Pulmonary vein isolation in patients with paroxysmal atrial fibrillation : Long-term clinical outcomes with first- and second-generation cryoballoons.

BACKGROUND: The aim of this study was to evaluate the long-term success rates of pulmonary vein isolation (PVI) using only first-generation cryoballoon (CB-1) and second-generation CB (CB-2) in patients with paroxysmal atrial fibrillation (PAF). PATIENTS AND METHODS: A total of 114 drug-refractory patients with PAF (mean age: 62 ± 10 years; 62.3 % males) were enrolled. All index ablation procedures were performed using a 28-mm CB. All patients were scheduled for outpatient clinic visits, followed by 24-h or 7­day Holter electrocardiogram (EGC) evaluation. RESULTS: All PVs in the CB-1 group and 367 of 368 (99.7 %) PVs in the CB-2 group were completely isolated during the index procedure. The most commonly observed complication was phrenic nerve palsy in four (4.3 %) patients with CB-2. The mean follow-up period for CB-1 and CB-2 was 33.4 ± 14.9 and 27.2 ± 10.6 months, respectively. Freedom from AF was 42.9 % for CB-1 and 74.2 % for CB-2 at the end of the follow-up period. The European Heart Rhythm Association score improved in patients without AF recurrence after the procedure (2.8 ± 0.4 vs. 1.2 ± 0.5, p < 0.001), whereas no significant improvement was observed in the symptomatic status of patients with recurrence (2.8 ± 0.4 vs. 2.2 ± 0.9, p = 0.149). CONCLUSION: Second-generation CB provided significantly better clinical outcomes than its predecessor and was associated with low peri- and postprocedural complications.

Impact of respiratory infectious epidemics on STEMI incidence and care.

The effect of respiratory infectious diseases on STEMI incidence, but also STEMI care is not well understood. The Influenza 2017/2018 epidemic and the COVID-19 pandemic were chosen as observational periods to investigate the effect of respiratory virus diseases on these outcomes in a metropolitan area with an established STEMI network. We analyzed data on incidence and care during the COVID-19 pandemic, Influenza 2017/2018 epidemic and corresponding seasonal control periods. Three comparisons were performed: (1) COVID-19 pandemic group versus pandemic control group, (2) COVID-19 pandemic group versus Influenza 2017/2018 epidemic group and (3) Influenza 2017/2018 epidemic group versus epidemic control group. We used Student's t-test, Fisher's exact test and Chi square test for statistical analysis. 1455 patients were eligible. The daily STEMI incidence was 1.49 during the COVID-19 pandemic, 1.40 for the pandemic season control period, 1.22 during the Influenza 2017/2018 epidemic and 1.28 during the epidemic season control group. Median symptom-to-contact time was 180 min during the COVID-19 pandemic. In the pandemic season control group it was 90 min (p = 0.183), and in the Influenza 2017/2018 cohort it was 90 min, too (p = 0.216). Interval in the epidemic control group was 79 min (p = 0.733). The COVID-19 group had a door-to-balloon time of 49 min, corresponding intervals were 39 min for the pandemic season group (p = 0.038), 37 min for the Influenza 2017/2018 group (p = 0.421), and 38 min for the epidemic season control group (p = 0.429). In-hospital mortality was 6.1% for the COVID-19 group, 5.9% for the Influenza 2017/2018 group (p = 1.0), 11% and 11.2% for the season control groups. The respiratory virus diseases neither resulted in an overall treatment delay, nor did they cause an increase in STEMI mortality or incidence. The registry analysis demonstrated a prolonged door-to-balloon time during the COVID-19 pandemic.

[Optimized programming during cardiac resynchronization therapy]. / Optimierte Programmierung der atrio-ventrikulären und ventrikulo-ventrikulären Verzögerungszeiten bei Patienten unter biventrikulärer Stimulation - ein pragmatischer Ansatz.

