Successful re-ablation of a permanent junctional reciprocating tachycardia with cryoenergy : Case report of a 19-year-old patient.

We report the case of a 19-year-old male patient who presented with a permanent junctional reciprocating tachycardia (PJRT). After a primarily successful radiofrequency ablation of a para-Hisian, midseptal, accessory pathway, recurrence of tachycardia was documented. Thereafter, successful ablation using cryoenergy was performed. Since this second ablation the patient has been free of tachycardia. Our case study shows that the treatment of PJRT in young adults using cryoenergy can be successfully and safely conducted, especially after tachycardia recurrence following an initial radiofrequency ablation.

Coronary sinus signal amplitude predicts left atrial scarring.

BACKGROUND: Left atrial scarring is recognised as a critical component in the maintenance of atrial fibrillation and is associated with the failure of interventional treatment. Diminished bipolar voltage (LV) has been proposed as a useful tool for left atrial scar quantification. We hypothesised that, due to its anatomic location, signals on the coronary sinus catheter might be used to predict the amount of left atrial low voltage. METHODS AND RESULTS: A total of 124 patients (42% women, average age 66 ± 9 years) were included. Forty-one with paroxysmal and 83 with persistent atrial fibrillation. Left atrial low-voltage (<0.5 mV, measured during sinus rhythm) area size and distribution varied considerably among the included patients (mean: 34.9%; maximum: 94.6%; minimum: 0.4%). Spearman correlation revealed a strong negative correlation between bipolar voltage of the signals on the coronary sinus catheter and the amount of left atrial scarring (R = -0.778, p < .0001). The optimal CS voltage cut off for prediction of left atrial low-voltage size of ≥50% was 1.9 mV with an area-under-the receiver-operating-characteristic (ROC) curve of 0.982, a sensitivity of 97% and a specificity of 98%. CONCLUSIONS: There is a strong negative correlation between the size of left atrial low-voltage areas (LVA) and coronary sinus signal amplitude. With increasing left atrial LVA size, CS signal amplitudes decrease, and vice versa. On the basis of these findings, average CS signal amplitudes of ≤1.9 mV can be used as a predictor for a left atrial low-voltage size of ≥50%.

Late deterioration of left ventricular function after right ventricular pacemaker implantation.

OBJECTIVES: Right ventricular (RV) pacing induces a left bundle branch block pattern on ECG and may promote heart failure. Patients with dual chamber pacemakers (DCPs) who present with progressive reduction in left ventricular ejection fraction (LVEF) secondary to RV pacing are candidates for cardiac resynchronization therapy (CRT). This study analyzes whether upgrading DCP to CRT with the additional implantation of a left ventricular (LV) lead improves LV function in patients with reduced LVEF following DCP implantation. METHODS: Twenty-two patients (13 males) implanted with DCPs and a high RV pacing percentage (>90%) were evaluated in term of new-onset heart failure symptoms. The patients were enrolled in this retrospective single-center study after obvious causes for a reduced LVEF were excluded with echocardiography and coronary angiography. In all patients, DCPs were then upgraded to biventricular devices. LVEF was analyzed with a two-sided t-test. QRS duration and brain natriuretic peptide (BNP) levels were analyzed with the unpaired t-test. RESULTS: LVEF declined after DCP implantation from 54±10% to 31±7%, and the mean QRS duration was 161±20 ms during RV pacing. NT-pro BNP levels were elevated (3365±11436 pmol/L). After upgrading to a biventricular device, a biventricular pacing percentage of 98.1±2% was achieved. QRS duration decreased to 108±16 ms and 106±20 ms after 1 and 6 months, respectively. There was a significant increase in LVEF to 38±8% and 41±11% and a decrease in NT-pro BNP levels to 3088±2326 pmol/L and 1860±1838 pmol/L at 1 and 6 months, respectively. CONCLUSION: Upgrading to CRT may be beneficial in patients with DCPs and heart failure induced by a high RV pacing percentage.

Successful intraprocedural anticoagulation with bivalirudin during pulmonary vein isolation in a patient with known heparin-induced thrombocytopenia type II.

