Characterization of Electrical Reconnection Following Pulmonary Vein Isolation Using First- and Second-Generation Cryoballoon.

BACKGROUND: Second-generation cryoballoon (CB-2) is associated with improved outcomes for pulmonary vein isolation (PVI) compared to first generation (CB-1). However, data regarding the predictors of pulmonary vein (PV) electrical reconnection are limited. In this study, we aimed to characterize the predilection sites and predictors of reconnection in patients with recurrent atrial tachyarrhythmia (ATa) after PVI using CB-1 and CB-2. METHODS: A total of 59 patients (mean age: 62 ± 11 years and 66% male) with recurrent ATa after previous CB-PVI, using either a 28-mm CB-1 or CB-2, underwent repeat ablation. PV reisolation was performed by irrigated radiofrequency ablation using three-dimensional electroanatomical mapping systems. RESULTS: Electrical PV reconnection was detected in 10 of 11 (91%) of CB-1 patients compared to 41 of 48 (85%) of CB-2 patients. Time to redo procedure after index CB-1 was 8.9 ± 10.2 months and 11.2 ± 7.0 months in CB-2. Bonus freeze was applied in all patients with CB-1 and 41% of the patients with CB-2. Superior quadrants of both superior PVs and inferior quadrants of the both inferior PVs exhibited higher predilection for conduction compared to other quadrants (P < 0.001). Multivariate binary logistic analysis revealed that right inferior PV (RIPV; odds ratio [OR]: 1.52, 95% confidence interval [CI]: 1.09-2.13, P = 0.014) and minimum temperature (OR: 1.09, 95% CI: 1.03-1.15, P = 0.004) were the independent predictors of electrical reconnection after CB-2 ablation. CONCLUSION: Conduction gaps after CB-1 and CB-2 were higher in inferior PVs compared to superior PVs. The RIPV and minimum CB temperature were independent predictors of PV electrical reconnection after CB-2.

J wave elevation to monitor quinidine efficacy in early repolarization syndrome.

We present the case of a 14-year-old female with early repolarization syndrome who presented with recurrent ventricular fibrillation and ICD shocks which were refractory to multiple drugs and catheter ablation. Treatment with quinidine, an Ito blocker, resulted in a normalization of J waves and suppression of VF. Interestingly, J wave amplitude correlated with the ventricular arrhythmia susceptibility and quinidine levels. The case highlights the importance of quinidine for management of ventricular arrhythmias in the context of early repolarisation and suggests that J wave amplitude may be an important indicator of therapeutic drug levels and arrhythmia susceptibility.

Optimizing fibrosis detection: a comparison of electroanatomical mapping and late enhancement gadolinium magnetic resonance imaging.

BACKGROUND: Fibrotic atrial cardiomyopathy plays an important role in determining the outcome of ablation in patients with atrial fibrillation (AF). Two main methods are being used for the evaluation of fibrosis: voltage-based high-density (HD) electroanatomical mapping (EAM) and late gadolinium enhancement MRI (LGE-MRI). The comparability between both methods in detecting fibrosis has not been systematically investigated. METHODS: LGE-MRIs of the left atrium (LA) were performed in 21 patients. LA-fibrosis was evaluated using a custom-designed software generating a 3D-model of the LA. HD-electroanatomical maps were recorded in each patient. After processing the maps and the MRI models by excluding the mitral valve, pulmonary veins, and the left atrial appendage, the LGE areas were measured and compared to the low voltage areas (LVA) in the HD maps using three different cutoff values of 0.5 mV, 0.7 mV, and 1.0 mV. RESULTS: The analysis revealed significant differences between EAM and LGE-MRI in assessing LA-fibrosis at 0.5-mV (for anterior and posterior walls) and 1.0-mV cutoffs (for anterior and posterior wall and septum). However, no significant differences were found between EAM and LGE-MRI when using a 0.7-mV cutoff for all the investigated areas. CONCLUSIONS: A voltage cutoff of 0.7 mV provided the best correlation between EAM and LGE MRI for detecting left atrial fibrosis. It supports the idea that a 0.5-mV cutoff may underestimate fibrosis, as areas with local signal voltages between 0.6 and 0.8 mV could also show LGE on MRI. Further research is needed to determine the ideal voltage cutoff for detecting left atrial fibrosis.