Cardiac resynchronization (CRT) has evolved as a therapeutic add-on tool in patients with refractory heart failure. Additional pacing of the left ventricle leads to relevant clinical and hemodynamic improvement. Optimized programming of these pacing systems may modulate therapeutic efficacy. Optimal atrio-ventricular (AV) and ventriculo-ventricular (VV) delay programming is documented to increase invasively and non-invasively determined parameters of cardiac hemodynamics. In this manuscript different options for determining optimal AV and VV delay are discussed and a pragmatic approach to optimize CRT programming is detailed. VV delay needs to be optimized as a first step of programming. Different techniques may estimate the individual need for sequential ventricular pacing. Especially electrocardiographic criteria during right and left ventricular pacing may approximate the time-delay for pre-excitation. Delay between aortic and pulmonic valve ejection can be determined using Doppler echocardiography may identify patients who benefit from sequential pacing. Optimizing AV delay is a domain of Doppler echocardiography where using a simple formula the AV delay that produces the best diastolic resynchronization of left atrial contraction and left ventricular ejection can be calculated.Using the above mentioned techniques a pragmatic, easy and fast method for increasing CRT performance can be established. In cases of worsening heart failure or relevant changes of left ventricular dimensions adaptions (re-optimization) of VV and AV delay may be needed.

Physical activity, cardiorespiratory fitness and carotid intima thickness: sedentary occupation as risk factor for atherosclerosis and obesity.

OBJECTIVE: The influence of occupational physical activity on markers of atherosclerosis, prevalence of metabolic syndrome and physical performance has been understudied in current literature. Main aim of this study was to examine the association between physical work environment and physiological performance measures, physical activity, metabolic parameters and carotid atherosclerosis among German career firefighters and sedentary clerks. PATIENTS AND METHODS: We prospectively examined and recruited 143 male German civil servants (97 firefighters [FFs], and 46 sedentary clerks [SCs]). Correlation for each parameter for the groups were compared using a linear regression model adjusted for age. RESULTS: 97 firefighters (FFs) showed higher maximal aerobic power (VO2max) of 3.17 ± 0.44 L/min compared to 46 sedentary clerks (SCs) 2.85 ± 0.52 L/min (-0.21 CI -0.39-0.04, p = 0.018). Physical activity (PA, in METS/week) in FFs was 3953 ± 2688 and in SC 2212 ± 2293 (-1791.86 CI -2650--934, p = 0.000). Body fat was 17.7 ± 6.2% in FFs and in SCs 20.8 ± 6.5% (1.98 CI -0.28-4.25, p = 0.086). Waist circumference was 89.8 ± 10.0 cm in FFs and in SCs 97.3 ± 11.7 (-4.89 CI 1.24-8.55, p = 0.009). Carotid intima media thickness (IMT) showed significant difference for the left carotid artery 0.69 ± 0.19 mm in FFs vs. SCs 0.81 ± 0.20 (0.07 CI 0.01-0.14, p = 0.030). Metabolic syndrome was found in 12 out of 98 FFs (13.4%), and in 14 out of 46 SCs (30.43%). CONCLUSIONS: FFs showed significantly higher physical activity levels compared with the SCs. SCs had higher cardiovascular risk profile, higher prevalence of metabolic syndrome, higher waist circumference and significantly higher IMT than FFs. In conclusion, sedentary occupations have higher cardiovascular risk secondary to accelerated atherosclerosis.

Morphological differences of the internal thoracic artery in patients with and without coronary artery disease--evaluation by duplex-scanning.

OBJECTIVE: The internal thoracic artery is an established arterial graft for myocardial revascularisation, especially of the left anterior descending artery because of a higher patency rate compared to venous grafts. It has never been investigated, whether there are morphological differences in this vessel between patients with or without coronary artery disease or if they are comparable to morphological changes in the common carotid artery. METHODS: We investigated the internal thoracic artery and the common carotid artery of 24 patients (12 with coronary artery disease, 12 without coronary artery disease) with an ultrasonic system on both sides. The intima-media thickness and the diameter of both vessels were estimated. RESULTS: The intima-media-thickness of the internal thoracic artery was comparable in all patients, independent of the presence of a coronary artery disease (0.51+/-0.11 mm with coronary artery disease, 0.50+/-0.17 mm without coronary artery disease, P>0.05). Compared with this the intima-media-thickness of the common carotid artery was thicker in patients with coronary artery disease (0.84+/-0.13 mm with coronary artery disease, 0.73+/-0.07 mm without coronary artery disease, P< or or =0.014). There was no correlation between the thickness of the internal thoracic artery and the common carotid artery (r=0.018, P>0.05). CONCLUSIONS: It could be demonstrated for the first with non-invasive ultrasound, that the intima-media-complex of the internal thoracic artery is protected of the influence of arteriosclerosis. There are no morphological differences like the intima-media-thickness of the common carotid artery. The proven protective mechanism underlines the widespread use of the internal thoracic artery as a coronary artery bypass graft.