We report the case of a 56-year-old female who presented with symptomatic paroxysmal atrial fibrillation. Anamnestic heparin-induced thrombocytopenia (HIT) type II was suspected, and a rapid diagnostic test showed antibodies against platelet factor 4. The heparin-induced platelet activation-assay was negative. Radiofrequency pulmonary vein isolation with intraprocedural anticoagulation using bivalirudin was ultimately performed. Dosing was controlled by monitoring the activated clotting time. Post-procedural blood tests were normal. There were no thromboembolic or bleeding events. Bivalirudin is a therapeutic option for anticoagulation during pulmonary vein isolation procedures in patients with a history of HIT type II.

[Transseptal puncture after device closure of patent foramen ovale: Is it feasible?]. / Transseptale Punktion nach PFO-Verschluss: Geht das?

CASE REPORT: The case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned. METHODS: Under transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy. CONCLUSION: This case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.

Atrial standstill in sinus node disease due to extensive atrial fibrosis: impact on dual chamber pacemaker implantation.

AIMS: Atrial standstill is characterized by the absence of atrial activity. We report about a series of cases, in which conventional atrial pacemaker lead implantation in patients with symptomatic sinus node disease failed due to lack of excitable right atrial tissue, thus, prompting the diagnosis of atrial standstill. We hypothesized that mapping of the atria with subsequent identification of myocardium still amenable to atrial pacing would allow dual chamber pacemaker implantation. METHODS AND RESULTS: In four patients, atrial lead implantation failed. In these patients, spontaneous or fibrillatory electrical activity was absent but the atria could not be captured despite high stimulation voltages at conventional atrial sites. We suspected partial or complete atrial standstill and subsequently confirmed this hypothesis by conventional (n = 1) or electroanatomical mapping (n = 3). Areas of fibrotic tissue were present in all patients as identified by lack of spontaneous electrical activity and inability of local electrical capture via the mapping catheter. Surviving atrial tissue, which could be electrically captured with subsequent conduction of activity to the atrioventricular (AV) node, was present in three patients. Successful targeted atrial lead implantation at these sites was achieved in all these patients. Isolated sinus node activity without conduction to the atria was found in one patient. CONCLUSION: Partial atrial standstill may be present and prevent atrial lead implantation in patients with sinus node disease. In these patients, recognition of partial atrial standstill and identification of surviving muscular islets with connection to the AV node by mapping studies may still allow synchronous AV sequential pacing.

[Recurrent microdislocation of pacemaker leads due to an aortic aneurysm of the aorta ascendens]. / Rezidivierende Mikrodislokationen von Schrittmachersonden aufgrund eines Aortenaneurysmas der Aorta ascendens.

We report about a 79 years old female patient which was admitted due to a symptomatic AV block 3rd degree. The coronary angiography excluded a coronary artery disease and the echocardiography revealed a normal left ventricular systolic function. Therefore a dual-chamber pacemaker was implanted. Following two micro-dislocations of the right ventricular lead, which required operative revisions, a computed tomography of the heart was performed. This detected an aneurysm of the ascending aorta (5 cm maximum diameter) with compression of the superior caval vein. This case shows that a possible cause of recurrent micro-dislocations could be a pathological anatomy of the heart.

[Wide QRS complex tachycardia in a patient with ischemic cardiomyopathy and prior ventricular tachycardia ablation]. / Breitkomplex-Tachykardie bei einem Patienten mit ischämischer Kardiomyopathie und stattgehabter Ablation einer ventrikulären Tachykardie.

CASE REPORT: This article reports the case of a 76-year-old patient with multiple implantable cardioverter defibrillator (ICD) interventions of the single chamber ICD. On admission the 12-lead electrocardiogram (ECG) documented a wide QRS complex tachycardia without clearly identifiable P waves. The patient had previously had two ventricular tachycardia (VT) ablations due to VT storms. The resting ECG revealed a sinus rhythm with a wide QRS complex. During the electrophysiological investigation typical atrial flutter could be detected and an ablation of the cavotricuspid isthmus was performed. During the follow-up period, the patient has been free from tachycardia. CONCLUSION: The case described emphasizes that a differentiation between supraventricular tachycardia (SVT) and VT based on a stored ECG without an atrial channel can be challenging.

