Repeat ablation for paroxysmal atrial fibrillation - Does adenosine play a role in predicting pulmonary vein reconnection patterns?

BACKGROUND: Pulmonary vein (PV) reconduction after PV isolation (PVI) unmasked by adenosine is associated with a higher risk for paroxysmal atrial fibrillation (PAF) recurrence. It is unknown if the reconnected PVs after adenosine testing and immediate re-ablation can predict reconnection and reconnection patterns of PVs at repeat procedures. We assessed reconnection of PVs with and without dormant-conduction (DC) during the first and the repeat procedure. METHODS: We included 67 patients undergoing PVI for PAF and a second procedure for PAF recurrence. DC during adenosine administration at first procedure was seen in 31 patients (46%). 264 PVs were tested with adenosine; DC was found in 48 PVs (18%) and re-ablated during first procedure. During the second procedure, all PVs where checked for reconnection. RESULTS: Fifty-eight patients (87%) showed PV reconnection during the second procedure. Reconnection was found in 152/264 PVs (58%). Of 216 PVs without reconnection during adenosine testing at the first ablation, 116 PVs (53.7%) showed reconnection at the repeat procedure. Overall, 14.9% of patients showed the same PV reconnection pattern in the first and second procedure, expected statistical probability of encountering the same reconnection pattern was only 6.6%(p = 0.012). CONCLUSIONS: In repeat procedures PVs showed significantly more often the same reconnection pattern as during first procedure than statistically expected. More than 50% of initial isolated PVs without reconnection during adenosine testing showed a reconnection during repeat ablation. Techniques to detect susceptibility for PV re-connection like prolonged waiting-period should be applied. Elimination of DC should be expanded from segmental to circumferential re-isolation or vaster RF application.

Effect of the FXa inhibitors Rivaroxaban and Apixaban on platelet activation in patients with atrial fibrillation.

Rivaroxaban and Apixaban, increasingly used for stroke prevention in non-valvular atrial fibrillation (AF), might impact platelet reactivity directly or indirectly. By inhibition of Factor Xa (FXa) they preclude not only generation of relevant thrombin amounts but also block signalling of FXa via protease activated receptors. However, weather FXa-inhibition affects platelet haemostasis remains incompletely known. One hundred and twenty-eight patients with AF on chronic anticoagulation with either Rivaroxaban or Apixaban for at least 4 weeks were included in the study. In a time course group (25 on Rivaroxaban, 13 on Apixaban) venous blood samples were taken before NOAC medication intake in the morning as well as 2 and 6 h afterwards. In 90 patients (Rivaroxaban n = 73, Apixaban n = 17) blood samples were drawn during left atrial RFA procedures before as well as 10 and 60 min after the first heparin application (RFA group). Platelet reactivity analyzed by whole blood aggregometry (Multiplate Analyzer, Roche) in response to ADP, Collagen, TRAP and ASPI (arachidonic acid) was not altered by Rivaroxaban or Apixaban neither in the time course nor in the RFA group. Moreover, soluble P-selectin, Thrombospondin, von Willebrand Factor and beta thromboglobulin plasma levels, measured by ELISA, showed no statistically significant changes in both clinical settings for either FXa-inhibitor. The present study fails to demonstrate any significant changes on platelet reactivity in patients with AF under chronic Rivaroxaban or Apixaban medication, neither for trough or peak levels nor in case of a haemostatic activation in vivo as depicted by RFA procedures.

Catheter Ablation for "Lone" Atrial Fibrillation: Efficacy and Predictors of Recurrence.

BACKGROUND: Atrial fibrillation in otherwise healthy young patients has been termed "lone" atrial fibrillation (AF). The best treatment choice is still under discussion. The aim of this study was to report on efficacy and safety of catheter ablation. METHODS: Among 855 patients referred to our center between 2011 and 2013, 76 (9%) met the diagnostic criteria for lone AF (mean age 45 ± 8 years; mean LA diameter 37 ± 4 mm; paroxysmal AF 82%; persistent AF 18%). The primary endpoint was freedom from any atrial tachycardia after the first ablation; the secondary endpoint was freedom from any atrial tachycardia after the last ablation procedure without antiarrhythmic drugs. RESULTS: The primary endpoint occurred in 56 patients (74%) after a mean follow-up time of 444 ± 344 days. The secondary endpoint occurred in 73 patients (96%) after a mean of 1.3 ablations/patient during a follow-up time of 459 ± 366 days. The risk of AF recurrence was not influenced by AF duration or by the type of AF (paroxysmal versus persistent). In a multivariate regression analysis smoking (P = 0.001), first degree atrioventricular block (P = 0.001), and early (< 3 months) AF recurrence (P = 0.001) were independently associated with a higher risk of AF recurrence. Major peri-procedural adverse events did not occur. CONCLUSIONS: Catheter ablation in young healthy patients is highly effective and safe. The outcomes are maintained during long-term follow-up irrespective of preoperative AF duration. Patients with AF recurrence were more likely to smoke, have first degree AV block and early AF recurrence.