Catheter-directed thrombolysis guided by pulmonary artery pressure registration in pulmonary embolism: a case report.

Background: Duration and dosage of thrombolysis for ultrasound-assisted catheter-directed thrombolysis (UACDT) in patients with intermediate high-risk pulmonary embolism remain controversial and treatment protocols vary. Case summary: A 58-year-old female patient suffered from a right-sided urolithiasis. The clinical course was complicated by an intermediate high-risk pulmonary embolism [pulmonary embolism severity index (PESI) score 108 points and simplified PESI ≥1] with bilateral proximal thrombus and significant right heart dysfunction. The pulmonary embolism response team (PERT) made a decision towards UACDT. The standard duration of UACDT ranges between 6 and 15 h depending on clinical parameters. In this particular case, the clinical parameters such as heart rate (no tachycardia) or oxygen saturation (chronic obstructive pulmonary disease) might lead to premature termination of UACDT. Therefore, PERT decided to additionally monitor pulmonary artery pressure (PAP) continuously during the UACDT via a separate pigtail catheter in the pulmonary artery. Ultrasound-assisted catheter-directed thrombolysis was performed using 1 mg/h recombinant tissue plasminogen activator (rtPA) per catheter, while PAP was registered continuously. Heart rate and oxygen saturation remained unchanged during UACDT. However, after 6 h of UACDT, systolic PAP decreased slightly from 62 to 55 mmHg and therapy was prolonged to 15 h. Pulmonary artery pressure dropped to 46 mmHg after 15 h. The patient was discharged from hospital at Day 7, and echocardiography revealed no signs of right heart dysfunction. Discussion: Dosage of the thrombolysis agent and duration of UACDT are still a matter of debate. Besides clinical parameters and transthoracic echocardiography, invasive real-time PAP monitoring during UACDT could facilitate important information for therapy guidance in selected cases.

Clinical significance of the rivaroxaban-dronedarone interaction: insights from physiologically based pharmacokinetic modelling.

Patients with atrial fibrillation may require rhythm control therapy in addition to anticoagulation therapy for the prevention of stroke. Since 2012, the European Society of Cardiology and European Heart Rhythm Association guidelines have recommended non-vitamin K antagonist oral anticoagulants, including rivaroxaban, for the prevention of stroke in patients with atrial fibrillation. During the same period, these guidelines have also recommended dronedarone or amiodarone as second-line rhythm control agents in certain patients with atrial fibrillation and no contraindications. Amiodarone and dronedarone both strongly inhibit P-glycoprotein, while dronedarone is a moderate and amiodarone a weak inhibitor of cytochrome P450 3A4 (CYP3A4). Based on these data and evidence from physiologically based pharmacokinetic modelling, amiodarone and dronedarone are expected to have similar effects on rivaroxaban exposure resulting from P-glycoprotein and CYP3A4 inhibition. However, the rivaroxaban label recommends against the concomitant use of dronedarone, but not amiodarone, citing a lack of evidence on the concomitant use of rivaroxaban and dronedarone as the reason for the different recommendations. In this report, we discuss evidence from clinical studies and physiologically based pharmacokinetic modelling on the potential for increased rivaroxaban exposure resulting from drug-drug interaction between rivaroxaban and dronedarone or amiodarone. The current evidence supports the same clinical status and concomitant use of either amiodarone or dronedarone with rivaroxaban, which could be considered in future recommendations.

Utility of esophageal temperature monitoring during pulmonary vein isolation for atrial fibrillation using duty-cycled phased radiofrequency ablation.

