[Catheter ablation of paroxysmal atrial fibrillation: extended recommendations considering safety improvements of pulmonary vein isolation with a cryoballoon--Case 11/2011]. / Katheterablation von paroxysmalem Vorhofflimmern: großzügigere Indikationsstellung durch verbesserte Sicherheit der Pulmonalvenenisolation mittels Cryoballon - Fall 11/2011.

HISTORY AND ADMISSION FINDINGS: A 71-year-old, male patient was referred to our clinic for paroxysmal palpitations with dyspnoe and fatigue since four years despite pharmacological treatment with flecainide and bisoprolol. INVESTIGATIONS: A paroxysmal atrial fibrillation was documented in a 24-hour Holter recording. A bicycle ergometry showed a hypertensive reaction during exercise without any sign of coronary insufficiency. Intracardiac thrombi could by excluded by transesophageal echocardiography. DIAGNOSIS, TREATMENT AND COURSE: The diagnosos of a drug-refractory paroxysmal atrial fibrillation was made and cryoballoon pulmonary vein isolation was performed. A follow-up 3 months after the ablation disclosed a freedom from atrial fibrillation documented in 7-day Holter recording. CONCLUSIONS: Compared to pharmacological rhythm control, interventional treatment has been established as more effective therapy for paroxysmal atrial fibrillation. However, patients should be referred to the ablation early enough to avoid structural atrial remodeling and thus transition into persistent or permanent atrial fibrillation. New technical developments e.g. cryoballoon catheter-system simplifies the procedure and has been reported to be effective and safe to use for circumferential pulmonary vein isolation. Should the very promising preclinical data on efficacy and safety of cryothermal energy ablation be confirmed by results of ongoing, controlled trials, the catheter ablation may become the fist-line treatment for all patients with paroxysmal atrial fibrillation.

[Risk stratification in non ischemic cardiomyopathy: a case report--Case 5/2010]. / Risikostratifizierung bei nichtischämischer Kardiomyopathie: Eine Kasuistik - Fall 5/2010.

HISTORY AND ADMISSION FINDINGS: A 65-year-old male patient with rapid increasing shortness of breath and newly diagnosed atrial fibrillation was admitted to our hospital. INVESTIGATIONS: The ECG revealed atrial fibrillation. Echocardiography showed severe decreased left ventricular function. The magnetic resonance imaging (MRI) scan confirmed the severe reduced left ventricular function with a two graded mitral regurgitation as well as a pronounced late enhancement in the posterobasal area of the interventricular septum. Cardiac catheterisation showed mild diffuse atherosclerosis of the coronary arteries without stenotic lesions. Multiple myocardial biopsies of the right ventricle revealed extensive remodelling processes with focal fibrosis in presence of mononuclear cell infiltrates, T-wave alternans and the heart rate variability were positive. DIAGNOSIS, TREATMENT AND COURSE: Nonischaemic cardiomyopathy (NICM) with severe reduced left ventriucular function was diagnosed. After successful electrical cardioversion and initiation of a sufficient heart failure treatment, the clinical symptoms as well as left ventricular function improved significantly. CONCLUSION: Risk stratification of sudden cardiac death remains a clinical challenge especially in NICM. Significantly predictors in ischaemic cardiomyopathy, such as heart rate turbulance (HRT) and T-wave alternans, are not useful or have no importance in NICM. However, the prognosis does not correlate with restricted left ventricular function in NICM. Cardiac MRI or marker of autonomic dysfunction could be helpful in risk stratification. How far late enhancement is a surrogate parameter or the real substrate for life threatening arrhythmias is still unclear. Non-invasive risk stratification could be helpful in borderline decisions, however, it should not be taken mandatory. Close-meshed control intervals of the clinical status under optimal medication are recommended, followed by a implantation of an implantable cardioverter-defibrillator (ICD) if needed. ICD implantation is superior to medical treatment in persistent depressed left ventricular function. The ideal time for ICD implantation in newly diagnosed NICM remains unclear at the moment.