[Careers in cardiac electrophysiology]. / Karrierewege in der Rhythmologie.

Cardiac electrophysiology has developed into a broad, exciting, and challenging subdiscipline of modern cardiology. The professional opportunities available to electrophysiologists are diverse and offer a wide variety of career goals. The aim of this article is to show young cardiologists what different career paths can look like if they opt for electrophysiology today. Personal testimonials from five experienced electrophysiologists on their own career paths show decisions, support, obstacles, and destinations of these paths to practice or university professorship. This article aims to support young cardiologists who are considering specialization in electrophysiology during their career planning.

Atrial fibrillation ablation using cryoballoon technology: Recent advances and practical techniques.

Atrial fibrillation (AF) affects 1-2% of the population, and its prevalence is estimated to double in the next 50 years as the population ages. AF results in impaired patients' life quality, deteriorated cardiac function, and even increased mortality. Antiarrhythmic drugs frequently fail to restore sinus rhythm. Catheter ablation is a valuable treatment approach for AF, even as a first-line therapy strategy in selected patients. Effective electrical pulmonary vein isolation (PVI) is the cornerstone of all AF ablation strategies. Use of radiofrequency (RF) catheter in combination of a three-dimensional electroanatomical mapping system is the most established ablation approach. However, catheter ablation of AF is challenging even sometimes for experienced operators. To facilitate catheter ablation of AF without compromising the durability of the pulmonary vein isolation, "single shot" ablation devices have been developed; of them, cryoballoon ablation, is by far the most widely investigated. In this report, we review the current knowledge of AF and discuss the recent evidence in catheter ablation of AF, particularly cryoballoon ablation. Moreover, we review relevant data from the literature as well as our own experience and summarize the key procedural practical techniques in PVI using cryoballoon technology, aiming to shorten the learning curve of the ablation technique and to contribute further to reduction of the disease burden.

Laser Balloon or Wide-Area Circumferential Irrigated Radiofrequency Ablation for Persistent Atrial Fibrillation: A Multicenter Prospective Randomized Study.

BACKGROUND: Pulmonary vein isolation is the cornerstone of ablation for persistent atrial fibrillation (AF). The role of balloon catheters in this patient population remains ill defined. We sought to compare efficacy and safety of the laser balloon (LB) with wide-area circumferential pulmonary vein isolation using irrigated radiofrequency current (RF) ablation and 3-dimensional mapping. METHODS AND RESULTS: In 6 European centers, patients with persistent AF were prospectively randomized. Follow-up included 3-day Holter ECG recordings and office visits at 3, 6, and 12 months. The primary efficacy end point was freedom from AF between 90 and 365 days after a single ablation. The primary safety end point was the incidence of any periprocedural complications. Of 152 enrolled patients, 134 (n=68 LB and 66 RF; 63% men; mean age, 66+10 years) with persistent AF (median AF history, 14 months; Q1-Q3, 7-36 months) underwent pulmonary vein isolation and completed the entire follow-up. Baseline parameters were similar in both groups. Procedure and fluoroscopy times were similar in both groups (135±38 and 14±9 minutes (LB) versus 128±51 and 11±9 minutes). The primary efficacy end point was met by 71.2% versus 69.3%, in the LB and RF groups, respectively (P=0.40). In the LB group, stroke (n=1), a false aneurysm (n=1), and phrenic nerve palsy (n=1) were observed. In the RF group, 2 patients developed a false aneurysm, and 1 patient needed surgical repair. CONCLUSIONS: An LB-guided strategy was associated with similar efficacy as wide-area circumferential pulmonary vein isolation using irrigated RF in patients with persistent AF. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.org. Unique identifier: NCT01863472.

High rate of durable pulmonary vein isolation after second-generation cryoballoon ablation: analysis of repeat procedures.