INTRODUCTION: A novel ablation system has been introduced for rapid treatment of atrial fibrillation (AF). This system delivers duty-cycled phased radiofrequency (RF) energy via an over-the-wire catheter (PVAC® , Medtronic) to achieve pulmonary vein (PV) isolation. Lower power and depth control suggests that collateral damage might be minimized. However, no studies have investigated the potential for thermal effect and damage to the esophagus. METHODS AND RESULTS: Ninety consecutive patients undergoing PV-isolation were evaluated. Group A (48 patients) had continuous luminal esophageal temperature (LET) monitoring using a temperature probe with 3 metal electrodes located in the vicinity of the targeted PV ostia. Ablation ceased when LET exceeded 40 °C. Only patients with LET ≥ 39 °C underwent endoscopic evaluation to assess esophageal damage. Group B (42 patients) excluded LET monitoring but all patients underwent endoscopy. In Group A, 27 (56%) patients showed LET ≥ 39 °C (mean LET 40.5 °C). Endoscopy revealed esophageal alterations in 5 (8%) (3 erythema and 2 intramural bleeding). One hundred eighty-nine out of 190 (99.5%) targeted PVs were successfully isolated, with 1 PV unsuccessful due to high LET. In Group B all 165 targeted PVs (100%) were successfully isolated. Endoscopy in Group 2 revealed no esophageal alterations. CONCLUSIONS: Using a duty-cycled, phased RF ablation system is safe and effective to isolate PVs. No Eso alteration was documented after ablation when LET was not monitored. This suggests that the LET probe may contribute to the thermal effect. Whether the documented increments in LET are due to direct tissue heating or possible interaction between the LET probe requires further investigation.

Diagnostic role of coronary CT angiography in paroxysmal or first diagnosed atrial fibrillation.

OBJECTIVES: The presence of coronary artery disease (CAD) in patients hospitalised with paroxysmal or first diagnosed atrial fibrillation (AF) has major implications for antithrombotic therapy and cardiovascular event rate. Coronary CT angiography (CCTA) is a feasible tool to identify patients with concealed CAD. We aimed to evaluate the diagnostic role of early CCTA in patients hospitalised with paroxysmal or first diagnosed AF. METHODS: In a 5-year single-centre retrospective analysis, 566 patients with paroxysmal or first diagnosed AF who underwent CCTA were enrolled to investigate the presence of CAD. RESULTS: In patients with paroxysmal or first diagnosed AF, CCTA revealed CAD (coronary artery stenosis ≥50%) in 39.2%. Cardiac catheterisation was performed in 31.6%, confirming CAD in 13.1% of all patients. In 8.0% percutaneous coronary intervention and in 0.5% coronary artery bypass grafting was performed. In patients with paroxysmal or first diagnosed AF: (1) angina pectoris per se does not predict CAD; (2) multivariable regression analysis revealed age, male sex and diabetes as risk factors for CAD in AF; (3) Framingham Risk Score for coronary heart disease and CHA2DS2-VASc-Score were relevant risk scores of CAD and (4) the classification of Coronary Artery Calcium score reference values according to the Multi-Ethnic Study of Atherosclerosis was a predictor of CAD. CONCLUSION: Patients with paroxysmal or first diagnosed AF are at risk for CAD, while CCTA is a feasible diagnostic tool for CAD. We recommend to integrate CT calcium scoring and CCTA into the diagnostic workup of patients with new-onset or paroxysmal AF.

Fast anatomical mapping of the carina and its implications for acute pulmonary vein isolation.