VT ablation based on CT imaging substrate visualization: results from a large cohort of ischemic and non-ischemic cardiomyopathy patients.

INTRODUCTION: The eradication of ventricular tachycardia (VT) isthmus sites constitutes the minimal procedural endpoint for VT ablation procedures. Contemporary high-resolution computed tomography (CT) imaging, in combination with computer-assisted analysis and segmentation of CT data, facilitates targeted elimination of VT isthmi. In this context, inHEART offers digitally rendered three-dimensional (3D) cardiac models which allow preoperative planning for VT ablations in ischemic and non-ischemic cardiomyopathies. To date, almost no data have been collected to compare the outcomes of VT ablations utilizing inHEART with those of traditional ablation approaches. METHODS: The presented data are derived from a retrospective analysis of n = 108 patients, with one cohort undergoing VT ablation aided by late-enhancement CT and subsequent analysis and segmentation by inHEART, while the other cohort received ablation through conventional methods like substrate mapping and activation mapping. The ablations were executed utilizing a 3D mapping system (Carto3), with the mapping generated via the CARTO® PENTARAY™ NAV catheter and subsequently merged with the inHEART model, if available. RESULTS: Results showed more successful outcome of ablations for the inHEART group with lower VT recurrence (27% vs. 42%, p < 0.06). Subsequent analyses revealed that patients with ischemic cardiomyopathies appeared to derive a significant benefit from inHEART-assisted VT ablation procedures, with a higher rate of successful ablation (p = 0.05). CONCLUSION: Our findings indicate that inHEART-guided ablation is associated with reduced VT recurrence compared to conventional procedures. This suggests that employing advanced imaging and computational modeling in VT ablation may be valuable for VT recurrences.

[Adults with congenital heart disease presenting to the emergency department : Potential pitfalls]. / Erwachsene mit angeborenen Herzfehlern im Notaufnahmedienst : Was ist zu beachten?

The number of adults with congenital heart disease (ACHD) already exceeds the number of children with congenital heart disease in the industrialized world. ACHD patients often show complex pathophysiology and anatomy even after reparative cardiac surgery. In case of complications patients may rapidly deteriorate and become unstable, even when they were asymptomatic or had only mild symptoms before the onset of the complication. Compared to all patients seen by emergency physicians, emergencies in ACHD patients are still rare. This review is aimed to guide management in ACHD emergency situations. Approximately two-thirds of all emergency admissions are caused by arrhythmias or acute heart failure. Sustained arrhythmias may rapidly lead to acute cardiac decompensation in ACHD patients. If medical treatment fails or patients present in hemodynamically unstable conditions, prompt electrical cardioversion is mandatory. Symptomatic bradycardia may require urgent pacemaker implantation. Depending on the underlying heart defect, placement of temporary transvenous pacemaker leads may be impossible. Acute heart failure in ACHD patients is often caused by acute right heart failure. Other more frequent emergencies are infections, syncope, thromboembolic events, and aortic dissection. It is highly recommended to contact the tertiary care center that follows the patient regularly early in case of patient presentation to the emergency room.

Temperature-controlled high-power short-duration ablation with 90 W for 4 s: outcome, safety, biophysical characteristics and cranial MRI findings in patients undergoing pulmonary vein isolation.