AIMS: Pulmonary vein isolation (PVI) using the first-generation cryoballoon (CB1) was characterized by a high rate of recovered pulmonary vein (PV) conduction along with a typical conduction gap pattern in patients with recurrent atrial tachyarrhythmia (ATa). Second generation (CB2) enables more uniform freezing. However, the rate of chronic PVI and PV conduction gap pattern is unknown. METHODS AND RESULTS: All patients with ATa recurrence undergoing a second procedure after CB2 or (historical) CB1 PVI (28 mm) were enrolled. In all patients, a left atrial three-dimensional electronatomic reconstruction was performed. The rates of chronic PVI and localization of PV conduction gaps were determined and compared between CB1 and CB2. Antral PV re-isolation was performed using irrigated-tip radiofrequency current energy ablation. Of 206 patients (CB2), 18 patients underwent the repeat procedure after 192 (75:245) days. In 6 of 18 (33%) patients, all PVs were electrically isolated whereas in the remaining 12 patients (66%) at least one PV demonstrated PV reconduction. Of 71 PVs [1 left common PV (LCPV)], 55 PVs (77%) were chronically isolated. The right superior PV (RSPV) was characterized by the lowest rate of chronic PVI (RSPV: 56%, LSPV: 76%, RIPV: 83%, LIPV: 94%, LCPV: 100%). Compared with CB1, CB2 ablation resulted in a significantly higher rate of chronic PVI (CB2: 77% vs. CB1: 32%; P < 0.0001) with the greatest improvement along both inferior PVs. CONCLUSION: Second-generation cryoballoon atrial fibrillation ablation is associated with a high rate of durable PVI in patients with ATa recurrence. The RSPV represents the PV with the greatest risk for left atrium-pulmonary vein reconnection.

Luminal esophageal temperature predicts esophageal lesions after second-generation cryoballoon pulmonary vein isolation.

BACKGROUND: The novel second-generation cryoballoon (CB) facilitates pulmonary vein isolation (PVI) by improved surface cooling. The impact of this redesign on collateral damage is unknown. OBJECTIVE: To investigate the incidence of esophageal lesions after PVI using the second-generation CB and the role of luminal esophageal temperature (LET) measurement as a predictor of lesion formation. METHODS: Thirty-two consecutive patients underwent PVI using the second-generation 28 mm CB. Target application time was 2 × 240 seconds. Ninety-two percent of the PVs were isolated after 1 cryoenergy application. Complete PVI was achieved in all patients. LET with 3 thermocouples was continuously measured during cryoenergy application. Freezing was interrupted only if weakening/loss of phrenic nerve function or low LET (<5 °C) was observed. RESULTS: The lowest measured LET was-12 °C (despite cryoapplication interruption). Postprocedural gastroesophagoscopy was performed after 1-3 days in all patients and showed lesions in 6 of 32 (19%) patients. A minimum LET of≤12 °C predicted esophageal lesions with 100% sensitivity and 92% specificity (area under the receiver-operator characteristic curve 0.97; 95% CI 0.93-1.02; P = .001). Persistent phrenic nerve palsy occurred in 2 (6%) patients during ablation at the right inferior pulmonary vein. Repeat gastroesophagoscopy confirmed healing of lesions after 16 ± 14 days. CONCLUSIONS: Second-generation 28 mm CB PVI is associated with significant esophageal cooling, resulting in lesion formation in 19% of the patients. LET measurement accurately predicts lesion formation and may enhance the safety of the novel device.

Ipsilateral pulmonary vein isolation performed by a single continuous circular lesion: role of pulmonary vein mapping during ablation.

