Incidence, Implications, and Management of Sense-B-Noise Failure in Subcutaneous Cardioverter-Defibrillator Patients: insights from a large Multicenter Registry.

AIMS AND BACKGROUND: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) offer potentially distinct advantages over transvenous defibrillator systems. Recent randomized trials showed significantly lower lead failure rates than transvenous ICD. Still, S-ICDs remain associated with the risk of inappropriate shocks (IAS). While previous studies have reported varying causes of IAS, this study explores a rare cause of IAS, referred to as "sense-B-noise." It was recently described in cases series, but its incidence has not been studied in a large cohort of S-ICD patients. METHODS: We retrospectively reviewed data from patients implanted with S-ICD models 1010, A209 and A219 between October 2009 and July 2023 across 9 centers in Europe and the USA. The analysis concentrated on determining the incidence and understanding the implications of sense-B-noise events. Sense-B-noise represents a rare manifestation of distinct electrogram abnormalities within the primary and alternate sensing vectors. Data were collected from medical records, device telemetry, and manufacturer reports for investigation. This registry is registered on https://clinicaltrials.gov (NCT05713708). RESULTS: S-ICD devices of the 1,158 patients were analyzed. The median follow-up time for all patients was 46 (IQR 23-64) months. In 107 patients (9.2%) ≥ 1 IAS was observed during follow-up. Sense-B-noise failure was diagnosed in 6 (0.5% and 5.6% of all IAS) patients, in all patients the diagnosis was made after an IAS episode. Median lead dwell time in the affected patients was 23 (2-70) months. To resolve the sense-B-noise defect, in three patients reprogramming to the secondary vector was undertaken, and two patients underwent system removal with subsequent S-ICD reimplantation due to low amplitude in secondary vector. In one patient the secondary vector was initially programmed, and subsequently, a S-ICD system exchange was performed due to T-wave oversensing IAS episodes. CONCLUSION: This multicenter analysis' findings shed light on a rare but clinically highly significant adverse event in S-ICD therapy. To our knowledge we provide the first systematic multicenter analysis investigating the incidence of sense-B-noise. Due to being difficult to diagnose and limited options for resolution, management of sense-B-noise is challenging. Complete system exchange may be the only option in some patients. Educating healthcare providers involved in S-ICD patient care is crucial for ensuring accurate diagnosis and effective management of sense-B-noise issues.

Balloon technologies for pulmonary vein isolation-12-month outcome and comparison of the novel radiofrequency balloon with the cryoballoon in patients with paroxysmal atrial fibrillation.

BACKGROUND: The cryoballoon (CB) has become a standard tool for pulmonary vein isolation (PVI), but the technology is limited in certain ways. A novel RF-balloon (Heliostar™, Biosense Webster, CA, USA) promises the advantages of a balloon technology in combination with 3D mapping. METHODS: To assess procedural data and outcome, all patients undergoing RF-balloon PVI were included and compared with data from consecutive patients undergoing CB PVI for paroxysmal AF. RESULTS: A total of 254 patients (63 ± 13 years, 54% male) were included: 30 patients undergoing RF-balloon and 224 patients CB PVI. Baseline parameters were comparable. Procedure duration (104.3 ± 35.3 min vs. 69.9 ± 23.1 min; p ≤ 0.001) and fluoroscopy time (16.3 ± 7.1 min vs. 11.6 ± 4.9 min; p ≤ 0.001) were longer using the RF-balloon; ablation time (43.5 ± 17.9 vs. 36.4 ± 15.6; p = 0.08) did not differ, and time-to-isolation (TTI) was shorter (18.2 ± 7.0 s vs. 62.8 ± 35.1 s; p ≤ 0.001). Second-generation RF-balloon cases showed shorter ablation time and TTI at comparable procedure duration and fluoroscopy time. One pericardial effusion occurred with the RF-balloon due to complicated transseptal access. During CB PVI in 4/224 patients (1.8%), a phrenic nerve palsy was observed. After 12 months, 78% of patients after RF-balloon and 81% of patients after CB PVI (p = 0.5) were free from atrial arrhythmias. CONCLUSION: The RF-balloon was safe and effective. Compared with the CB, TTI was shorter, but procedure durations and fluoroscopy times were longer. This can be attributed to a learning curve and the initial necessity for separate 3D map preparation. Considering the results with the second-generation RF-balloon, more experience is needed to determine the potential benefits.

The omnipolar mapping technology-a new mapping tool to overcome "bipolar blindness" resulting in true high-density maps.