BACKGROUND: Fast anatomical mapping (FAM) of the left atrium and pulmonary veins (PV) during PV isolation (PVI) generates anatomical information about the carina region additionally. We aimed to investigate the utility of these data in relation to conduction abilities of the intervenous carina. METHODS: We investigated 71 patients with drug-refractory atrial fibrillation (AF) who underwent first-time circumferential PVI using an electroanatomical mapping system. Carina width between ipsilateral PV was measured using FAM and an integrated distance measurement tool. Encirclings were divided into carina ablation and noncarina ablation groups based on the necessity of carina ablation to achieve PVI. RESULTS: In total, 142 encirclings were analyzed and first-pass isolation was observed in 102 (72%) encirclings. Nonfirst-pass PVI solely due to a gap on the line or persistent carina conduction was observed in 10 (7%) and 30 (21%) encirclings, respectively. Encirclings were classified into a carina ablation group (n = 30, 21%) and noncarina ablation group (n = 112, 79%). Carina width was significantly larger in the carina ablation vs nonarina ablation group (right: 11.9 ± 1.5 mm vs 8 ± 1.4 mm, P < .001/left: 12.1 ± 1.3 mm vs 8.1 ± 1.1 mm, P < .001) requiring additional carina ablation. CONCLUSION: Carina-related PV conduction is a common finding after the first-pass ablation during PVI. Measurement of carina width using FAM is feasible and its value correlates with the necessity of carina ablation to achieve PVI.

Case Report: Living on the Edge-Transcatheter Mitral Valve Repair Related Infective Endocarditis.

Background: Infective endocarditis (IE) following mitral valve edge-to-edge repair is a rare complication with high mortality. Case summary: A 91-year-old male patient was admitted to intensive care unit with sepsis due to urinary tract infection after insertion of a urinary catheter by the outpatient urologist. Two weeks ago, the patient was discharged from hospital after successful transcatheter edge-to-edge mitral valve repair (TEER) using a PASCAL Ace device. The initially withdrawn blood revealed repeatedly Proteus mirabilis bacteremia as causal for the sepsis due to urinary tract infection. An antibiotic regime with Ampicillin/Sulbactam was initiated and discontinued after 7 days. During the clinical course the patient again developed fever and blood cultures again revealed P. mirabilis. In transesophageal echocardiography (TOE), IE of the PASCAL Ace device was confirmed by a vegetation accompanied by a mild to moderate mitral regurgitation. While the patient was stable at this time and deemed not suitable for cardiac surgery, the endocarditis team made a decision toward a prolonged 6-week antibiotic regime with an antibiotic combination of Ampicillin 2 g qds and Ciprofloxacin 750 mg td. Due to posterior leaflet perforation severe mitral regurgitation developed while PASCAL Ace vegetations were significantly reduced by the antibiotic therapy. Therefore, the patient underwent successful endoscopic mitral valve replacement. Another 4 weeks of antibiotic treatment with Ampicillin 2 g qds followed before the patient was discharged. Discussion: P. mirabilis is able to form biofilms, resulting in a high risk for endocarditis following transcatheter mitral valve repair especially when device endothelization is incomplete. Endoscopic mitral valve replacement could serve as a bailout strategy in refractory Clip-endocarditis.

Ventricular fibrillation with prominent early repolarization associated with a rare variant of KCNJ8/KATP channel.

BACKGROUND: Early repolarization in the inferolateral leads has been recently recognized as a frequent syndrome associated with idiopathic ventricular fibrillation (VF). We report the case of a patient presenting dramatic changes in the ECG in association with recurrent VF in whom a novel genetic variant has been identified. CASE REPORT: This young female (14 years) was resuscitated in 2001 following an episode of sudden death due to VF. All examinations including coronary angiogram with ergonovine injection, MRI, and flecainide or isoproterenol infusion were normal. The patient had multiple (>100) recurrences of VF unresponsive to beta-blockers, lidocaine/mexiletine, verapamil, and amiodarone. Recurrences of VF were associated with massive accentuation of the early repolarization pattern at times mimicking acute myocardial ischemia. Coronary angiography during an episode with 1.2 mV J/ST elevation was normal. Isoproterenol infusion acutely suppressed electrical storms, while quinidine eliminated all recurrences of VF and restored a normal ECG over a follow-up of 65 months. Genomic DNA sequencing of K(ATP) channel genes showed missense variant in exon 3 (NC_000012) of the KCNJ8 gene, a subunit of the K(ATP) channel, conferring predisposition to dramatic repolarization changes and ventricular vulnerability.