BACKGROUND: High-power short-duration (HPSD) radiofrequency ablation (RFA) is highly efficient and safe while reducing procedure and RF time in pulmonary vein isolation (PVI). The QDot™ catheter is a novel contact force ablation catheter that allows automated flow and power adjustments depending on the local tissue temperature to maintain a target temperature during 90 W/4 s lesions. We analysed intraprocedural data and periprocedural safety using the QDot-catheter in patients undergoing PVI for paroxysmal atrial fibrillation (PAF). METHODS: We included n = 48 patients undergoing PVI with the QDot-catheter with a temperature-controlled HPSD ablation mode with 90 W/4 s (TC-HPSD). If focal reconnection occurred besides repeat ablation, the ablation mode was changed to 50 W/15 s (QMode). N = 23 patients underwent cerebral MRI to detect silent cerebral lesions. RESULTS: Mean RF time was 8.1 ± 2.8 min, and procedure duration was 84.5 ± 30 min. The overall maximal measured catheter tip temperature was 52.0 °C ± 4.6 °C, mean overall applied current was 871 mA ± 44 mA and overall applied energy was 316 J ± 47 J. The mean local impedance drop was 12.1 ± 2.4 Ohms. During adenosine challenge, n = 14 (29%) patients showed dormant conduction. A total of n = 24 steam pops were detected in n = 18 patients (39.1%), while no pericardial tamponade occurred. No periprocedural thromboembolic complications occurred, while n = 4 patients (17.4%) showed silent cerebral lesion. CONCLUSIONS: TC-HPSD ablation with 90 W/4 s using the QDot-catheter led to a reduction of procedure and RF time, while no major complications occurred. Despite optimized temperature control and power adjustment, steam pops occurred in a rather high number of patients, while none of them leads to tamponade or to clinical or neurological deficits.

Predictors of low voltage areas in persistent atrial fibrillation: is it really a matter of time?

BACKGROUND: Time has been postulated as an important factor for electrical remodeling of the left atrium (LA) in persistent atrial fibrillation (AF) ('AF begets AF'). However, it is still a matter of debate if structural changes are the cause or consequence of AF. We sought to determine the clinical and invasive parameters, which correlate with LA scar as determined by voltage mapping, in patients with persistent AF. METHODS: Seventy consecutive patients undergoing ablation of persistent (49%) or long-standing persistent AF (51%), between January 2013 and February 2014, were enrolled in the study. Besides clinical parameters, 2D echocardiographic assessment of LA size and LA pressure (LAP) after transseptal puncture was also considered. Bipolar endocardial signals with a mean voltage amplitude < 0.1 mV during AF were defined as LA scar. RESULTS: In the univariable analysis, LA scar was associated with age, gender, coronary artery disease (CAD), glomerular filtration rate (GFR), LA size and LAP. Arrhythmia duration, mild to moderate mitral regurgitation (MR), left ventricular dysfunction and left ventricular hypertrophy showed no significant correlation with atrial scar (all p > 0.05). In a multivariable regression model, LA scar area was independently associated with age, female gender and LA area. AF duration was not associated with LA scar. CONCLUSIONS: In this study, older age, greater LA area and female gender predicted the degree of LA scar, while other variables tested did not. In particular, we found no significant association between AF duration and LA scar.

Neonates and infants requiring life-long cardiac pacing: How reliable are epicardial leads through childhood?

BACKGROUND: In the literature, data is lacking on mid-term results of epicardial pacemaker implantation in neonates and infants. Our aim was to evaluate the mid-term results of epicardial pacemakers implanted in infants under 1 year of age. METHODS AND RESULTS: We conducted a retrospective review of patients who underwent pacemaker implantation between 2000 and 2017. Pacemaker and lead parameters were reviewed at discharge, 2, 4 and more than 5 years after implantation. A total of 71 patients aged 4 ±â€¯3 months and weighing 4 ±â€¯2 kg were included in the study. Indications for pacemaker implantation were: acquired AV-block (n = 44), congenital AV block (n = 22), sick sinus syndrome (n = 4) and AV block type Mobitz II (n = 1). Median follow-up time was 5 years (range: 1 month-17 years). At 5 years of follow-up, atrial lead energy threshold for pacing decreased significantly (0.72 ±â€¯0.71 µJ to 0.45 ±â€¯0.35 µJ; P < 0.001) but was stable for ventricular leads (0.57 µJ [0.05; 39.47] to 0.64 µJ [0.13; 9.45], P = 0.97). Atrial lead impedance increased significantly (569 ±â€¯137 Ω to 603 ±â€¯134 Ω, P < 0.001), whereas ventricular lead impedance decreased (603 ±â€¯202 Ω to 490 ±â€¯150 Ω, P < 0.001) after 5 years. Repeat operations were required for generator change (n = 55), lead exchange (n = 17) and infection (n = 1). At 2, 5 and 10 years, atrial lead survival was 96%, 91% and 76% and ventricular lead survival was 94%, 82% and 75%, respectively (P = 0.45). CONCLUSION: Stable pacing thresholds after 5 years indicated that epicardial pacemakers are safe for infants under 1 year of age until at least school enrolment age. However, due to stimulation at higher heart rates in infancy, battery depletion is a frequent occurrence.