BACKGROUND: Omnipolar mapping (OT) is a novel tool to acquire omnipolar signals for electro-anatomical mapping, displaying true voltage and real-time wavefront direction and speed independent of catheter orientation. The aim was to analyze previously performed left atrial (LA) and left ventricular (LV) maps for differences using automated OT vs. standard bipolar settings (SD) and HD wave (HDW) algorithm. METHODS: Previously obtained SD and HDW maps of the LA and LV using a 16-electrode, grid-shaped catheter were retrospectively analyzed by applying automated OT, comparing voltage, point density, pulmonary vein (PV) gaps, and LV scar area. RESULTS: In this analysis, 135 maps of 45 consecutive patients (30 treated for LA, 15 for LV arrhythmia) were included. Atrial maps revealed significantly higher point densities using OT (21471) vs. SD (6682) or HDW (12189, p < 0.001). Mean voltage was significantly higher using OT (0.75 mV) vs. SD (0.61 mV) or HDW (0.64 mV, p < 0.001). OT maps detected significantly more PV gaps per patient vs. SD (4 vs. 2), p = 0.001. In LV maps, OT revealed significantly higher point densities (25951) vs. SD (8582) and HDW (17071), p < 0.001. Mean voltage was significantly higher for OT (1.49 mV) vs. SD (1.19 mV) and HDW (1.2 mV), p < 0.001. Detected scar area was significantly smaller using OT (25.3%) vs. SD (33.9%, p < 0.001). CONCLUSION: OT mapping leads to significantly different substrate display, map density, voltage, detection of PV gaps, and scar size, compared to SD and HDW in LA and LV procedures. Successful CA might be facilitated due to true HD maps.

Comparison of pulsed-field ablation versus very high power short duration-ablation for pulmonary vein isolation.

BACKGROUND: The newly introduced nonthermal pulsed field ablation (PFA) is a promising technology to achieve fast pulmonary vein isolation (PVI) with high acute success rates and good safety features. However, previous studies have shown that very high power short duration ablation (VHPSD) is also highly effective and fast to achieve PVI with potentially less arrhythmia recurrence compared to conventional radiofrequency ablation. Data comparing PFA to VHPSD-PVI is lacking. OBJECTIVE: This study compared procedural and outcome data for PFA-PVI to VHPSD-PVI in patients with paroxysmal or persistent atrial fibrillation (PAF/persAF). METHODS: Consecutive patients undergoing de novo PVI (PFA or VHPSD) were included in this analysis. For PFA-PVI a pentaspline 20 electrode catheter was used. For VHPSD-PVI an enhanced irrigated catheter with a power setting of 70 W/7 s (70 W/5 s at posterior wall) was employed in conjunction with electro-anatomical mapping. All procedures were performed in deep analgo-sedation. RESULTS: A total of n = 114 patients (n = 57[50%] PFA, n = 17[30%] PAF; n = 40[70%] persAF) were included in this analysis. PVI was successful in all patients. The PFA group revealed a significantly shorter procedure duration (65 ± 17 min vs. 95 ± 23 min, p < 0.01) but longer fluoroscopy time (PFA 15 ± 5 min and VHPSD 12 ± 3 min; p < 0.001). At follow-up after median 125 days (interquartile range: 109-162) n = 46 PFA (80.7%) and n = 44 VHPSD pts (77.2%) were free from atrial arrhythmia after a single procedure (p = 0.819). Two tamponades occurred in the PFA while in VHPSD two pts suffered groin bleedings. One clinically nonsignificant PV stenosis occurred in the VHPSD group. CONCLUSION: Pulsed-field ablation and VHPSD-PVI seem to be highly effective and safe to achieve PVI in the setting of PAF and persAF with comparable arrhythmia-free survival. However, procedure duration for PFA PVI is significantly shorter and therefore may be of potential benefit. Compared to PFA VHPSD-PVI might ensure information on left atrial substrate allowing to target concomitant secondary tachycardias.

Comparison of pulsed field ablation and cryoballoon ablation for pulmonary vein isolation.

