[Lead placement in cardiac implantable electronic devices]. / Elektrodenplatzierung in der kardialen Devicetherapie.

The implantation of electrodes for cardiac implantable electronic devices (CIED) requires profound technical understanding and precise execution. The positioning of electrodes in the right ventricle and atrium has significant implications for patient safety and the effectiveness of CIED therapy. Particular focus is given to the distinction between apical and septal stimulation in ventricular positioning. Based on current data, this article provides a practice-oriented guide that leads implanters through the individual steps of electrode positioning. The implantation of electrodes for physiological stimulation (cardiac resynchronization therapy, CRT, and conduction system pacing, CSP) is not addressed in this article.

[Perioperative management for cardiovascular implantable electronic devices]. / Perioperatives Management bei der Versorgung mit aktiven Rhythmusimplantaten.

Cardiovascular implantable electronic devices (CIED) are an important part of modern cardiology and careful perioperative planning of these procedures is necessary. All information relevant to the indication, the procedure, and the education of the patient must be available prior to surgery. This provides the basis for appropriate device selection. Preoperative antibiotic prophylaxis and perioperative anticoagulation management are essential to prevent infection. After surgery, postoperative monitoring, telemetric control, and device-based diagnostics are required before discharge. These processes need to be adapted to the increasing trend towards outpatient care. This review summarises perioperative management based on practical considerations.

Reverse structural left atrial remodeling and atrial tachycardia in patients with repeat ablation for atrial fibrillation.

BACKGROUND: Catheter ablation has been evolved to a cornerstone in the therapy of atrial fibrillation (AF); however, atrial tachycardias (AT) after AF ablation are still an important issue. Besides the electrical recurrence of atrial tachyarrhythmia after ablation, left atrial (LA) remodeling has received attention as a consequence of AF. OBJECTIVE: The aim of this study is to evaluate predictors for AT recurrence and LA remodeling in patients with repeat AF ablation procedures. METHODS AND RESULTS: One hundred thirteen patients who underwent repeat AF ablation with 3D electro-anatomical mapping system were evaluated. Mean age was 63.1 ± 9.3 years, and 2.3 ± 0.5 ablation procedures were performed during a time period of 22 [IQR 7;48] months. Reverse structural LA remodeling (LA volume decreased more than 15%) was observed in 25 (22.1%) patients. LA volume index (LAVI) during first procedure was the only predictor for positive reverse structural LA remodeling (hazard ratio (HR): 1.03, 95% CI: 1.00-1.07, p = .036) in multivariate analysis. Fifty-nine (52.2%) patients experienced only AF and 54 (47.8%) patients AT after first procedure. Female gender (HR: 5.21, 95% CI: 1.66-18.08, p = .006), LAVI (HR: 1.06, 95% CI: 1.02-1.11, p = .008) and LA scar percentage (HR: 1.08, 95% CI: 1.02-1.17, p = .019) were independent significant predictors for AT recurrence in multivariate analysis. CONCLUSIONS: Reverse structural LA remodeling occurred in a quarter of patients with repeat ablation procedures for AF. Only larger LAVI during first procedure predicted reverse structural LA remodeling. Half of the patients experienced AT between first and last ablation procedure. Female gender, larger LAVI and larger scar area were significant predictors for AT after catheter ablation for AF.

Antithrombotic therapy after angioplasty of pulmonary vein stenosis due to atrial fibrillation ablation: A two-center experience and review of the literature.

Background: Pulmonary vein stenosis (PVS) is a severe complication of atrial fibrillation (AF) ablation resulting in narrowing of affected pulmonary veins (PVs). Interventional treatment consists of angioplasty with or without PV stenting. The optimal postprocedural antithrombotic therapy is not known. Study aims: To investigate the impact of antithrombotic medical therapy on recurrence of PVS after PV angioplasty. Methods: A retrospective study of patients undergoing PV angioplasty with or without stent implantation in two German centers was performed. Postinterventional antithrombotic therapy consisted of either dual antiplatelet therapy (DAPT) or a combination of oral anticoagulation with single or dual antiplatelet therapy for 3-12 months after intervention. Angiographic follow-up was recommended 3, 6, and 12 months after intervention and in case of symptom recurrence. Results: Thirty patients underwent treatment of 42 PVS. After intervention, twenty-eight patients received triple therapy and 14 patients received dual therapy/DAPT; restenosis occurred in 5/22 (22.7%) patients with triple therapy and 8/14 (57.1%) patients with dual therapy/DAPT PV (p = .001). Estimated freedom from PV restenosis after 500 days was 18.8 ± 15.8% (dual therapy/DAPT) and 76.2 ± 10.5% (triple therapy) (p = .003). Univariate regression analysis revealed postprocedural medication as a significant risk factor for restenosis (p = .019). No bleeding events occurred regardless of applied antithrombotic therapy. Conclusion: Triple antithrombotic therapy after PV angioplasty is associated with less frequent restenosis as compared to dual antiplatelet therapy or a combination of anticoagulation and single antiplatelet therapy. No severe bleeding events occurred in patients on triple therapy. These findings need to be confirmed in larger patient cohorts.