Catheter ablation in ASymptomatic PEDiatric patients with ventricular preexcitation: results from the multicenter "CASPED" study.

BACKGROUND: As there are limited data about the clinical practice of catheter ablation in asymptomatic children and adolescents with ventricular preexcitation on ECG, we performed the multicenter "CASPED" (Catheter ablation in ASymptomatic PEDiatric patients with Ventricular Preexcitation) study. METHODS AND RESULTS: In 182 consecutive children and adolescents aged between 8 and 18 years (mean age 12.9 ± 2.6 years; 65% male) with asymptomatic ventricular preexcitation, a total of 196 accessory pathways (APs) were targeted. APs were right sided (62%) or left sided (38%). The most common right-sided AP location was the posteroseptal region (38%). Ablation was performed using radiofrequency (RF) energy (93%), cryoablation (4%) or both (3%). Mean procedure time was 137.6 ± 62.0 min with a mean fluoroscopy time of 15.6 ± 13.8 min. A 3D mapping or catheter localization system was used in 32% of patients. Catheter ablation was acutely successful in 166/182 patients (91.2%). Mortality was 0% and there were no major periprocedural complications. AP recurrence was observed in 14/166 patients (8.4%) during a mean follow-up time of 19.7 ± 8.5 months. A second ablation attempt was performed in 20 patients and was successful in 16/20 patients (80%). Overall, long-term success rate was 92.3%. CONCLUSION: In this retrospective multicenter study, the outcome of catheter ablation for asymptomatic preexcitation in children and adolescents irrespective of antegrade AP conduction properties is summarized. The complication rate was low and success rate was high, the latter mainly depending on pathway location. The promising results of the study may have future impact on the ongoing risk-benefit discussion regarding catheter ablation in the setting of asymptomatic preexcitation in children and adolescents.

[Use of the NavX navigation system in ablation of atrial fibrillation]. / Einsatz des Navigationssystems NavX bei der Ablationsbehandlung von Vorhofflimmern.

Catheter ablation, notably the electric isolation of pulmonary veins, has become a well-established therapeutic approach in symptomatic atrial fibrillation. The NavX navigation system has been described to facilitate pulmonary vein isolation in patients with AF. EnSite NavX (Endocardial Solutions, St. Jude Medical, Inc., St. Paul, MN, USA) is a novel navigation system that measures the local voltage on every standard intra-cardiac electrode and calculates the electrode position in three-dimensional (3D) space. Any individual electrode of each catheter in 3D-space can be displayed and labelled individually. The geometry of any cardiac chamber can be reconstructed and additional information, e.g. electrical activation spreading, can be displayed colour coded on the surface. Recent studies investigating the possible advantages of this system in the ablation of persistent or paroxysmal atrial fibrillation are summarized. All reports showed a significant reduction in fluoroscopy and procedure time by the use of the NavX system compared to conventional fluoroscopic catheter guidance. This benefit can be obtained with simple visualisation of all intracardiac catheters alone or with additional reconstruction of the left atrium and pulmonary veins.

[Magnetic navigation in invasive electrophysiological diagnostic and therapy]. / Magnetische Navigation in der elektrophysiologischen Diagnostik und Therapie.

Electrophysiological stimulation and ablation is currently performed with manually deflectable catheters of different lengths and curves. Disadvantages of conventional therapy are catheter stiffness, limited local stability, risk of dislocation or perforation, and reduced tissue contact in regions with difficult access. Fluoroscopy to control catheter movement and position may require substantial radiation times. Magnetic navigation was first applied for right heart catherization in congenital heart disease in 1991; the first electrophysiological application took place in 2003. Today, an ablation electrode with small magnets is aligned in the patient's heart by two external magnets positioned at both sides of the thorax. Antegrade and retrograde movement of the distal catheter tip are performed via an external device on the patient's thigh. Three-dimensional MRI scans acquired before intervention can be merged with electroanatomical reconstruction, leading to further reductions of radiation burden. During treatment of supraventricular tachyarrhythmias high local precision of magnetically guided catheters, good local stability, and a substantially reduced radiation time have been reported. First applications in ventricular tachyarrhythmias and complex congenital cardiac defects indicate a comparable effect. Limitations of this therapy are the application in left atrial procedures (open irrigated ablation catheters not yet available), difficult transaortic retrograde approach (high lead flexibility), and the considerable costs. Magnet-assisted navigation is feasible during percutaneous coronary interventions of tortuous coronary arteries and in positioning guidewires in coronary sinus side branches for resynchronisation therapy. Future applications will be complex left atrial procedures, magnetically guided cardiac stem cell therapy, local drug application, and extracardiac vessel therapy.