INTRODUCTION: Pulmonary vein isolation (PVI) remains the cornerstone in the treatment of atrial fibrillation (AF). PVI using cryoballoon (CB) technology has emerged as a standard procedure in many centers. Recently, pulsed field ablation (PFA) has been introduced and used to achieve PVI. First data show high acute and favorable long-term outcomes. So far, data comparing these new "single shot" devices are sparse. We sought to compare procedural and outcome data for first time PFA users versus CB in patients undergoing de novo PVI. Furthermore, potentially postprocedural discomfort and affection of autonomic ganglia were assessed. METHODS AND RESULTS: A retrospective analysis and comparison of all de novo PVIs with PFA and CB was performed. Furthermore, PFA PVI learning curve was evaluated. During follow-up, repeat outpatient visits and Holter electrocardiogram were performed to analyze arrhythmia-free survival. Discomfort analysis was obtained by prescribed analgesic medication within first 48 h after PVI. Potential changes in heart rate (HR) between baseline and at 3-month follow-up were evaluated. A total of 108 patients (54 PFA and 54 CB; PFA; 33 (30%) female) with paroxysmal and persistent AF were analyzed. Type of AF was comparable (Patients suffering from PAF: PFA: 16 (30%), CB: 17 (31%), p = 1.0). In 107 (99%) patients, successful PVI was achieved. Transient phrenic palsy omitted complete PVI in one CB patient. A trend for a shorter overall procedure duration was observed in the PFA group (PFA: 64.5 ± 17.5 min; CB: 73.0 ± 24.8 min; p = 0.07). Excluding LA mapping time (first 14 cases), procedure time was significantly shorter using PFA (PFA: 58.0 ± 12.5 min, CB: 73.0 ± 24.8 min, p = 0.0001). Fluoroscopy time was significantly longer for PFA (PFA: 15.3 ± 4.7 min, CB: 12.3 ± 5.3 min; p = 0.001), but significantly less contrast medium was used (PFA: 12 ± 6 mL; CB: 51 ± 29 mL, p < 0.0001). Subgroup analysis of the PFA group revealed a significant shortening of procedure duration over time (first tertile: 72.7 ± 13.5 min, second tertile: 67.3 ± 21.7 min, third tertile: 53.4 ± 9.8 min, first vs. third tertile p < 0.0001). Two cardiac tamponades occurred in the PFA group (p = 0.495), of which one was most likely related to complex transseptal puncture. In the first 48 h after PVI, the number of prescribed analgesics due to postprocedural pain was equal between both groups (PFA: 7 (13%) patients, CB: 10 (19%) patients, p = 0.598). After a FU of 273 ± 129 days, 35 of 47 patients (74%) after PFA and 36 of 50 patients (72%) after CB PVI were free of any atrial arrhythmia (HR: 0.98, p = 0.88). Only in the PFA group, a significant increase in HR 3 months after PVI was observed (pre-PVI: 61 ± 8 beats/min, post-PVI: 65 ± 9 beats/min, p = 0.008). CONCLUSION: The new PFA technology is equally effective and safe as compared to CB for complete PVI with potentially shorter procedure time and significantly less contrast medium. However, AF recurrence rates after PFA PVI seem to be comparable to CB PVI.

Implementation and first outcomes of a novel standard operating procedure for preprocedural transoesophageal echocardiography screening in course of atrial arrhythmia ablation.

AIMS: Preprocedural transoesophageal echocardiography (TEE) screening for left atrial (LA) thrombi is the standard of care in many centres performing atrial fibrillation (AF) ablation. However, TEE imposes procedural risks for patients and is often challenging to implement in daily practice, besides causing patient discomfort. At our centre, a novel standard operating procedure (SOP) was implemented, aiming to identify patients that can be exempt from TEE screening. We aimed to assess whether this screening approach may reduce preprocedural TEEs without imposing patients of higher risks for cerebrovascular events (CVEs). METHODS AND RESULTS: Data of 1874 consecutive patients treated by catheter ablation of LA arrhythmias between 2018 and 2022 were retrospectively analysed. A cohort of 937 patients, where decision to perform TEE screening was based on a new SOP (considering rhythm at admission, CHA2DS2-VASc score, and sufficient anticoagulation), was compared to a matched cohort receiving TEE before every procedure. Number of performed TEEs and incidences of CVEs were compared. Implementation of the new SOP led to a 67% reduction in TEEs performed (old SOP: 933 vs. new SOP: 305). No significant differences between the groups were detected regarding transitory ischaemic attack (old SOP: 5 vs. new SOP: 3; P = 0.48) and stroke (no events). No solid thrombi were detected during TEE screening. CONCLUSION: The number of preprocedural screening TEEs before AF ablation procedures can be safely reduced by applying risk stratification based on rhythm at admission and CHA2DS2-VASc score, if anticoagulation was performed properly.

First long-term outcome data for the MicraVR™ transcatheter pacing system: data from the largest prospective German cohort.