Gender differences in onset of symptoms in AV nodal re-entrant and accessory pathway-mediated re-entrant tachycardia.

PURPOSE: Is onset of symptoms in AV nodal re-entrant tachycardia (AVNRT) and accessory pathway-mediated re-entrant tachycardia (AVRT) patients gender-specific? METHODS: Intra- and inter-gender differences in onset of symptoms and mechanism of supraventricular tachycardia in adult patients undergoing catheter ablation for AVNRT or AVRT (N=230) were documented. RESULTS: Women with AVNRT were significantly younger at onset of symptoms compared to men (38+/-18, 51+/-18 years, p=0.01). Male AVNRT patients were significantly older at onset of symptoms compared to male AVRT patients (51+/-18, 25+/-11 years, p=0.04) but there was no difference in women. Symptoms beginning <30 years in men predicted AVRT in 73%, and beginning >or=30 years the predominant mechanism was AVNRT (85%). In women AVNRT was the most likely mechanism independent of symptom onset (>75%). CONCLUSIONS: Symptoms beginning in patients with AVNRT and AVRT prior to age 30 correlates with a 70% incidence of AVRT in men and a 80% incidence of AVNRT in women. Onset of palpitations >or= age 30 relates to AVNRT in 85% of patients.

[Curative treatment in a patient with exercise induced syncope]. / Kurative Therapie bei einem Patienten mit belastungsabhängigen Synkopen.

HISTORY: A 38 year old man suffered from exercise-induced reproducible dizziness and syncopes. INVESTIGATIONS AND DIAGNOSIS: During exercise testing a ventricular tachycardia at a rate of 300 beats/min was identified as the cause of the symptoms. Because of the ventricular morphology with inferior axis, left bunde branch block and the typical monomorphic repetitive characteristics, idiopathic adenosine-sensitive ventricular tachycardia was diagnosed. TREATMENT AND CLINICAL COURSE: Curative catheter ablation of the arrhythmogenic focus in the right ventricular outflow tract was performed. The patient has now been free of symptoms for more than two years. The characteristics of idiopathic ventricular tachycardia and the electrophysiological techniques are described. CONCLUSION: Idiopathic ventricular tachycardia is a rare cause of syncope in young patients without underlying heart disease and can be cured by catheter ablation. Exclusion of cardiac diseases, especially arrhythmogenic right ventricular cardiomyopathy, is of prognostic value.

[Recurrent ventricular tachycardias following myocardial infarction: linear ablation strategy using an electroanatomical mapping system]. / Rezidivierende ventrikuläre Tachykardien nach Myokardinfarkt: Lineare Ablationsstrategie unter Einsatz eines elektroanatomischen Mappingsystems.

BACKGROUND AND AIM OF STUDY: The implantable cardioverter defibrillator (ICD) is the therapy of choice for patients with ventricular tachycardia (VT) after myocardial infarction. In some patients frequent ICD shocks occur, often resulting in clinical problems, if antiarrhythmic drugs insufficiently suppress them. Our aim was to describe electro-anatomical mapping and ablation techniques in patients with VTs, in which conventional strategy treatments have failed. PATIENTS AND METHODS: 17 patients (69.5 +/- 8 years, 12 male) were included. During 3 months before ablation the number of ICD shocks was 21 +/- 8 (mean +/- SD). Using an electro-anatomical mapping system (CARTO), activation mapping was performed in 12 patients during hemodynamically tolerable, stable VT. In 5 cases with "non-mappable" VT only voltage mapping during sinus rhythm was obtained. The aim was to characterize the underlying scar tissue precisely in order to modify the substrate with an individual strategic linear lesion, thus preventing re-induction of VT. RESULTS: Procedure time was 184 +/- 9 minutes, fluoroscopy time totalled 19 +/- 9 minutes. Lesion lines were established with 13 +/- 9 ablation pulses. In 15 patients (88 %) acute ablation of the VT was successful. During a follow-up of 8 +/- 7 months, 2 patients had a recurrence of the VT. Two patients developed a VT with a different morphology. In another case ventricular fibrillation occurred. No major complications were observed. CONCLUSION: Electro-anatomical mapping combined with an individual linear ablation strategy is a safe and effective method to prevent symptomatic VT in patients after myocardial infarction.

