Heart rate variability as a predictor of successful catheter-guided pulmonary vein isolation for atrial fibrillation.

BACKGROUND: This retrospective observational study investigated the relationship between heart rate variability (HRV) and atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) by cryoballoon or radiofrequency ablation (RF). METHODS: We enrolled 497 patients who underwent PVI using first-generation cryoballoon (CB1), second-generation cryoballoon (CB2), or RF. We analyzed HRV as a surrogate for modulation of the intrinsic autonomic nervous system using 24­h Holter recordings 1 or 2 days after the procedure and compared the recurrence and non-recurrence group with regard to ablation methods. Furthermore, we calculated recurrence-free survival (RFS) below/over HRV cut-off values for the whole study population and separately for each ablation method. RESULTS: All except one of the five time-based HRV parameters analyzed were significantly lower in the non-recurrence group than in the recurrence group after CB2. Only a trend toward lower HRV for the non-recurrence group was found after RF and no remarkable differences were detected after CB1. The HRV parameters below their calculated cut-off were associated with a significantly higher RFS rate 2 years after CB2. This also applied to root mean sum of squared distance (rMSSD) and the percentage of adjacent NN interval differences greater than 50 ms (pNN50) after RF. No differences were found regarding CB1. Concerning rMSSD, the sensitivity, specificity, and difference in RFS increased when using cut-offs that were calculated including only CB2 patients. Multivariate cox regression analysis showed that low rMSSD values could independently predict AF recurrence after adjusting for covariates (hazard ratio: 0.50; p < 0.001). CONCLUSION: Low values of rMSSD early after a PVI could independently predict AF recurrence, especially after CB2.

[Shock, hemoconcentration, and generalized edema in a 47-year-old man]. / Schock, Hämokonzentration und generalisierte Ödeme bei 47-jährigem Patienten.

We report the case of a 47-year-old man who was admitted because of syncope. Upon hospital admission, he rapidly developed circulatory shock with generalized edema and a severe hemoconcentration with a hematocrit of 70%. The condition was stabilized with infusion of 17 l of cristalloid fluids over a period of 24 h. After ruling out possible secondary causes, the diagnosis of a systemic capillary leak syndrome--a severe transient endothelial barrier dysfunction of unknown origin--was made. A triad of hypotension, hemoconcentration (hematocrit >60%) and macromolecular extravasation is the typical finding; furthermore, a strong association with monoclonal gammopathy of unknown significance (MGUS) is described.

[Diagnostic laparoscopy under dual antiplatelet therapy with clopidogrel and aspirin]. / Diagnostische Laparoskopie unter doppelter thrombozytenaggregationshemmender Therapie mit Clopidogrel und ASS.

Dual antiplatelet therapy using aspirin and a thienopyridine (e.g. clopidogrel) is known to be essential in patients in whom percutaneous coronary intervention with stent implantation has been performed in order to prevent stent thrombosis and its fatal consequences. On the other hand dual antiplatelet therapy increases the incidence of perioperative bleeding complications. In case of urgent or emergency surgery the risk of perioperative stent thrombosis on the one hand and the perioperative bleeding risk on the other has to be evaluated carefully in order to keep time period without sufficient platelet inhibition as short as possible. The presented case offers a strategy for managing perioperative administration of antiplatelet agents.