[Focal atrial tachycardias: diagnostics and therapy]. / Fokale atriale Tachykardien: Diagnostik und Therapie.

In this article, typical characteristics of focal atrial tachycardias are described and a systematic approach regarding diagnostics and treatment options in the field of invasive cardiac electrophysiology (EP) is presented. Subjects of this article include the definition of focal atrial tachycardias, knowledge about localizing the origin of such, and guidance on how to approach an invasive EP study (e.g., administration of medication during the EP study to provoke tachycardias). Further, descriptions will be found on how to localize the origin of focal atrial tachycardias with the help of the 12-lead ECG and invasive three-dimensional mapping to successfully treat focal atrial tachycardias with catheter ablation.

A novel wide-band dielectric imaging system to guide radiofrequency ablation for pulmonary vein isolation.

INTRODUCTION: Recently, the wide-band dielectric mapping system Kodex-EPD was introduced. This study reports the first clinical experience using a novel system to guide pulmonary vein isolation (PVI) with radiofrequency (RF) ablation. METHODS AND RESULTS: The study included 20 consecutive patients undergoing de-novo PVI for symptomatic paroxysmal or persistent atrial fibrillation guided by Kodex-EPD. The primary efficacy endpoint was successful PVI. Secondary endpoints included procedural parameters and complications. In all 20 patients (mean age 68 ± 8 years, 12 male patients, paroxysmal fibrillation in 14/20 [70%] patients), PVI was successfully completed. One patient underwent additional cavo-tricuspid isthmus ablation for concomitant typical atrial flutter and one patient required additional ablation of a focal atrial tachycardia. A conventional three-dimensional image of the left atrium as well as the innovative endocardial panoramic view were used to guide catheter manipulation and ablation. Median procedure time was 115 [1st; 3rd quartile 93,75; 140] min and median total fluoroscopy time was 9.9 [9.7; 11.2] min, of which a median of 0.8 [0.6; 0.9] min was required to create left atrial maps. Complete left atrial imaging using Kodex-EPD was achieved within a median of 7.1 [5.7; 8.3] min. Median RF ablation time was 45.1 [34.6; 58.7] min. No major complications were observed. CONCLUSION: RF ablation PVI guided by Kodex-EPD seems safe and feasible. The system provides effective three-dimensional guidance for PVI.

[Atypical atrial fibrillation : Diagnostics and therapy]. / Atypisches Vorhofflattern : Diagnostik und Therapie.

In contrast to typical atrial flutter, atypical atrial flutter is a heterogeneous group of right and left atrial macro- or localized reentry tachycardias whose critical component for maintaining tachycardia is not the cavotricuspid isthmus. Atypical atrial flutter occurs more frequently after previous catheter ablation and after cardiac surgery. The intraprocedural success rate during ablation is high, although the recurrence rate depends on structural changes in the atria as well as the underlying mechanism. This article provides an overview of the mechanisms as well as mapping and ablation strategies of the most common forms of right and left atrial atypical atrial flutter. This article is part of the "EP Basics" series for targeted continuing education in invasive electrophysiology. Basics, clinic and therapy of atypical atrial flutter are presented with focus on clinically relevant aspects. Procedures and findings of invasive electrophysiological diagnostics and ablation treatment are the focus of this article.

Acute and long-term success of left atrial anterior line and mitral isthmus line ablation in patients after mitral valve surgery.