Plasma levels of NT-pro-BNP in patients with atrial fibrillation before and after electrical cardioversion.

OBJECTIVE: Plasma levels of brain natriuretic peptide (BNP) have been examined in studies on patients with persistent atrial fibrillation, both before and after electrical cardioversion. Studied patients often showed a comorbidity with congestive heart failure, which complicates interpretation of measured BNP values as a natriuretic peptide. The aim of this study was to examine plasma levels of N-terminal fragment pro-brain natriuretic peptide (NT-pro-BNP), which is the more stable but inactive cleavage product of pro-BNP in patients with atrial fibrillation, but normal left ventricular ejection fraction, before and after electrical cardioversion. PATIENTS AND METHODS: NT-pro-BNP plasma levels of 34 consecutive patients were measured before, shortly after and 11 days after electrical cardioversion. All patients showed a normal ejection fraction after echocardiographic or laevocardiographic criteria. RESULTS: At baseline, all patients showed elevated NT-pro-BNP compared to a healthy control group (1086 vs. 66.9 pg/ml, p<0.001). After a mean follow-up time of 11 days in patients with persistent restored sinusrhythm, NT-pro-BNP decreased from 1071 pg/ml at baseline to 300 pg/ml (p<0.001). In contrast, patients with recurrence of atrial fibrillation showed increased levels from 1570.5 pg/ml at baseline to 1991 pg/ml (p=0.13; n.s.). Recurrence of atrial fibrillation was independent from height of NT-pro-BNP levels at baseline (p=0.23). CONCLUSIONS: Atrial fibrillation in patients with a normal left ventricular ejection fraction is associated with elevated NT-pro-BNP plasma levels, which decrease when a persistent sinus-rhythm can be restored by electrical cardioversion. On the other hand, NT-pro-BNP seems to increase (n.s.) when recurrence of atrial fibrillation occurs. Finally, NT-pro-BNP is no valid predictor for long-term success of sinus-rhythm restoration by electrical cardioversion.

Gene-specific trans-regulatory functions of magnesium for chloroplast mRNA stability in higher plants.

In higher plant chloroplasts the accumulation of plastid-encoded mRNAs during leaf maturation is regulated via gene-specific mRNA stabilization. The half-lives of chloroplast RNAs are specifically affected by magnesium ions. psbA mRNA (D1 protein of photosystem II), rbcL mRNA (large subunit of ribulose-1,5-bisphosphate carboxylase), 16 S rRNA, and tRNA(His) gain stability at specific magnesium concentrations in an in vitro degradation system from spinach chloroplasts. Each RNA exhibits a typical magnesium concentration-dependent stabilization profile. It shows a cooperative response of the stability-regulated psbA mRNA and a saturation curve for the other RNAs. The concentration of free Mg(2+) rises during chloroplast development within a range sufficient to mediate gene-specific mRNA stabilization in vivo as observed in vitro. We suggest that magnesium ions are a trans-acting factor mediating differential mRNA stability.

[Statins do not prevent restenosis after coronary angioplasty: where to go from here?]. / Statine verringern nicht die Restenoserate nach konventioneller Koronarangioplastie. Wie geht es jetzt weiter?

BACKGROUND: Despite the use of intracoronary stents, approximately 15-20% of patients who undergo percutaneous transluminal coronary angioplasty (PTCA) experience symptomatic restenosis. Known mechanisms of restenotic lesion formation are smooth muscle cell proliferation, extracellular matrix production, remodeling and decreased programmed cell death (apoptosis). RESULTS AND STUDIES: Experimental observations suggest that HMG-CoA reductase inhibitors ("statins") reduce the risk of restenosis. The activity of statins limits the rate of synthesis, not only of cholesterol, but also of a range of other molecules involved in cellular function. Their benefits in primary and secondary prevention of atherosclerosis have been widely recognized. Clinical trials using different types of statins were designed to evaluate their ability to influence the incidence of restenosis after successful conventional PTCA. The results clearly demonstrated that statins reduce lipid levels but do not prevent restenosis. Experimental evidence has failed to translate into clinical effect. The underlying pathological reasons for this shortcoming as well as promising alternative approaches including vascular gene therapy and brachytherapy will be discussed in this review.