The anticoagulant effect of heparin during radiofrequency ablation (RFA) in patients taking apixaban or rivaroxaban.

PURPOSE: Measuring the anticoagulant effect of heparin during radiofrequency ablation (RFA) in patients taking apixaban and rivaroxaban is challenging, since the activated coagulation time (ACT) does not seem to reflect the true anticoagulant activity of these drugs. We therefore evaluated coagulation properties of apixaban and rivaroxaban during RFA by different coagulation assays to better monitor periprocedural hemostasis. METHODS: The study included 90 patients (61 ± 12 years) with atrial fibrillation who underwent RFA procedures. Patients received 20 mg rivaroxaban (n = 73) once or 5 mg apixaban (n = 17) twice daily 4 weeks prior to the procedure. During RFA, unfractionated heparin i.v. was given to maintain an ACT of 250-300 s. Blood samples were taken before and 10, 60, and 360 min after heparin administration. RESULTS: Heparin displayed a lower anti-Xa activity in rivaroxaban-treated patients compared to apixaban-treated patients. In contrast, D-dimer and prothrombin fragment F1+2 plasma levels indicated a higher activation of the coagulation cascade in apixaban/heparin than in rivaroxaban/heparin patients. This discordant coagulative state measured in vitro had no clinical impact in terms of bleeding or thromboembolic complications. CONCLUSION: We found different biochemical responses to rivaroxaban/heparin and apixaban/heparin during RFA. Precaution is necessary when monitoring periprocedural hemostasis in DOAC patients to avoid mismanagement.

[Arrhythmia in adults with congenital heart disease : Acute and long-term management]. / Herzrhythmusstörungen bei Erwachsenen mit angeborenem Herzfehler : Akut- und Langzeitmanagement.

During the last few decades, the management of cardiac arrhythmias in adult patients with congenital heart disease (CHD) has undergone a significant change from a conservative, mainly pharmacological approach, to interventional techniques such as catheter ablation or device implantation (pacemakers, implantable cardioverter defibrillators [ICD]). The long-term efficacy of these strategies is as dependent on the hemodynamic status of the patient and the type of arrhythmia as it is on the underlying heart defect and any preceding surgery. Pharmacological agents and electrical cardioversion are at the forefront of treatment for tachyarrhythmias. Individualized thromboprophylaxis plays an important role in acute and in long-term management. Catheter ablation seems to show a more favorable outcome compared with a pharmacological approach in the long-term management of supraventricular tachyarrhythmias. Surgical procedures, including arrhythmia surgery (such as the Fontan conversion operation), may improve the arrhythmia. In symptomatic patients with bradyarrhythmias, such as sinus node dysfunction, pacemaker implantation is usually indicated. In the management of ventricular arrhythmias catheter ablation is also increasingly used. This is dominated by the individual risk stratification for the prevention of sudden cardiac death (SCD). However, the ICD is still the therapeutic cornerstone in most cases. The management of cardiac arrhythmias in adult CHD patients should be performed at specialized centers where all aspects of diagnosis and treatment are covered.

Electrophysiologic effects and efficacy of intravenous propafenone in terminating atrioventricular reentrant tachycardia in children.

In pediatric patients with atrioventricular reentrant tachycardia, intravenous propafenone exhibits its electrophysiologic effects in a dose-dependent manner by slowing or blocking retrograde conduction at the accessory connection. The high drug efficacy (81%) in terminating tachycardia is not dependent on patient age or retrograde conduction properties of the accessory connection.

Impact of baseline atrial fibrillation cycle length on acute and long-term outcome of persistent atrial fibrillation ablation.