Long-term sinus rhythm stability after intraoperative ablation of permanent atrial fibrillation.

INTRODUCTION: Short- and medium-term sinus rhythm (SR) rates after intraoperative radiofrequency ablation to treat permanent atrial fibrillation (AF) are well documented. Is rhythm success stable during a long-term follow-up? METHODS AND RESULTS: A total of 130 patients who had undergone intraoperative radiofrequency cooled-tip endocardial ablation (SICTRA) of permanent AF (mean AF duration 6+/-5 years) concomitant to open heart surgery more than 3 years ago were followed up using electrocardiogram (ECG), Holter-ECG, and echocardiography and compared with 12-month follow-up data. In 55% of patients, only the left atrium and in 45%, both atria were treated using SICTRA. Mitral valve replacement was performed in 21, mitral valve reconstruction in 25, aortic valve replacement in 13, CABG procedures in 51 (including 11 patients with additional mitral valve surgery), and complex procedures in 20 patients. Sixty-nine percent of patients (90/130) were in stable SR after a median period of 48 months, whereas 28% (36/130) were in AF and 3% (4/130) were in atrial flutter. In between the 12-month follow-up and the long-term follow-up, seven patients converted to AF after having documented SR, two patients converted to typical right atrial flutter after being in SR, and two patients from AF to left atrial macroreentry. After left and biatrial SICTRA, SR rates were comparable (73% vs 66%, P = 0.45). Echocardiography revealed 73% of patients in SR to have effective left atrial contraction. CONCLUSIONS: SICTRA restores long-term stable SR in 69% of all patients. Nine percent of patients reconverted back to atrial arrhythmia after having documented SR at 12 months.

Predicting successful pulmonary vein isolation in patients with atrial fibrillation by brain natriuretic Peptide plasma levels.

BACKGROUND: Catheter ablation for atrial fibrillation is a clinically established treatment by now while success rate varies between 60% and 85%. Interventional treatment of atrial fibrillation is still a challenging technique associated with a long procedure time and risk of major complications in up to 6 % of treated patients. The aim of this study was to investigate the predictive value of plasma brain natriuretic peptide (BNP) in patients undergoing pulmonary vein isolation concerning stable sinus rhythm after ablation. METHODS: In 68 consecutive patients with atrial fibrillation (AF) and normal left ventricular ejection fraction, BNP was measured at baseline before pulmonary vein isolation (PVI). All patients received a 7-days-holter monitoring 3 months after radiofrequency (RF) ablation in order to detect recurrent AF episodes. RESULTS: 48 patients with paroxysmal and 20 patients with persistent AF were enrolled. Baseline BNP was significantly higher in patients with persistent AF compared to patients with paroxysmal AF (145,5 pg/ml vs. 84,4 pg/ml; p<0,05). 3 months after PVI 38 patients (79,1%) with paroxysmal AF had a stable sinus rhythm documented on 7-days-holter monitoring, where as in 10 patients (20,9%) AF episodes were detected. Patients with a successful PVI showed significantly lower BNP plasma levels at baseline compared to patients with AF recurrrence (68,7 pg/ml vs. 144,1 pg/ml; p<0,05). In patients with persistent AF 55% (11 cases) had no recurrence of AF at 3 months 7-days holter and in 9 patients (45%) AF recurred. BNP plasma levels at baseline were lower in patients with stable sinusrhythm after 3 months compared to the group of recurrent AF (105,8 pg/ml vs. 193,3 pg/ml; p=0,11). CONCLUSIONS: Patients with AF and low preprocedural BNP plasma levels showed a better outcome after PVI. Thus BNP may be helpful in patient selection for a successful treatment of AF by PVI.

Long-term impact of a bonus freeze on clinical outcome: Analysis of effective and non-effective bonus freezes in cryoballoon ablation.