[Atrial lead placement in cases of intraoperative atrial fibrillation]. / Vorhofsondenplatzierung bei Patienten mit Vorhofflimmern.

AIM: Evaluating the efficiency of a prescribed concept for atrial lead placement in cases of intraoperative atrial fibrillation (AF). METHODS: Over the period from 11/1998 to 5/2000, we carried out a prospective study on 40 patients with AF. After implantation of the screw electrode into the lateral wall of the atrium, an amplitude of the intracardial ECG of > or = 1.4 mV was arbitrarily defined as tolerable. At amplitudes of < 1.4 mV, atrial overdrive-stimulation occurred at 400 to 800 ppm in order to convert the AF to sinus rhythm (SR). Following successful overdrive-stimulation, the atrial electrode was positioned according to standard values (P-wave > 3 mV, pacing threshold < 0.5 V at 0.5 ms). In the case of unsuccessful intraoperative atrial stimulation, the electrode was repositioned until an amplitude of > or = 1.4 mV was reached. In all cases bipolar atrial screw electrodes (Model 4068, Medtronic Inc., Minneapolis, MN, USA) were implanted. The intraoperative measurements were carried out via the atrial channel of a 5311 PSA (Medtronic Inc., Minneapolis, MN, USA). In follow-up after 6 weeks, the atrial stimulation threshold was measured in [V] at 0.5 ms and the signal amplitude of the P-wave in [mV], or in the case of AF detection with successful mode switch activation. RESULTS: In 31/40 patients (77.5 %) with intraoperative persistent AF, fibrillation amplitudes of 1.4 to 3.1 mV (mean value 1.9 +/- 0.4 mV) were measured. In 9/40 patients (22.5 %) with intraoperative AF, 4 cases of conversion to SR using burst stimulation were documented. Atrial lead placement was performed using standard values. After 6 weeks, 33/40 patients (82.5 %) had SR, while intermittent AF episodes with successful mode switch activation were documented in 21 patients (52.5 %). The P-wave amplitude was 3.63 +/- 0.69 mV (range 1.8 to 4.9 mV), the atrial stimulation threshold was 1.3 +/- 0.4 mV (range 0.4 to 1.9 mV). Atrial lead adjustment due to sensing defects was not required for any patients. CONCLUSION: The results show that all atrial leads implanted in accordance with this concept demonstrate proper sensing at SR as well as under AF, with successful mode switch episodes and acceptable stimulation thresholds.

[Ventricular bigeminy with fixed with fixed coupling at rest and during exercise as the cause of recurrent dizziness and syncope--successful anti-arrhythmic therapy by high frequency current catheter ablation of a right ventricular arrhythmogenic focus. A case report]. / Ventrikulärer Bigeminus mit fixer Kopplung in Ruhe und unter Belastung als Ursache für rezidivierende Schwindelattacken und Synkopen--erfolgreiche antiarrhythmische Therapie durch Hochfrequenzstrom-Ablation eines rechtsventrikulären arrhythmogenen Fokus. Ein Fallbericht.

In a 52-year-old patient with beginning dilatative cardiomyopathy dizziness and syncopes could be observed due to a ventricular bigeminy at rest and under exercise conditions. The patient also showed a marked reduction of exercise capacity and was handicapped in his profession as electrician and unable to work for more than 10 months. Antiarrhythmic drug therapy including the subsequent use of all available antiarrhythmic agents failed in suppressing this arrhythmia. In an electrophysiological study the arrhythmogenic focus could be localized in the right ventricular outflow tract. Application of radiofrequency current resulted in instantaneous termination of the extrasystoly; this result could be documented in repeat Holter monitorings over 12 weeks to present. This case report shows that radiofrequency catheter ablation can in special cases be applied for therapy of extrasystolic phenomena when clinical symptoms necessitate treatment and antiarrhythmic drug therapy fails.

[Successful high frequency current catheter ablation of an accessory conduction pathway in the "neck region" of a coronary sinus aneurysm. A case report]. / Erfolgreiche Hochfrequenzstrom-Katheterablation einer akzessorischen Leitungsbahn im "Halsbereich" eines Koronarsinus-Aneurysmas. Ein Fallbericht.