BACKGROUND: A short baseline atrial fibrillation (AF) cycle length (CL) has been associated with a worse outcome after catheter ablation for AF, whereas the impact of a long baseline AFCL is unknown. We investigated the influence of AFCL on acute and long-term success in a large series of patients undergoing catheter ablation for persistent AF. METHODS: Overall, 177 consecutive patients undergoing catheter ablation of persistent AF using a sequential ablation approach were included in the analysis. AFCL was measured in the left atrial appendage (LAA) at baseline and following each ablation step. The primary endpoint was freedom from any atrial arrhythmia off antiarrhythmic drugs (AAD) with a single ablation procedure after 12 months. RESULTS: Mean AFCL was 164 ± 24 ms. A shorter AFCL was associated with longer AF duration, larger LA diameter, and longer procedure duration. Termination to sinus rhythm (SR) was achieved in 57 (32 %) patients. Baseline AFCL was shorter (161 ± 24 ms) in patients without AF termination compared to patients with AF termination (169 ± 23 m, p = 0.03). The primary endpoint was reached less frequently in patients with a short (<155 ms) AFCL (18 vs. 38.5 %, p = 0.006). Patients with an AFCL between 155 and 200 ms had the best outcome compared to patients with AFCL <155 or ≥200 ms (40 vs. 18 %, p = 0.003). CONCLUSIONS: Patients with a baseline AFCL between 155 and 200 ms have the best outcome after a single ablation procedure for persistent AF compared to patients with an AFCL of <155 or ≥200 ms.

Forces on cardiac implantable electronic devices during remote magnetic navigation.

BACKGROUND: Remote magnetic navigation systems are used for catheter navigation in cardiac electrophysiological ablation procedures. In this setting, ferromagnetic particles will be moved by changes in the magnetic field. It is unknown to what extent cardiac implantable electronic devices (CIED) are affected by the magnetic field when using magnetic navigation, and whether these forces may exceed the limit of 5 N that is set forth by German and European norms for implanted electrodes. METHODS: A total of 121 rhythm devices were examined in a magnetic field of 0.1 T using the NIOBE II(®) Magnetic Navigation System (Stereotaxis, St. Louis, USA). Forces acting on the devices were measured with the force measurement tool Futek LRF 400 (Futek Advanced Sensor Technology Inc., Irvine, CA, USA). A standardized protocol of different movements of the magnetic field including all three dimensions was performed and maximal forces on the CIED were assessed. RESULTS: Out of 121 devices, 78 different pacemakers (54 different model families from 11 manufacturers) and 43 different cardioverter-defibrillators (26 different model families from 6) were examined. The mean force that could be observed was 0.33 ± 0.13 N for pacemakers (range 0.16-1.12 N) and 1.05 ± 0.11 N for cardioverter-defibrillators (range 0.86-1.38 N) when exposed to the magnetic field. CONCLUSION: Exposure of pacemakers or implantable cardioverter-defibrillators to a magnetic field of 0.1 T does not result in a force exceeding the regulatory demanded 5 N that could damage the connected leads.

Visualization of multiple catheters in left atrial ablation procedures. Comparison of two different 3D mapping systems.

BACKGROUND: Visualization of intracardiac catheters placed in predefined anatomic locations is a cornerstone for successful atrial fibrillation (AF) ablation. The 3D mapping system Carto3™ (Biosense Webster, Diamond Bar, CA, USA) released in 2009 provides the possibility to visualize more than one intracardiac catheter at a time. The aim of the study was to evaluate the feasibility and safety of the system, to show the learning curve, and to compare it to the established Ensite NavX™ system regarding procedural handling parameters. METHODS: A total of 100 patients were enrolled in the study. The Carto3™ system was used by a team of four specialized operators in 50 patients (mean age 62±9 years, paroxysmal AF n=28, persistent AF n=17, left atrial flutter n=5). Patients were consecutively enrolled and matched (regarding type of ablated arrhythmias, ablation strategy, left atrial size, age, and gender) with patients ablated during the same time period with the EnSite NavX™ system. In patients with paroxysmal AF, ostial pulmonary vein isolation (PVI) was performed. Patients with persistent AF underwent PVI plus additional ablation of complex fractionated atrial electrograms (CFAE) and patients with left atrial flutter were treated with specific lines. RESULTS: In 50 case-control pairs, all procedures were performed as planned without complications in both groups except one cardiac tamponade in 1 patient in the Ensite NavX™ control group. The learning curve using the Carto3™ system was fast regarding x-ray time and procedural duration and reached the level of the EnSite NavX™ system after 15 and 25 patients, respectively. CONCLUSION: The Carto3™ system with its feature of visualizing several catheters is feasible and safe compared to an established system, e.g., Ensite NavX™. The learning curve is steep regarding reduction of x-ray time and procedural duration.

