2.04; P = 0.35), smoking status (22.2% smokers vs. 28.4%; P = 0.23), and renal function (GFR >60 mL/min in 96.7% of all patients vs. 95.7%; P = 0.76). There were significantly lower values for left ventricular ejection fraction (52.5% vs. 59.7%; P < 0.001), female sex (17.0% vs. 47.5%; P < 0.001), hyperlipidaemia (37.9% vs. 58.9%; P < 0.001), and family history of cardiovascular disease (CVD) (15.0 vs. 31.9%; P = 0.001) in the AFL vs. AFIB cohorts. Coronary artery disease with stenoses >50% was found in 26.3% of all patients with available coronary status in AFL and in 7.0% in AFIB (P < 0.001). Coronary artery disease with stenoses >75% in 16.4% in AFL whereas only in 1.4% in AFIB (P < 0.001). Multivessel disease was detected in 10.5% in AFL and 0.7% in AFIB (P < 0.001). After correction for age, left ventricular ejection fraction, BMI, CHA2DS2-VASc-Score and its individual components, smoking status, hyperlipidaemia, and family history of CVD, there was a more than five-fold increase in the likelihood of CAD with stenosis >50% in AFL as compared to AFIB [odds ratio (OR 5.26)]. A multivariate analysis was performed in the AFL group. Patients with clinically relevant stenoses (>75%) were older (70.6 years vs. 63.8 years; P = 0.001), had a higher number of risk factors (3.08 vs. 2.24; P ≤ 0.0016) and a higher CHA2DS2-VASc-Score (3.20 vs. 2.00; P < 0.0001). With logistic regression, significant CAD could be predicted by higher values for CHA2DS2-VASc-Score with an exponential rise to a pretest-probability of 42.1% at a value of 4 points. CONCLUSION: These data suggest that typical atrial flutter constitutes a manifestation of previously asymptomatic CAD. Due to the inclusion criteria, CAD has to be considered silent and chronic in most of the patients. Therefore, the presence of typical atrial flutter in formerly healthy patients should raise suspicion of otherwise silent CAD and initiate further investigations and risk stratification with particular emphasis on the individual CHA2DS2-VASc-Scores.