AIMS: Complete pulmonary vein isolation (CPVI) can be achieved by continuous circular lesions (CCL) around the ipsilateral pulmonary veins (PVs) guided by a 3D-mapping system. We investigated whether CPVI can be achieved with a single CCL around the isplilateral PVs without recording PV activity during ablation. METHODS AND RESULTS: Fifty patients with atrial fibrillation underwent ablation of CCLs around ipsilateral PVs guided by 3D mapping. One or two Lasso catheters were placed within the PVs. Lasso tracings were hidden to physicians during ablation. After completion of CCLs, Lasso tracings were evaluated. If PV activation was present, conduction gaps (CGs) were identified and ablated with guidance by the local electrogram and the Lasso catheter(s). In 21 patients (42%), CPVI was achieved after ablation of a single CCL around ipsilateral PVs. Pulmonary vein isolation was achieved in 43 patients (86%) in the right-sided PVs and in 21 patients (42%) in the left-sided PVs. In the remaining patients, there were eight CGs in right-sided CCLs and 40 CGs in left-sided CCLs. Conduction gaps along the left CCLs were found at the ridge between the PV ostia and the left atrial appendage in 27 out of 40 CGs (68%). Mean time from the P-wave onset to the earliest PV potential was 112±35 ms in the presence of a CG at the roof, and 166±59 ms in patients with CGs at other locations in left-sided CCLs (P<0.05). CONCLUSION: Complete pulmonary vein isolation is difficult to achieve with a single CCL around ipsilateral PVs without continuous recording of PV activation during ablation.

Characterization of conduction recovery after pulmonary vein isolation using the "single big cryoballoon" technique.

BACKGROUND: Pulmonary vein isolation using the cryoballoon technique (CB-PVI) has evolved into a simple and safe alternative for point-by-point radiofrequency ablation. Systematic analysis of conduction recovery occurring after CB-PVI and causing recurrent atrial fibrillation has not yet been performed. OBJECTIVE: The purpose of this study was to analyze conduction recovery after PVI using the single big (28-mm) cryoballoon technique. METHODS: Twenty-six patients with recurrent atrial tachyarrhythmia after previous CB-PVI underwent repeat ablation. Pulmonary vein (PV) reisolation was performed by antral irrigated radiofrequency ablation using electroanatomic mapping. For analysis of the location of conduction gaps, the ipsilateral LA-PV junction was divided into six equally distributed segments. RESULTS: PV reconduction frequently occurred into multiple (>2) PVs (54% patients). Conduction gaps could be abolished by single point ablation in 63% (lateral) and 41% (septal) of patients or by incomplete circular lesions in the remaining patients. A significantly higher number of patients exhibited conduction recovery at inferior segments (85% lateral, 77% septal) compared with superior segments (42% lateral, 31% septal). Furthermore, the ridge between PV ostia and left atrial appendage (LAA) was highly associated with reconduction into lateral PVs (81% of patients). Retrospective analysis of the initial CB-PVI-procedure revealed lower freezing temperatures at superior than inferior PVs as well as sharp catheter angulations with loss of central cryoballoon alignment to reach inferior PVs. CONCLUSION: Conduction recovery after CB-PVI occurs at a high incidence at inferior sites around ipsilateral PV ostia and the LAA-PV ridge. Modifications of the technique to ensure optimal balloon-tissue contact at predilection sites may improve long-term success rates.

Catheter ablation of multiple unstable macroreentrant tachycardia within the right atrium free wall in patients without previous cardiac surgery.

BACKGROUND: Macroreentrant atrial tachycardia (AT) involving the right atrial free wall (RAFW) has been reported in patients without atriotomy. Catheter ablation of these ATs remains challenging due to the multiple morphologies of ATs with unstable reentrant circuits in some patients. The purpose of this study was to clarify the electrophysiological characteristics of these ATs and attempt the novel approach for catheter ablation. METHODS AND RESULTS: Electrophysiological study and catheter ablation were performed in 17 patients (14 men; 71 [quartile 1, 67; quartile 3, 76] years) with reentrant ATs originating from the RAFW using 3D mapping. All patients had no history of cardiac surgery. Clinical ATs with stable cycle length and atrial activation were identified in 11 patients (group A). All ATs were successfully ablated. In the remaining 6 patients, clinical tachycardia continuously changed, with a different cycle length and P-wave morphology and atrial activation sequence during mapping or entrainment study (group B). A complete isolation of the RAFW was attempted in group B. After complete isolation was achieved in 5 of 6 patients, ATs were not induced in these 6 patients. The number of previous failed catheter ablations and induced ATs were higher in group B than in group A. During 31 (19; 37) months of follow-up, AT recurrence developed in 27% patients from group A and 33% from group B. CONCLUSIONS: Multiple and unstable macroreentrant ATs from the RAFW can occur in patients without a history of cardiac surgery. The RAFW isolation has the potential to abolish all ATs.