In this case report the electrophysiological findings in a 24 year old female patient are demonstrated. For about 12 years she suffered from recurrent atrioventricular reentrant tachycardia with a rate of 230 beats per minute. Electrophysiological study resulted in diagnosis of a posteroseptal accessory pathway. Ablation was attempted primarily from a left ventricular access, but the pathway could not be reached from this position. After contrasting the coronary sinus a large coronary sinus aneurysm could be diagnosed. The accessory pathway was located in the "neck"-region of the aneurysm. By application of radiofrequency current in this location the bypass tract could be ablated. This case report shows that accessory pathways in coronary sinus aneurysms can be ablated without complications in this location.

Cardiogenic shock due to thrombotic thrombocytopenic purpura.

We report the case of a 49-year-old man with thrombotic thrombocytopenic purpura (TTP) leading to cardiogenic shock. Laboratory data were typical for TTP with thrombocytopenia and microangiopathic hemolytic anemia. The electrocardiogram recorded significant ST-segment elevations in the anterior and inferior leads. In addition' coronary angiography showed normal epicardial coronary arteries with slow flow. The patient died due to electromechanical dissociation six hours after admission. During autopsy typical features of thrombotic thrombocytopenic purpura were found. Histological preparation of the heart showed a diffuse myocardial necrosis due to microvascular thrombosis. Cardiac involvement is common in TTP but extended myocardial necrosis has been reported in only a few cases.

[Therapy options for Prinzmetal angina induced ventricular vulnerability]. / Therapieoptionen einer Prinzmetal-Angina induzierten ventrikulären Vulnerabilität.

We report about a 46 year old male, who survived sudden cardiac death caused by recurrent ventricular tachycardia as the clinical manifestation of a vasospastic right coronary artery. After implantation of an implantable cardioverter defibrillator, the patient did not respond to conservative treatment despite of different drug therapies. Therefore, the vasospastic right coronary artery was treated by a percutaneous transluminal coronary angioplasty and stenting, which could not reduce the occurrence of further tachycardias. Finally, the patient underwent an operative myocardial revascularization combined with sympathectomy. During the whole follow-up of six months no new episodes of ventricular tachyarrhythmias have occurred.

[Curative therapy in symptomatic atrial ectopy]. / Kurative Therapie bei symptomatischer atrialer Extrasystolie.

A female patient without underlying heart disease was highly symptomatic from short runs of atrial ectopy. Sustained atrial tachycardia or atrial fibrillation never occurred. Due to ineffective pharmacological therapy, catheter ablation combined with electroanatomic mapping (CARTO) was performed effectively. Characteristics of ectopic atrial tachycardia and the electrophysiological techniques are described.

Identification and ablation of atypical atrial flutter. Entrainment pacing combined with electroanatomic mapping.

Differentiation between typical and atypical atrial flutter solely based upon surface ECG pattern may be limited. However, successful ablation of atrial flutter depends on the exact identification of the responsible re-entrant circuit and its critical isthmus. Between August 2001 and June 2003, we performed conventional entrainment pacing within the cavotricuspid isthmus in 71 patients with sustained atrial flutter. In patients with positive entrainment we considered the arrhythmia as typical flutter and treated them with conventional ablation of the cavotricuspid isthmus. As a consequence of negative entrainment we performed 3D-electroanatomic activation mapping (CARTO trade mark ). Conventional ablation of the right atrial isthmus was successful in all patients (n = 54) with positive entrainment. We performed electroanatomic mapping in the remaining 17 patients (14 male; age 60.9 +/- 16 years) resulting in the identification of 6 cases with typical and 11 cases with atypical flutter. Therefore, entrainment pacing was able to predict the true presence of typical atrial flutter in 91.5%. Atypical flutter was right sided in 4 patients and left sided in 7 cases. Electrically silent ("low voltage") areas probably demonstrating atrial myopathy were identified in all cases with left sided and in 2 patients with right sided flutter. In these patients targets for ablation lines were located between silent areas and anatomic barriers (inferior pulmonary veins, mitral respectively tricuspid annulus, or vena cava inferior). In 1 patient, the investigation was stopped due to variable ECG pattern and atrial cycle lengths. In the remaining cases, ablation was acutely successful. One patient, after surgical closure of a ventricular septal defect, demonstrated a dual-loop intra-atrial reentry tachycardia dependent on two different isthmuses. This arrhythmia required ablation of those distinct isthmuses to be interrupted. After a mean follow-up of 8.8 +/- 3.4 months, there was one patient with a recurrence of left-sided atrial flutter. Another patient developed permanent atrial fibrillation shortly after the procedure. Mean duration time of the procedure was 235.6 +/- 56.4 min (right atrium: 196 +/- 17.3 min; left atrium: 267.2 +/- 59.5 min), and average fluoroscopy time was 21.8 +/- 11.7 min (right atrium: 9.5 +/- 6 min; left atrium: 28.9 +/- 7 min). There was no incidence of serious complications associated with these procedures. In conclusion, conventional pacing in the cavotricuspid isthmus combined with electroanatomic mapping was an effective method to differentiate between typical and atypical atrial flutter. Electroanatomic mapping was a powerful tool both for identification of different atrial re-entrant circuits including their critical isthmuses as well as for effective application of individual ablation line strategies.