BACKGROUND: Perimitral flutter and atrial fibrillation may occur in patients with prior surgical mitral valve (MV) repair or replacement and can be challenging for percutaneous catheter ablation. This study sought to determine the feasibility, acute success and durability of catheter ablation of atrial fibrillation or atrial tachycardia by way of a mitral isthmus line (MIL) or an anterior line (AL). METHODS: A total of 81 patients (49 males, mean age 62±11 years) with prior MV replacement (n = 30) or reconstruction (n = 51) underwent creation of a MIL (34) and/or an AL (72). RESULTS: Acute bidirectional block of the MIL was successfully achieved in 24/34 cases and of the AL in 64/72 patients. Patients of the control group without prior MV surgery were matched 1:1 with the valve group. In the AL control subgroup, acute bidirectional block was achieved in 65/72 patients. Acute blockage in the MIL control subgroup could be achieved in 31/34 patients. The MIL valve subgroup showed the worst results in terms of durability, whereas a similar trend emerged in the control group and the AL valve subgroup (probability of failure in MIL valve subgroup 2.224 vs. MIL control subgroup 0.605 [Hazard Ratio (HR) = 0.27, 95% confidence interval (CI), 0.11-0.65), P = .004]; probability of failure in AL valve subgroup 0.844 vs. AL control subgroup 1.03 [HR = 1.22 (95% CI, 0.66-2.26), P = .523]). CONCLUSIONS: Percutaneous creation of MIL and AL is feasible and safe in patients with prior MV replacement/repair and associated with moderate acute and long-term success rates to achieve bidirectional block.

Impact of a time-to-effect-guided ablation protocol in cryoballoon ablation on the durability of pulmonary vein isolation.

BACKGROUND: Cryoballoon (CB)-based pulmonary vein isolation (PVI) has proven to be as effective as radiofrequency-based ablation. Different ablation protocols took the individual time-to-isolation (TTI) into account aiming at shorter but equally or even more effective freeze cycles. The current study sought to assess the impact of the TTI on PVI durability in patients undergoing a repeat procedure for recurrence of atrial tachyarrhythmia (ATA). METHODS AND RESULTS: In 205 patients with ATA recurrence after previous CB-based PVI, a total of 806 pulmonary veins (PVs) were identified. A total of 126 out of 806 PVs (16%) were previously treated with a TTI-guided ablation (Protocol #1; TTI + 120 s), in 92/806 (11%) PVs TTI was only monitored (m) but fixed freeze cycles were applied (Protocol #2; mTTI) and in 588/806 (73%) a fixed freeze cycle was applied without mTTI. There was no difference in the PV-reconduction rate between the groups (p = .23). The right inferior pulmonary vein (RIPV) showed overall significantly higher reconduction rates compared to the other PVs (RIPV-left inferior PV p < .003, -left superior PV p < .001, -right superior PV p < .013). Twenty-one patients (10%) were demonstrated to have only electrical reconduction of the RIPV, while all other PVs were still electrically isolated. CONCLUSIONS: The TTI-based CB ablation protocol did not show significant differences regarding PV-reconduction rates compared to the other ablation protocols.

Impact of obesity on acute complications of catheter ablation for cardiac arrhythmia.

INTRODUCTION: The prevalence of obesity is increasing. However, data on the periprocedural complication rate of catheter ablation for arrhythmia in patients stratified by body mass index (BMI) are scarce. METHODS: This study included 1000 consecutive patients (age 62.0 ± 14.4 years) undergoing catheter ablation for cardiac arrhythmia. The primary study endpoint was any periprocedural major complication (cardiac tamponade, pseudoaneurysm, arteriovenous fistula, transient ischemic attack, stroke, valve damage, myocardial infarction, or death). RESULTS: The mean BMI was 27.6 ± 5.1 kg/m2 and the majority of patients were overweight (BMI 25.0-29.9 kg/m2 , 43.4%). A BMI of 30.0-34.9 kg/m2 (Class I obesity) was present in 177 (17.7%) of patients, a BMI of 35.0-39.9 kg/m2 (Class II obesity) in 67 (6.7%), and a BMI ≥ 40 kg/m2 (Class III obesity) in 16 (1.6%). There were 31 major complications (3.1%) and one fatality (0.1%) due to terminal heart failure in a patient undergoing palliative ventricular tachycardia ablation. There was no significant impact of the BMI on the rate of major complications (p = .495). Compared to normal weight patients, odds ratios for complications in overweight patients, as well as Class I, II, and III obesity were 1.1 (95% confidence interval (CI): 0.8, 1.7), 1.3 (CI: 0.6, 2.6), 1.4 (CI: 0.5, 4.1), and 1.6 (CI: 0.4, 6.3), respectively. Radiation exposure and procedure duration were significantly increased in obese patients (p < .001 and p = .001, respectively). CONCLUSION: In this study, obesity did not have a significant impact on the incidence of periprocedural complications after CA for cardiac arrhythmia.