The 'single big cryoballoon' technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study.

AIMS: Cryothermal energy (CTE) ablation via a balloon catheter (Arctic Front, Cryocath) represents a novel technology for pulmonary vein isolation (PVI). However, balloon-based PVI approaches are associated with phrenic nerve palsy (PNP). We investigated whether 'single big cryoballoon'-deployed CTE lesions can (i) achieve acute electrical PVI without left atrium (LA) imaging and (ii) avoid PNP in patients with paroxysmal atrial fibrillation (PAF). METHODS AND RESULTS: After double transseptal punctures, one Lasso catheter and a big 28 mm cryoballoon catheter using a steerable sheath were inserted into the LA. PV angiography and ostial Lasso recordings from all PVs were obtained. Selective PV angiography was used to evaluate balloon to LA-PV junction contact. CTE ablation lasted 300 s, and the PN was paced during freezing at right-sided PVs. Twenty-seven patients (19 males, mean age: 56 +/- 9 years, LA size: 42 +/- 5 mm) with PAF (mean duration: 6.6 +/- 5.7 years) were included. PVI was achieved in 97/99 PVs (98%). Median (Q(1); Q(3)) procedural, balloon, and fluoroscopy times were 220 min (190; 245), 130 min (90; 170), and 50 min (42; 69), respectively. Three transient PNP occurred after distal PV ablations. No PV stenosis occurred. Total median (Q(1); Q(3)) follow-up time was 271 days (147; 356), and 19 of 27 patients (70%) remained in sinus rhythm (3-month blanking period). CONCLUSION: Using the single big cryoballoon technique, almost all PVs (98%) could be electrically isolated without LA imaging and may reduce the incidence of PNP as long as distal ablation inside the septal PVs is avoided.

Three-dimensional reconstruction of the anatomic course of the right phrenic nerve in humans by pace mapping.

BACKGROUND: Endocardial catheter ablation at the right atrial to superior vena cava junction or right pulmonary vein isolation, especially in balloon-guided procedures, is associated with risk for phrenic nerve palsy. OBJECTIVE: The purpose of this study was to obtain a three-dimensional reconstruction of the individual phrenic nerve course. METHODS: Electroanatomic reconstruction (CARTO, Biosense Webster) of the superior vena cava, right atrium, left atrium, and right superior and inferior PVs was performed. The phrenic nerve pace map was obtained using maximal stimulation output (10 V, 2.9 ms) and annotated on the three-dimensional map. RESULTS: Eighteen patients with paroxysmal atrial fibrillation (12 men and 6 women, mean age 61 +/- 10 years) were included in the study. The phrenic nerve course was reconstructed over a mean craniocaudal length of 40 +/- 17 mm (mediolateral 11 +/- 4 mm). Median phrenic nerve distance to the right superior PV ostium was 12 mm (range 2-39 mm). The phrenic nerve could be captured in 16 of 18 patients but only in 7 of 18 patients from the right superior PV. The complete electroanatomic map was performed in 48 +/- 23 minutes, including the phrenic nerve pace map (14 +/- 6 min). CONCLUSION: Pace mapping of the phrenic nerve using electroanatomic mapping can be performed within a reasonable time frame and provides important information on the true anatomic course of the phrenic nerve. The three-dimensional display of its position in relation to potential ablation targets may be of value in preventing phrenic nerve palsy, particularly when innovative ablation energies are used. However, phrenic nerve pacing exclusively from the right superior PV appears insufficient to exclude a close anatomic relationship.