[Catheter ablation of ectopic atrial tachycardia by electrical pulmonary vein disconnection]. / Katheterablation einer ektopen atrialen Tachykardie mittels elektrischer Pulmonalvenendiskonnektion.

We report a 25-year-old female patient with a long history of symptomatic paroxysmal supraventricular tachycardia. Electroanatomic activation mapping demonstrated a focal tachycardia originating in the right upper pulmonary vein, 3 cm distal to the ostium. Due to the recent experiences in the management of focal atrial fibrillation with catheter ablation, direct ablation applied inside the pulmonary vein was avoided. Instead, an electrical disconnection of the pulmonary musculature from the left atrium guided by a circumferential 10-electrode mapping catheter was performed. The patient has since been asymptomatic during follow-up.

[Clinical experiences with cooled radiofrequency ablation of ectopic atrial tachycardia employing an electroanatomic mapping system]. / Klinische Erfahrungen mit der gekühlten Radiofrequenzablation ektoper atrialer Tachykardien unter Einsatz eines elektroanatomischen Mappingsystems.

Due to its variable origin success for ablation of ectopic atrial tachycardia (EAT) has been difficult to achieve using conventional mapping and ablation strategies. In contrast, no information in the literature is available about the use of a nonfluoroscopic, 3-dimensional electroanatomic mapping system (CARTO) combined with the cooled ablation technology creating deeper lesions in experimental studies compared to standard catheters. In 20 consecutive patients (15 female; age 52.5 +/- 15.4 years), a single focus responsible for clinical EAT has been mapped. Twelve EATs were located in the right atrium, whereas 8 foci were left sided including 3 origins within a pulmonary vein (PV). Due to the reported development of PV stenosis in the ablative treatment of focal atrial fibrillation, direct ablation applied inside the PV was avoided. Instead, PV-disconnection achieved by the use of a Lasso trade mark catheter in 1 case and by circumferential ablation around the PV in 2 other patients was preferred. In 2 patients, ablation was not attempted because of an origin located directly in the area of the atrioventricular node. In another case, CARTO mapping was stopped due to persistent mechanical termination of the tachycardia with no possibility of reinduction. In the latter, ablation was performed in sinus rhythm at the earliest mapped site before terminating. Three weeks later another episode of EAT was noted in this patient. In the remaining 17 cases, ablation was associated with acute success and no recurrences of sustained tachycardia in all patients. Mean duration time was 192 +/- 53.3 min (right atrium 161 +/- 37.9 min; left atrium 229.6 +/- 46.2 min), and average fluoroscopic time was 22.8 +/- 9.7 min (right atrium 17.1 +/- 6.2 min; left atrium 29.8 +/- 8.9 min). There was no incidence of serious complications associated with this procedure. In conclusions, electroanatomical mapping including cooled ablation was a safe and feasible strategy in treating EATs. The benefit of this technique may imply the combination of both precise localization of the focus and effective applications of radiofrequency pulses, thereby minimizing acute failures or reablation. Due to the time consuming point by point data acquisition, the ability to generate precise maps demonstrating the earliest activation at their exact anatomical location can be limited by transient or persistent termination of the tachycardia.