Cardiac dysrhythmias in pediatric patients before and 1 year after transcatheter closure of atrial septal defects using the amplatzer septal occluder.

To prospectively assess the incidence of cardiac dysrhythmias before and after closure of atrial septal defects (ASDs) using the Amplatzer septal occluder (ASO), 24-hour Holter electrocardiograms (ECGs) were performed before and 1 year after the procedure in 23 pediatric patients (9 male and 14 female). Patients' ages ranged from 2 to 15 years (mean, 7.1 years). All had an ASD of the secundum type that was completely closed (n = 22) or had a small residual shunt (n = 1). No preexisting dysrhythmia was present in 22 patients; atrioventricular nodal reentrant tachycardia had been diagnosed in 1 patient. During the observation period, no clinical dysrhythmia occurred. Analysis of the Holter ECGs before the intervention showed regular sinus rhythm in 20 patients and sinus rhythm with intermittent atrial rhythm in 3 patients. Atrial premature complexes (APCs) were detected in 1 patient, and a ventricular couplet was present in 1 patient. The Holter ECG 1 year after the intervention showed sinus rhythm in 18 patients and sinus rhythm with intermittent atrial rhythm in 5 patients. APCs were still observed in 1 patient and seen for the first time in 1 patient; 1 patient and rare ventricular premature complexes. In conclusion, cardiac dysrhythmias on Holter ECG in pediatric patients before and 1 year after transcatheter ASD closure with the ASO device are rare and benign. Regular Holter monitoring seems to be useful in detecting late dysrhythmias.

Prediction of normal QT intervals in children.

Measuring QT intervals in individual children is of great importance, particularly in view of increasing evidence linking long QT syndrome to subsequent risk for sudden death. Three hundred seventy-three healthy subjects, 185 women and 188 men, aged 5.2 to 16.5 years, were investigated with a 12-lead-standard electrocardiogram (ECG). Values for predicted QTp50 and QTp95 (percentiles) were calculated by using the cycle length (RR interval [RRI]) and the measured QT interval. We used multiple regression analysis to test the influence of possible important variables and the resulting data were used to generate tables. Additionally, predicted QTp values were compared to QTc values after Bazett's correction. RRI, body height, age, and sex turned out to influence the QTp values most. For clinical use, data are presented in tabular form by RRI and age for both genders. The tables are of great clinical value in predicting the upper limits of normal QTp95 for individual children. Bazett's correction tends to underestimate the values found in our data when heart rate increases.

[Transesophageal electroconversion of atrial reentrant tachycardias early or late following surgery for congenital heart disease]. / Transösophageale Elektrokonversion atrialer Reentry-Tachykardien in der Früh- oder Spätphase nach Operationen angeborener Herzfehler.

Atrial reentrant tachycardias (ART) are a potentially life-threatening complication in survivors of congenital heart disease surgery. From July 1993 to December 1997, temporary transesophageal pacing was used to convert 29 tachycardia episodes in 19 patients. At the time of the first tachycardia episode, patients' ages were 1 month to 26 years (mean 9.8 yrs). Time from operation to onset of first tachycardia episode ranged from 1 day to 19 years. Onset was within the first 2 weeks postoperatively in 6 patients and occurred later in 13 patients (1 to 19 years after operation). Postoperative pacemaker implantation had been performed in 2 pts; 17 of 19 pts were receiving antiarrhythmic medication. After placing a quadripolar transesophageal catheter, atrial and ventricular signals were recorded and atrial stimulation performed. Atrial cycle length of tachycardia ranged from 160-380 ms with 1:1 to 4:1 AV conduction. Temporary transesophageal pacing was performed following an algorithm starting with 4 extrastimuli (20 ms below atrial cycle length of tachycardia). Tachycardia terminated in 27 of 29 cases (93%) without complications. In 3 cases, conversion was achieved by pacing after amiodarone 5 mg/kg i.v. After tachycardia conversion, sinus- or pacemaker rhythm was present in 20 cases. In 9 cases atrial fibrillation was recorded; spontaneous conversion to sinus rhythm occurred after a maximum of 3 min (7 cases) or persisted and required direct current cardioversion (2 cases). In conclusion, transesophageal atrial pacing is an effective, relatively noninvasive method for conversion of atrial reentrant tachycardias after operation for congenital heart disease.