Phenylthiazolyl-hydrazide and its derivatives are potent inhibitors of tau aggregation and toxicity in vitro and in cells.

One of the key pathological features of Alzheimer's disease is the aggregation of tau protein. We are therefore searching for compounds capable of inhibiting this reaction. On the basis of an initial screen of 200000 compounds [Pickhardt, M., Gazova, Z., von Bergen, M., Khlistunova, I., Wang, Y., Hascher, A., Mandelkow, E. M., Biernat, J., and Mandelkow, E. (2005) Anthraquinones inhibit tau aggregation and dissolve Alzheimer's paired helical filaments in vitro and in cells, J. Biol. Chem. 280, 3628-3635], we performed an in silico screen and predicted a new phenylthiazolyl-hydrazide (PTH) compound as a possible hit [Larbig, G., Pickhardt, M., Lloyd, D. G., Schmidt, B., and Mandelkow, E. (2007) Screening for inhibitors of tau protein aggregation into Alzheimer paired helical filaments: A ligand based approach results in successful scaffold hopping. Curr. Alzheimer Res. 4 (3), 315-323.]. Synthesis of this compound showed that it was indeed active in terms of inhibiting de novo tau aggregation and disassembling preformed aggregates (IC50 = 7.7 microM and DC50 = 10.8 microM). We have now synthesized 49 similar structures and identified the core of the PTHs to be crucial for activity, thus representing a lead structure. Analysis of the binding epitope by saturation transfer difference NMR shows strong interactions between the tau protein and the ligand in the aromatic regions of the inhibitor. By chemical variation of the core, we improved the inhibitory potency five-fold. The compounds showed a low toxicity as judged by an N2A cell model of tau aggregation and lend themselves for further development.

Screening for inhibitors of tau protein aggregation into Alzheimer paired helical filaments: a ligand based approach results in successful scaffold hopping.

The aggregation of tau protein into paired helical filaments is one of the hallmarks of Alzheimer's disease and related dementias. We therefore continue our search for non-toxic, cell penetrating inhibitors of tau aggregation, which hold potential for brain penetration. Pickhardt et al. (2005) have reported a high throughput screen for tau aggregation inhibitors previously, which resulted in the identification of several hit classes. Here we report the identification of novel inhibitors which were not present in the initial high throughput assay. This was achieved by transformation of the high throughput screen data into the 3D relationships of virtual pharmacophores The pharmacophore models were utilized in a virtual screen of a Maybridge database. The virtual screen provided 136 hits; 19 representative hits were selected and assayed, this resulted in two novel leads with an IC(50) < 13 microM. These two leads feature a novel scaffold for tau aggregation inhibitors.

Atrial fibrillation reduces the atrial impedance amplitude during cardiac cycle: a novel detection algorithm to improve recognition of atrial fibrillation in pacemaker patients.

AIMS: In carriers of dual chamber pacemakers and implantable cardioverter-defibrillators (ICD), detection of atrial fibrillation (AF) is crucial for adequate mode switch function and to avoid inappropriate shock delivery. Detection algorithms rely on the atrial rate and on the relationship of atrial to ventricular intracardiac electrograms, but the relative portion of misclassified AF episodes remains high. Although myocardial impedance is a reliable indicator of contraction, little is known about atrial impedance as a marker of atrial arrhythmias. Methods During an electrophysiological study, we investigated the effect of induced AF on impedance at the right atrial free wall (RAFW) and right atrial appendage (RAA) in 20 patients. Using biphasic square-wave pulses (128 Hz, 200 microA/15 micros), impedance changes were recorded during sinus rhythm (SR-1), atrial pacing at 120 beats/min, AF induced by rapid atrial burst pacing, and after spontaneous AF termination (SR-2). Results At the RAA, peak-to-peak impedance amplitude during cardiac cycle (DeltaZ) dropped from 51.7 +/- 35.3 Omega (SR-1) or 49.6 +/- 30.6 Omega (pacing) to 24.6 +/- 22.0 Omega (AF, P< or =0.0005), and subsequently increased to 37.7 +/- 24.7 Omega (SR-2, P < or = 0.0004 v. AF). At the RAFW, DeltaZ changed from 16.2 +/- 15.5 Omega (SR-1) or 13.5 +/- 9.9 Omega (pacing) to 5.9 +/- 4.1 Omega (AF, P < or = 0.003), and to 11.4 +/- 10.7 Omega (SR-2, P < or = 0.015). Given a discrimination threshold of 65%, the sensitivity and the specificity of DeltaZ to detect AF were 79 +/- 18 and 89 +/- 14%, respectively (95% confidence interval). CONCLUSION: AF causes DeltaZ drop in pacemaker and ICD recipients. This impedance based algorithm can be used as an alternative method of AF detection.