Long-term outcomes after cryoballoon pulmonary vein isolation: results from a prospective study in 605 patients.

OBJECTIVES: The purpose of this study was to investigate long-term outcomes of freedom from atrial fibrillation (AF) after pulmonary vein (PV) isolation using cryoballoon ablation with balloon-size selection based on individual PV diameters. BACKGROUND: Data are lacking on long-term outcomes from cryoablation and on the most effective balloon size. METHODS: This was a prospective observational study involving 605 consecutively enrolled patients with symptomatic paroxysmal AF (n = 579) or persistent AF. Cryoballoon size was based on magnetic resonance imaging and/or conventional angiograms. Patients were followed up every 3 months during the first year after discharge and every 6 months in the second year. After 24 months, follow-up was on an outpatient basis with documented AF episodes recorded. RESULTS: The PV isolation was achieved without touch-up in 91.1% of patients, using the smaller balloon in 26.7%, the larger balloon in 25.6%, and both balloons in 47.7% of patients. Follow-up data for >12 months (median 30 months; interquartile range 18 to 48 months) were available for 451 patients, 278 (61.6%) of whom were free of AF recurrence with no need for repeat procedures after the 3-month blanking period. Rates of freedom from AF after 1, 2, and 3 repeat procedures (using cryoballoon or radiofrequency ablation with similar success rates) were 74.9%, 76.2%, and 76.9%, respectively. Use of the smaller balloons or both balloons produced the highest rates of long-term freedom from AF. Phrenic nerve palsy occurred in 12 patients (2%), resolving within 3 to 9 months. CONCLUSIONS: Rates of long-term freedom from AF after cryoballoon ablation are similar to those reported for radiofrequency ablation. A choice between balloons may improve outcomes.

Novel robotic catheter manipulation system integrated with remote magnetic navigation for fully remote ablation of atrial tachyarrhythmias: a two-centre evaluation.

AIMS: Studies have shown that remote magnetic navigation is safe and effective for ablation of atrial arrhythmias, although optimal outcomes often require frequent manual manipulation of a circular mapping catheter. The Vdrive robotic system ('Vdrive') was designed for remote navigation of circular mapping catheters to enable a fully remote procedure. This study details the first human clinical experience with remote circular catheter manipulation in the left atrium. METHODS AND RESULTS: This was a prospective, multi-centre, non-randomized consecutive case series that included patients presenting for catheter ablation of left atrial arrhythmias. Remote systems were used exclusively to manipulate both the circular mapping catheter and the ablation catheter. Patients were followed through hospital discharge. Ninety-four patients were included in the study, including 23 with paroxysmal atrial fibrillation (AF), 48 with persistent AF, and 15 suffering from atrial tachycardias. The population was predominately male (77%) with a mean age of 60.5 ± 11.7 years. The Vdrive was used for remote navigation between veins, creation of chamber maps, and gap identification with segmental isolation. The intended acute clinical endpoints were achieved in 100% of patients. Mean case time was 225.9 ± 70.5 min. Three patients (3.2%) crossed over to manual circular mapping catheter navigation. There were no adverse events related to the use of the remote manipulation system. CONCLUSIONS: The results of this study demonstrate that remote manipulation of a circular mapping catheter in the ablation of atrial arrhythmias is feasible and safe. Prospective randomized studies are needed to prove efficiency improvements over manual techniques.

Magnetically guided irrigated gold-tip catheter ablation of persistent atrial fibrillation--techniques, procedural parameters and outcome.