PURPOSE: Data on bonus freeze characteristics and their impact on complication rates and long-term clinical outcome are limited. METHODS: Pulmonary vein isolation (PVI) using a 28 mm 2nd-generation cryoballoon (CB) was performed in 169 patients (pts). The isolation temperatures, time to isolation and minimal temperatures of the cryoapplications were documented. RESULTS: The study included 92 pts who received one bonus freeze after PVI in group I and 77 pts who did not receive a bonus freeze in group II. After a mean follow-up time of 19.0±8.6 months in group I and 16.4±7.5 months in group II, 67 of 92 pts (72.8%) and 49 of 75 pts available to follow up (65.3%; p = 0.221) were free of atrial tachyarrhythmia, respectively. Phrenic nerve palsy occurred in 5.4% of the pts in group I (5/92 pts) and 1.3% of the pts in group II (1/77 pts; p = 0.22). Both the mean nadir temperatures of the bonus freezes and mean nadir temperatures of the isolation freezes differed significantly between the recurrent and non-recurrent pts in group I. The predilection sites of the reconduction for both groups were the inferior aspect of the inferior pulmonary veins. CONCLUSION: The impact of a bonus freeze on long-term clinical outcome was not significant for two reasons: 1) The necessity of a bonus freeze was low because the long-term clinical success rate without a bonus freeze was high; and 2) the majority of bonus freezes, especially at the predilection sites, such as the inferior PV, appeared to be ineffective.

[Takotsubo cardiomyopathy mimicking an acute myocardial infarction]. / Fehldiagnose eines akuten Myokardinfarkts: die Takotsubo-Kardiomyopathie.

BACKGROUND: Takotsubo cardiomyopathy is characterized by a transient left ventricular dysfunction. The resulting acute symptoms including electrocardiographic changes and elevated myocardial biomarkers often mimic an acute myocardial infarction. However, obstructive coronary artery disease can be excluded by angiography. There is only little information available in the literature. The precise pathophysiology is still unknown. CASE REPORT: The case of a 56-year-old woman with typical manifestation of a highly symptomatic Takotsubo cardiomyopathy is described. The diagnosis was suspected by angiographic absence of obstructive coronary disease. During the following days, Takotsubo cardiomyopathy was confirmed by cardio-MRI and echocardiography. The patient was treated with drugs. 12 days after admission, cardiac function was completely restored. The patient was discharged without showing any symptoms. CONCLUSION: Although takotsubo cardiomyopathy is rather rare, it should be considered as a relevant differential diagnosis mimicking acute myocardial infarction. Despite a generally good prognosis under conservative treatment, complications are reported in 17.7% of all cases in the literature. Therefore, intensive treatment and monitoring are mandatory.

Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases.

INTRODUCTION: The aim of the study was to identify criteria for rapid recognition and successful treatment of esophageal perforation after radiofrequency ablation for atrial fibrillation (AF). METHODS AND RESULTS: Esophageal perforation occurred in five patients after intraoperative (n = 4) or percutaneous (n = 1) AF ablation. Patients presented with high fever (n = 3) or severe chest/epigastric pain (n = 2) 8-28 days after ablation. WBC count was elevated at presentation in all patients (15,460 +/- 2,910/muL), CRP showed a delayed rise. Thoracic CT detected free air in all. Neurologic complications occurred in three cases (60%) with a delay of 5-40 hours after first symptoms. Only one (20%) developed neurologic complications within the first 24 hours. Two patients (40%) died before surgery could be performed. In both, time from symptom onset to diagnosis was significant (24 and 36 hours). Three patients (60%) underwent esophageal resection and survived. In two of them, treatment was rapid with time from symptoms to surgery of 24 hours; they had favorable outcome. In the third surviving patient, surgery was late (5 days after first symptoms); permanent neurologic residues remained. CONCLUSION: The leading symptom of esophageal perforation is high fever or severe chest/epigastric pain. Fever is not necessarily present. Leukocytosis is the earliest and most sensitive laboratory marker, thoracic CT the most valuable diagnostic examination. The dramatic neurologic complications occur with a delay of at least a few hours after first symptoms. Immediate surgery may prevent neurologic complications and could possibly result in a high survival rate without residues. Delay of treatment seems to have devastating results.