Pulmonary vein isolation by high-intensity focused ultrasound: first-in-man study with a steerable balloon catheter.

BACKGROUND: High-intensity focused ultrasound (HIFU) applied via a steerable balloon catheter (ProRhythm, Ronkonkoma, NY) is a novel technology for pulmonary vein (PV) isolation. OBJECTIVE: The purpose of this study was to assess the short-term and long-term success rates of PV isolation in patients with paroxysmal atrial fibrillation (AF) using the steerable HIFU balloon catheter. METHODS: A total of 15 patients (7 female), mean age 59 +/- 8 years, with a long (8 +/- 5 years) history of drug-refractory, symptomatic paroxysmal AF were enrolled. After double transseptal puncture, a lasso catheter and the 16F HIFU balloon catheter (11F shaft) were inserted into the left atrium (LA). After PV angiography, phrenic nerve (PN) pacing (10 V, 2.9 ms) was conducted. In case of PN capture at the right superior PV ostium, patients were excluded (n = 3). To achieve complete PV isolation, HIFU was repeatedly applied with an acoustic power of 45 W for 40 to 90 seconds. Follow-up included telephonic interviews, transtelephonic Holter electrocardiogram, and office visits after 1, 3, and 6 months. RESULTS: Complete electrical PV isolation was achieved in 41 of 46 (89%) PVs. Median follow-up time was 387 days (range 120 to 424 days). Seven of 12 (58%) patients were free of AF without antiarrhythmic drugs. In 2 patients, only a single AF episode was documented, resulting in an overall chronic success of 75%. Despite negative PN pacing, 2 patients experienced right-sided PN palsy, which had not resolved after 12 months. CONCLUSION: In patients with paroxysmal AF, acute PV isolation can be achieved in 89% using a steerable HIFU balloon; 58% of all patients were free of AF and 75% reached the primary end point defined as a reduction of AF episodes to less than 50%. However, further studies need to improve identification of patients at risk for PN palsy.

Pulmonary vein conduction is the major finding in patients with atrial tachyarrhythmias after intraoperative maze ablation.

INTRODUCTION: Electrophysiological (EP) data from patients with recurrent atrial tachyarrhythmias (ATa) after intraoperative maze ablation are limited. Furthermore, the clinical course after accomplishing pulmonary vein (PV) isolation using the double lasso technique (DLT) is unknown. METHODS AND RESULTS: EP study and catheter ablation (CA) was guided by a three-dimensional electroanatomic mapping system (3-D EA, CARTO, Biosense-Webster) combined with simultaneous ipsilateral PV mapping using the DLT. Defined endpoints were: (1) identification of conduction gaps within the ipsilateral PVs, (2) elimination of all PV spikes, and (3) ablation of clinical ATas. CA was performed in eight patients (four females, 62 +/- 5 years, LA: 50 +/- 6 mm) with drug refractory ATa (9.1 +/- 6.3 years) despite non-"cut and sew" maze operation. Electrical PV conduction was demonstrated in the majority of patients (7/8). All endpoints were achieved. Repeat ablations were required in three patients. Second ablation was due to typical atrial flutter (n = 1) and atrial fibrillation (n = 2). One patient required three ablations due to a left atrial macroreentrant tachycardia. During a mean follow-up of 15.5 +/- 4.8 months, 7/8 patients were free of ATa recurrences. CONCLUSION: Incomplete lesions after non-"cut and sew" maze operation are associated with PV conduction and recurrence of ATas. Electrical isolation of ipsilateral PVs and completion of linear lesions guided by 3-D EA mapping is feasible and successful in maintaining sinus rhythm during mid term follow-up. Completeness of linear lesions using EP endpoints should be confirmed during the initial surgical procedure to minimize ATa recurrences.