PURPOSE: Magnetically guided irrigated ablation has been introduced for atrial fibrillation (AF) ablation. However, data on ablation of persistent AF is scarce, and first-generation platinum-iridium catheters were burdened by char formation at the catheter tip. Furthermore, energy transmission of these catheters may be suboptimal. Irrigated gold-tip catheters have been introduced to overcome these problems. METHODS: Antral pulmonary vein (PV) isolation (PVAI) was performed using a 5-mm irrigated gold-tip magnetic catheter (power setting, 48 °C maximum, 50 W, 15 s lesion duration; flow-rate, 30 mL/min). The catheter tip was guided by a uniform magnetic field and a motor drive. Left atrial maps were created using an impedance-based left atrial reconstruction and fused with a preprocedural CT or an intraprocedural rotational angiography-based scan. RESULTS: Fifty-seven patients (42 male, 61.9 ± 8.8 years) underwent PVAI for symptomatic, drug-refractory persistent AF. PVAI was performed successfully in all patients confirmed by entrance block. Procedure time (skin-to-skin) was 214 ± 47 min (104-354 min). Fluoroscopy time was 31 ± 21 min. Ablation time was 4,153 ± 1,350 s. No char or thrombus formation was found at the catheter tip. One pericardial tamponade was observed. Freedom from atrial tachyarrhythmias could be achieved in 57.9 % of the patients included in a follow-up of 11.6 ± 4.2 month. There was a trend to a better outcome in patients without previous attempts of AF ablation (n = 48; 60.4 % vs. 44.4 %, p = 0.47). CONCLUSIONS: Remote magnetic navigation for PVAI seems to be safe and feasible using an irrigated gold-tip catheter. Effectiveness of this novel technique can be confirmed by mid-term outcome.

Left atrial lesion formation and volume overload by open irrigation ablation technology during pulmonary vein antrum isolation: acute effects on cardiac hemodynamics.

PURPOSE: Our goal was to evaluate acute effects of left atrial lesion formation and volume overload on hemodynamics during pulmonary vein antrum isolation (PVAI) as it might be a potential cause of acute pulmonary edema. METHODS: In consecutive patients presenting for PVAI, open irrigation ablation was performed (50 W, 48°C, 15 s lesion duration, saline flow rate 30 mL/min). Blood samples were drawn from the left atrium and the pulmonary artery immediately before and 30 min after PVAI. The cardiac output (CO) and stroke volume (SV) were calculated by the method of Fick. RESULTS: We included 61 (27 female, 61 ± 11 years) patients suffering from paroxysmal (px; 33) or persistent (per; 28) atrial fibrillation (AF) in this study. A total of 2,917 ± 242 mL of volume was infused (2,651 ± 223 mL pxAF vs. 3,184 ± 255 mL perAF, (p < 0.01)). Total ablation time was 60 ± 7 min (52 ± 7 min in pxAF vs. 69 ± 8 min in perAF; (p < 0.001)). CO increased from 5.2 ± 1.3 to 6.2 ± 1.5 L/min (p < 0.001) during PVAI (5.7 ± 1.3 to 6.5 ± 1.7 L/min in pxAF; (p < 0.002) and 4.8 ± 1.1 to 5.9 ± 1.2 L/min in perAF; (p < 0.001)). SV increased from 74 ± 24 to 83 ± 21 mL (p < 0.005) during PVAI, and subgroups showed an increase of 82 ± 23 to 88 ± 22 mL in pxAF (p < 0.009) and 62 ± 21 to 76 ± 16 mL in perAF (p < 0.009). CONCLUSIONS: From our preliminary experience, left atrial scarring and volume overload during PVAI do not seem to impact negatively hemodynamics. On the contrary, an improvement in cardiac output was documented acutely independent of type of AF.

Incidence of adequate ICD interventions in patients with hypertrophic cardiomyopathy supposed to be at high risk for sudden cardiac death.

INTRODUCTION: Although the incidence of sudden cardiac death (SCD) is as low as 1%/year in un-selected patients (pts) with hypertrophic cardiomyopathy (HCM), higher-risk populations may benefit from prophylactic implantation of an ICD. Risk assessment in HCM is thus important and currently based on the presence or absence of different risk markers (RM). STUDY AIM: The objective of this study is to correlate the incidence of adequate ICD interventions in HCM with the presence of different RM. METHODS: Fifty pts with HCM had ICD implantation, either for secondary (n = 2/4%), or primary prophylaxis of SCD (n = 48/96%). ICD for primary prophylaxis pts had more than 1 (2-4) RM. Outflow obstruction was present in 25 pts, the other 25, including I patient each after septal ablation and myectomy, were non-obstructive. ICD memories were read out and interpreted in accordance with established guidelines. RESULTS: The number of RM per patient was 1.7 +/- 0.8. During follow-up of 2.0 +/- 0.5 [0.2-6.3] years, adequate ICD interventions (11 episodes) were documented in 5, inadequate ICD interventions in 3 pts.Thirteen pts had at least I episode of atrial fibrillation. Pts with versus without events had a longer follow-up (3.2 +/- 4.3 vs. 1.8 +/- 2.6 years, P < 0.05), and were more frequently nonobstructive (all 5; P = 0.05).Within the time period observed no single RM was predictive for arrhythmic events. CONCLUSIONS: Incidence of appropriate ICD discharges was 4-5%/patient-year, supporting the proposed risk stratification. No single RM was predictive for future arrhythmic events.