Role of diabetes in heart rhythm disorders.

The incidence of diabetes mellitus (DM) is increasing rapidly. DM is the leading cause of cardiovascular diseases, which can lead to varied cardiovascular complications by aggravated atherosclerosis in large arteries and coronary atherosclerosis, thereby grows the risk for macro and microangiopathy such as myocardial infarction, stroke, limb loss and retinopathy. Moreover diabetes is one of the strongest and independent risk factor for cardiovascular morbidity and mortality, which is associated frequently with rhythm disorders such as atrial fibrillation (AF) and ventricular arrhythmias (VA). The present article provides a concise overview of the association between DM and rhythm disorders such as AF and VA with underlying pathophysiological mechanisms.

Rotational Angiography Based Three-Dimensional Left Atrial Reconstruction: A New Approach for Transseptal Puncture.

AIM: Rotational angiography is a well-known method for the three-dimensional (3-D) reconstruction of left atrium and pulmonary veins during left-sided atrial arrhythmia ablation procedures. In our study, we aimed to review our experience in transseptal puncture (TSP) using 3-D rotational angiography. METHODS: We included a total of 271 patients who underwent atrial fibrillation ablation using cryoballoon. Rotational angiography was performed to get the three-dimensional left atrial and pulmonary vein reconstructions using cardiac C-arm computed tomography. The image reconstruction was made using the DynaCT Cardiac software (Siemens, Erlangen, Germany). RESULTS: The mean age of the study population was 61 ± 10 years. The indications for left atrial arrhythmia ablation were paroxysmal AF in 140 patients (52%) and persistent AF patients in 131 (48%) patients. The success rate of TSP using only rotational guidance was (264/271 patients, 97.4%). In the remaining seven patients, transesophageal guidance was used after the initial attempt due to thick interatrial septum in five patients and difficult TSP due to abnormal anatomy and mild pericardial effusion in the remaining two patients. Mean fluoroscopy dosage of the rotational angiography was 4896.4 ± 825.3 µGym(2). The mean time beginning from femoral vein puncture to TSP was 12.3 ± 5.5 min. CONCLUSION: TSP guided by rotational angiography is a safe and effective method. Our results indicate that integration of rotational angiographic images into the real-time fluoroscopy can guide the TSP during the procedure.

Occupation and metabolic syndrome: is there correlation? A cross sectional study in different work activity occupations of German firefighters and office workers.

BACKGROUND: The treatment and prevention of the metabolic syndrome (MetS) is currently one of the major challenges in medicine. The impact of working conditions on metabolic risk has not been adequately studied. Our objective was to compare the prevalence of MetS and metabolic risk in two extremely different occupational groups: firefighters and office workers. METHODS: A total of 143 male subjects (97 firefighters and 46 office workers) from Germany participated in the study. Anthropometric characteristics, metabolic risk parameters as well as laboratory parameters were collected. MetS was diagnosed according to criteria of the International Diabetes Federation. RESULTS: Sedentary occupation showed a significant tendency towards obesity. Abdominal waist circumference was significantly greater in office workers than in firefighters [5.08 CI (1.44-8.71), p = 0.007]. Concerning metabolic risk factors, abnormal HDL, triglycerides, BMI, blood pressure and waist circumference values were more frequently found in office workers than in firefighters. The MetS was detected in almost 33 % of office workers as compared with only 14 % in firefighters (p = 0.015). Regarding MetS in an international comparison, the prevalence of MetS in German office workers was high and in firefighters it was extremely low. CONCLUSIONS: Sedentary occupation as an office worker is associated with a high risk of MetS. Both groups need to be made aware of the metabolic risks, and health promoting concepts such as corporate sports activities or education in healthy nutrition need to be implemented to counteract the development of the MetS and cardiovascular risk factors.

The Total Incidence of Complications and the Impact of an Anticoagulation Regime on Adverse Events After Cryoballoon Ablation of Atrial Fibrillation: A Single-Center Study of 409 Patients.