Focal atrial tachycardia originating from the non-coronary aortic sinus: electrophysiological characteristics and catheter ablation.

OBJECTIVES: We sought to investigate electrophysiological characteristics and catheter ablation in patients with focal atrial tachycardia (AT) originating from the non-coronary aortic sinus (AS). BACKGROUND: In patients with failed ablation of focal AT near the His bundle (HB) region, an origin from the non-coronary AS should be considered because of the close anatomical relationship. METHODS: This study included 9 patients with focal AT, in 6 of whom attempted radiofrequency (RF) ablation had previously failed. Activation mapping was performed during tachycardia to identify an earliest activation in the atria and the AS. The aortic root angiography was performed to identify the origin in the AS before RF ablation. RESULTS: Focal AT was reproducibly induced by atrial pacing. Mapping in atria demonstrated that the earliest atrial activation was located at the HB region, whereas mapping in the non-coronary AS demonstrated that an earliest atrial activation preceded the atrial activation at the HB by 12.2 +/- 6.9 ms and was anatomically located superoposterior to the HB in all 9 patients. Also, His potentials were not found at the successful site in the non-coronary AS in all 9 patients. The focal AT was terminated in <8 s in all 9 patients. Junctional beats and PR prolongation did not occur during RF application in all 9 patients. No complications occurred in any of the nine patients. All 9 patients were free of arrhythmias without antiarrhythmic drugs during a follow-up of 9 +/- 3 months. CONCLUSIONS: In patients with focal AT near the HB region, mapping in the non-coronary AS can improve clinical outcome.

Pacemaker therapy in very elderly patients: long-term survival and prognostic parameters.

BACKGROUND: Permanent pacing is the therapy of choice for treating severe and/or symptomatic bradyarrhythmia. However, augmented life expectancy and increasing health care expenditures have led to questions concerning the routine use of electrotherapy in very elderly patients. This study is aimed at assessing data on the actual number, characteristics, and survival of patients requiring pacing therapy at age > or =80 years. METHODS: Between 1971 and 2000, 1588 patients aged > or =80 years completed a standardized 6- to 12-month follow-up after pacemaker (PM) implantation, resulting in a total of 5244 patient years. Kaplan-Meier analyses were computed to visualize survival differences in various subgroups and implantation periods. RESULTS: Today, patients aged > or =80 years account for 32% of all PM implantations. An increasing 5-year survival after PM implantation to the current rate of 66% was found, compared to 37% and 47% in the previous decades. Based on a mean survival time of 8 years, clinical symptoms can be effectively treated with costs of < or =500 dollars per patient per year. Prognostic parameters were the decade of implantation (relative risk [RR] 0.80, CI 0.67-0.96, P < or =.02), a history of presyncope (RR 0.73, CI 0.57-0.95, P < or =.02), and male sex (RR 1.20, CI 1.04-1.40, P < or =.02). However, none of these parameters can be recommended for estimating outcome or for guiding device selection. CONCLUSIONS: Patients aged > or =80 years account for an increasing portion of PM implantations. Considering the remaining life expectancy of 8 years in these patients, PM therapy is a clinically and economically effective therapeutic option to control bradyarrhythmia-related symptoms.