Cryoballoon pulmonary vein isolation supported by intracardiac echocardiography: integration of a nonfluoroscopic imaging technique in atrial fibrillation ablation.

INTRODUCTION: cryoballoon ablation has been adopted for pulmonary vein (PV) isolation (PVI) in many centers. Complete occlusion of PV by an adequately sized balloon is crucial for effectiveness of cryoenergy delivery. The aim of this study was to evaluate intracardiac echocardiography (ICE) as an alternative imaging technique compared to angiographic imaging in cryoballoon PVI. METHODS AND RESULTS: a total of 75 PVs were treated in 22 patients (61 ± 13 years, 17 male) undergoing PV cryoballoon ablation for drug refractory paroxysmal atrial fibrillation. Decision for an adequate balloon size was based on diameters of the PV antra assessed by ICE and PV angiography. Per PV 2.4 ± 0.4 cryoenergy pulses were applied. Decision for the balloon size was similar either based upon angiography or on ICE. A single 23 or 28 mm balloon was chosen in 10 and 3 patients, respectively. Two different sized balloons were used in 9 patients. PVI was evaluated after 2 cryoenergy applications. Total occlusion of the PV confirmed by ICE color flow Doppler (CFD) during ablation predicted successful PVI in 70 of 75 (93%) and unsuccessful PVI in 8 of 8 (100%). PV flow registered by pulsed wave Doppler at the PV ostium pre- and postablation was 0.48 ± 0.10 and 0.51 ± 0.12 m/s, respectively (n.s.). PVI was finally confirmed by entrance block in all PVs. No procedural complications occurred. CONCLUSIONS: ICE is a feasible novel imaging technique in cryoballoon ablation procedures. It allows decision for adequate balloon size, exact balloon placement, prediction of acute ablation success, and excludes acute narrowing of PV ostia.

Adaptive servoventilation improves cardiac function in patients with chronic heart failure and Cheyne-Stokes respiration.

BACKGROUND AND AIMS: Sleep disordered breathing (SDB), especially Cheyne-Stokes respiration (CSR) is common in patients with chronic heart failure (CHF). Adaptive servoventilation (ASV) was recently introduced to treat CSR in CHF. The aim of this study was to investigate the effects of ASV on CSR and CHF parameters. METHODS: In 29 male patients (63.9+/-9 years, NYHA> or =II, left ventricular ejection fraction [LV-EF]< or =40%), cardiorespiratory polygraphy, cardiopulmonary exercise (CPX) testing, and echocardiography were performed and concentrations of NT-proBNP determined before and after 5.8+/-3.5 months (median 5.7 months) of ASV (AutoSet CS2, ResMed) treatment. All patients also received guideline-driven CHF therapy. RESULTS: Apnoea-hypopnoea-index was reduced from 37.4+/-9.4/h to 3.9+/-4.1/h (p<0.001). Workload during CPX testing increased from 81+/-26 to 100+/-31 W (p=0.005), oxygen uptake (VO2) at the anaerobic threshold from 12.6+/-3 to 15.3+/-4 ml/kg/min (p=0.01) and predicted peak VO2 from 58+/-12% to 69+/-17% (p=0.007). LV-EF increased from 28.2+/-7% to 35.2+/-11% (p=0.001), and NT-proBNP levels decreased significantly (2285+/-2192 pg/ml to 1061+/-1293 pg/ml, p=0.01). CONCLUSIONS: In selected patients with CHF and CSR, addition of ASV to standard heart failure therapy is able to improve SDB, CPX test results, LV-EF and NT-proBNP concentrations.