[Catheter ablation of ventricular tachycardias in patients with ischemic cardiomyopathy]. / Katheterablation ventrikulärer Tachykardien bei Patienten mit ischämischer Kardiomyopathie.

Radiofrequency (RF) ablation is an effective treatment option of scar-related ventricular tachycardias (VT) in patients with ischemic cardiomyopathy. Several studies proved the benefit of VT catheter ablation, which has become routine in most electrophysiology laboratories. This article provides practical instructions to perform a VT catheter ablation. The authors describe conventional and substrate-based mapping and ablation strategies as well as concepts for image integration. This article continues a series of publications created for education in advanced electrophysiology.

Pulsed-field ablation combined with ultrahigh-density mapping in patients undergoing catheter ablation for atrial fibrillation: Practical and electrophysiological considerations.

BACKGROUND: Pulsed-field ablation (PFA) yields a novel ablation technology for atrial fibrillation (AF). PFA lesions promise to be highly durable, however clinical data on lesion characteristics are still limited. OBJECTIVE: This study sought to investigate PFA lesion creation with ultrahigh-density (UHDx) mapping. METHODS: Consecutive AF patients underwent PFA-based pulmonary vein isolation (PVI) using a multispline catheter (Farwave, Farapulse Inc.). Additional ablation, including left atrial posterior wall isolation (LAPWI) and mitral isthmus ablation (MI) were performed in a subset of persistent AF patients. The extent of PFA-lesions and decrease of LA-voltage were assessed with pre- and post PFA UHDx-mapping (Orion™ catheter and Rhythmia™ 3D-mapping system, Boston Scientific). RESULTS: In 20 patients, acute PVI was achieved in 80/80 PVs, LAPW isolation in 9/9 patients, MI ablation in 2/2 (procedure time: 123 ± 21.6 min, fluoroscopy time: 19.2 ± 5.5 min). UHDx-mapping subsequent to PVI revealed early PV-reconnection in five case (5/80, 6.25%). Gaps were located at the anterior-superior PV ostia and were successfully targeted with additional PFA. Repeat UHDx mapping after PFA revealed a significant decrease of voltage along the PV ostia (1.67 ± 1.36 mV vs. 0.053 ± 0.038 mV, p < .0001) with almost no complex electrogram-fractionation at the lesion border zones. PFA-catheter visualization within the mapping system was feasible in 17/19 (84.9%) patients and adequate in 92.9% of ablation sites. CONCLUSION: For the first time illustrated by UHDx mapping, PFA creates wide antral circumferential lesions and homogenous LAPW isolation with depression of tissue voltage to a minimum. Although with a low incidence, early PV reconnection can still occur also in the setting of PFA.

Complications and mortality after catheter ablation of ventricular arrhythmias: risk in VT ablation (RIVA) score.

AIMS: Catheter ablation of ventricular arrhythmias (VA) has proven to be an effective therapeutic option for secondary arrhythmia prophylaxis. We sought to assess the procedural efficacy, safety and in-hospital mortality of a large patient cohort with and without structural heart disease undergoing VA ablation. METHODS: A total of 1417 patients (804 patients with structural heart disease) undergoing 1792 endo- and epicardial procedures were analyzed. Multivariable risk factor analysis for occurrence of major complications and intrahospital mortality was obtained and a score to allow preprocedural risk assessment for patients undergoing VA ablation procedures was established. RESULTS: Major complication occurred in 4.4% of all procedures and significantly more often in patients with structural heart disease than in structurally normal hearts (6.0 vs. 1.8%). The frequency of these periprocedural complications was significantly different between procedures with sole right ventricular and a combination of RV and LV access (0.5 vs. 3.1%). The most common complication was cardiac tamponade in 46 cases (3.0%). Intrahospital death was observed in 32 patients (1.8%). Logistic regression model revealed presence of ischemic heart disease, epicardial ablation, presence of oral anticoagulation or dual antiplatelet therapy as independent risk factors for the occurrence of complications or intrahospital death, while a history of previous heart surgery was an independent predictor with a decreased risk. Based on this analysis a risk score incorporating 5 standard variables was established to predict the occurrence of complications and intrahospital mortality. CONCLUSIONS: Safety of VA catheter ablation mainly relies on patient baseline characteristics and the type of access into the ventricles or epicardial space.