AIM: Data evaluating the complications of pulmonary vein isolation (PVI) using second-generation cryoballoons (CB) related to different anticoagulation regimes are limited. This study evaluates the total complications and the impact of novel oral anticoagulants (NOACs) compared to phenprocoumon on adverse events in the setting of PVI using CB. METHODS AND RESULTS: PVI was performed using second-generation CB by two experienced investigators. A total of 409 patients (58.9% male; mean age = 61 ± 10 years) with atrial fibrillation were included in this study. In group I, 150/409 (36.7%) patients received phenprocoumon therapy, and in group II, 259/409 (63.3%) patients were treated with NOACs (rivaroxaban: n = 193; dabigatran: n = 48; and apixaban: n = 18). In both groups, the rates of major complications were similar (group I [phenprocoumon]: four pts (2.7%) vs. Group II [NOACs]: seven pts (2.7%); P = 0.999). In this cohort, 275 patients were ablated with the bonus freeze protocol, and 134 patients were ablated without bonus freezes. The procedure duration significantly decreased with the bonus freeze protocol from 102.3 ± 24.6 min to 68.5 ± 16.2 min (P < 0.001). The impact of the bonus freeze on the postprocedural increase of C-reactive protein (CRP) levels was significant compared to the postprocedural CRP levels after procedures without the bonus freeze protocol (postprocedural CRP level+ bonus protocol: 1.6 ± 1.2 mg/L vs. postprocedural CRP level+ nonbonus protocol: 1.3 ± 1.3 mg/L; P = 0.04). CONCLUSION: The incidence of adverse events in PVI using the second-generation CB with the periprocedural administration of NAOCs was not significantly different compared to phenprocoumon. Further, large-scale randomized studies are needed to evaluate the safety of two anticoagulation regimes comparing vitamin K antagonists and NOACs, as well as different NOAC regimes, in patients undergoing PVI using cryoballoon ablation.

Cryoballoon ablation for pulmonary vein isolation in patients with atrial fibrillation: preliminary results using novel short-tip cryoballoon.

PURPOSE: In this study, we aimed to report our preliminary experience regarding the impact of the novel short-tip (ST) cryoballoon (CB) on procedural efficacy and signal quality during pulmonary vein (PV) isolation for both paroxysmal and persistent atrial fibrillation. METHODS: Between March, 2015, and August, 2015, we enrolled a total of 64 patients (47 patients male, 73 %) with a mean age of 60 ± 11 years. In the study population, 31 patients (48 %) underwent PVI using Advance (ADV) CB and 33 (52 %) patients with ST CB. In all patients, a 28-mm balloon was used. RESULTS: Acute procedural success rates were 100 % for the entire study population. A statistically insignificant increase in the percentage of PV signal recordings was observed with ST CB in all PVs compared to ADV CB [88 vs. 81 % for left superior PV (LSPV), 82 vs. 78 % for left inferior PV (LIPV), 85 vs. 84 % for right superior PV (RSPV), 82 vs. 71 % for right inferior PV (RIPV), p < 0.05]. Additionally, the difference in minimum temperature reached during the procedure per PV was not statistically significant between ST CB and ADV CB except the LIPV (LSPV -44.2 ± 5.9 vs. -45.6 ± 5.3 °C, p = 0.970; LIPV -38.7 ± 4.6 °C vs -44.6 ± 6.8 °C, p < 0.001; RSPV -45.6 ± 7.4 °C vs.-47.2 ± 6.1 °C, p = 0.168; RIPV -41.4 ± 5.1 °C vs.-43.7 ± 6.3 °C, p = 0.360). Time to isolation for each PV was similar between ST and ADV CB (p > 0.05). CONCLUSION: Our preliminary findings indicated similar acute procedural success for the novel ST CB compared with second generation ADV CB. The increase in the ratio of PV signal recordings obtained during the PVI using the novel ST CB was not significant.