Clinical outcomes of cryoballoon ablation for pulmonary vein isolation: Impact of intraprocedural heart rhythm.

BACKGROUND: The current study sought to assess the impact of the intraprocedural heart rhythm (sinus rhythm [SR] vs. atrial fibrillation [AF]) on acute procedural characteristics, durability of pulmonary vein isolation (PVI) and long-term clinical outcomes of cryoballoon (CB) ablation. METHODS: A total of 195 patients with symptomatic paroxysmal (n = 136) or persistent AF (n = 59) underwent CB-based PVI. Ablation procedures were either performed in SR (SR group; n = 147) or during AF (AF group; n = 48). Persistent AF was more frequent in the AF group than in the SR group (62% vs. 20%). All other patient baseline characteristics did not differ between the two groups. RESULTS: The nadir temperature during the CB applications was significantly lower in the AF group than in patients in the SR group (-49 [interquartile range, -44; -54]°C vs. -47 [-42; -52]°C, p = 0.002). Median procedure and fluoroscopy times as well as the rate of real-time recordings were not different between the two groups. Repeat ablation for the treatment of atrial arrhythmia recurrence was performed in 60 patients (SR: 44 [30%] patients; AF: 16 [33%] patients), with a trend towards a lower rate of pulmonary vein reconnections in the AF group (p = 0.07). There was no difference in 3-year arrhythmia-free survival (p = 0.8). CONCLUSIONS: Cryoballoon-based PVI during AF results in lower nadir balloon temperatures and a trend towards a higher durability of PVI as compared to procedures performed in SR. The rate of real-time PVI recordings was not affected by the intraprocedural heart rhythm.

[Practical guide for safe and efficient cryoballoon ablation for atrial fibrillation : Practical procedure, tips and tricks]. / Leitfaden zur sicheren und effizienten Kryoballon-Vorhofflimmerablation : Praktisches Vorgehen, Tipps und Tricks.

In the current guidelines on treatment of atrial fibrillation, cryoballoon-based catheter ablation of atrial fibrillation is recommended in addition to radiofrequency ablation and has become established as a standard procedure in the clinical routine of many centers for index pulmonary vein isolation. A safe, simplified and often durable pulmonary vein isolation can be achieved by a systematic approach. This review article provides a practical guide for all steps of cryoballoon-based pulmonary vein isolation, including preprocedural preparation and postinterventional follow-up. Both cryoballoon systems currently available on the market are considered.

[Pulmonary vein isolation using radiofrequency ablation]. / Pulmonalvenenisolation mittels Radiofrequenzablation.

Catheter ablation represents the primary treatment for most arrhythmias. The effectiveness of catheter ablation for the treatment of atrial fibrillation is superior to drug therapy. Therefore, catheter ablation has been established as an increasingly common procedure in clinical routine. In this context, the electrical isolation of the pulmonary veins (PVI) constitutes the cornerstone of the interventional therapy of paroxysmal and persistent atrial fibrillation. This article describes the procedure of pulmonary vein isolation utilizing radiofrequency point-by-point ablation. It shall be a practical guide for the staff in the electrophysiological laboratory. This article continues a series of manuscripts focusing on interventional electrophysiology topics in the course of EP (electrophysiology) training.This article describes the procedure of pulmonary vein isolation utilizing radiofrequency point-by-point ablation. It shall be a practical guide for the staff in the electrophysiological laboratory. This article continues a series of manuscripts dealing with topics of interventional electrophysiology in the course of EP training.

[Puncture techniques in invasive cardiac electrophysiology]. / Punktionstechniken in der invasiven Elektrophysiologie.

Due to good results, increasing standardization and lack of equivalent alternatives, catheter ablation has been established as an increasingly common procedure in clinical routine. This article describes common and necessary puncture techniques in catheter ablation (puncture of the groin vessels, transseptal puncture, pericardial puncture) and represents a practical instruction for the catheter laboratory. This article is part of a series of manuscripts presenting topics of interventional electrophysiology in the course of electrophysiology training.