AIMS: The MicraVR™ transcatheter pacing system (TPS) has been implemented into clinical routine for several years. The primary recipients are patients in need for VVI pacing due to bradycardia in the setting of atrial fibrillation (AF). Implantation safety and acute success have been proven in controlled studies and registries. So far only few long-term real-life data on TPS exist. We report indication, procedure and outcome data from two high-volume implanting German centers. METHODS: Between 2016 and 2019, 188 (of 303) patients were included. During follow-up (FU), TPS interrogation was performed after 4 weeks and thereafter every 6 months. RESULTS: Indication for TPS implantation in 159/188 (85%) patients was permanent or intermittent AV block III° in the setting of atrial fibrillation. The mean procedure duration was 50 min [35.0-70.0]. The average acute values after system release were: thresholds: 0.5V [0.38-0.74]/0.24ms; R-wave sensing: 10.0mV [8.1-13.5]; impedance: 650 Ohm [550-783]; RV-pacing demand: 16.9% [0.9-75.9]; and battery status: 3.15 V [3.12-3.16]. During FU of 723.4 ± 597.9 days, neither pacemaker failure nor infections were reported. Long-term FU revealed: thresholds: 0.5V [0.38-0.63]/0.24 ms; sensing: 12.3mV [8.9-17.2]; impedance: 570 Ohm [488-633]; RV-pacing demand: 87.1% [29.5-98.6]; and battery status 3.02 V [3.0-3.1]. Forty-three patients died from not-device-related causes. CONCLUSION: This to date largest German long-term dataset for MicraVR™ TPS implantation revealed stable device parameter. Foremost, battery longevity seems to fulfill predicted values despite a significant increase in RV-pacing demand over time and even in patients with consecutive AV-node ablation. Of note, no infections or system failure were observed.

Pulmonary vein isolation for atrial fibrillation using true high-power short-duration vs. cryoballoon ablation.

AIMS: Pulmonary vein isolation (PVI) is achievable and effective using radiofrequency (RF) catheter (CA) or cryoballoon (CB) ablation. The newly introduced high RF-power short-duration ablation (HPSD) technique has shown promising results. Data comparing HPSD- to CB-PVI is sparse. We sought to investigate success rates and procedural differences of HPSD-PVI vs. CB-PVI in patients undergoing ablation for PAF and persAF. METHODS: Consecutive patients undergoing de novo PVI (HPSD or CB) were included. A power setting of 70W/7 s (70W/5 s at posterior wall) using a flexible tip catheter with enhanced irrigation was considered as true HPSD. Follow-up consisted of out-clinic pts visits, tele-consultation, 48-h Holter ECG, app-based telemonitoring and cardiac implanted electronic devices (CIED) interrogation. RESULTS: 721 patients (46 HPSD, 675 CB) were analyzed. In all HPSD (27 persAF [59%]) and CB patients (423 persAF [63%]), PVI was successfully achieved. Procedure duration was significantly longer for HPSD (91 ± 19 min vs. 72 ± 18 min, p < 0.01). Ablation time was similar in both groups (HPSD: 44 ± 19 min vs. CB: 40 ± 17 min; p = 0.347). No major complications occurred in HPSD. For CB-PVI, in 25 (3.7%; p = 0.296) patients, complications occurred. At a follow-up of 290 ± 135 days, arrhythmia-free survival using HPSD was non-inferior to CB-PVI in the Kaplan-Meier survival analysis (p = 0.096). CONCLUSION: PVI using HPSD is equally effective and safe to CB-PVI. This analysis revealed a similar arrhythmia-free survival after HPSD and CB with low complication rates. Procedure duration for CB was significantly shorter while LA dwell time excluding mapping was equal. Currently, a prospective trial is conducted to corroborate these findings.

Incidence of premature battery depletion in subcutaneous cardioverter-defibrillator patients: insights from a multicenter registry.

BACKGROUND: The subcutaneous ICD established its role in the prevention of sudden cardiac death in recent years. The occurrence of premature battery depletion in a large subset of potentially affected devices has been a cause of concern. The incidence of premature battery depletion has not been studied systematically beyond manufacturer-reported data. METHODS: Retrospective data and the most recent follow-up data on S-ICD devices from fourteen centers in Europe, the US, and Canada was studied. The incidence of generator removal or failure was reported to investigate the incidence of premature S-ICD battery depletion, defined as battery failure within 60 months or less. RESULTS: Data from 1054 devices was analyzed. Premature battery depletion occurred in 3.5% of potentially affected devices over an observation period of 49 months. CONCLUSIONS: The incidence of premature battery depletion of S-ICD potentially affected by a battery advisory was around 3.5% after 4 years in this study. Premature depletion occurred exclusively in devices under advisory. This is in line with the most recently published reports from the manufacturer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04767516 .

Impact of ventricular arrhythmia management on suboptimal biventricular pacing in cardiac resynchronization therapy.

BACKGROUND: Reduced biventricular pacing (BiVP) is a common phenomenon in cardiac resynchronization therapy (CRT) with impact on CRT-response and patients' prognosis. Data on treatment strategies for patients with ventricular arrhythmia and BiVP reduction is sparse. We sought to assess the effects of ventricular arrhythmia treatment on BiVP. METHODS: In this retrospective analysis, the data of CRT patients with a reduced BiVP ≤ 97% due to ventricular arrhythmia were analyzed. Catheter ablation or intensified medical therapy was performed to optimize BiVP. RESULTS: We included 64 consecutive patients (73 ± 10 years, 89% male, LVEF 30 ± 7%). Of those, 22/64 patients (34%) underwent ablation of premature ventricular contractions (PVC) and 15/64 patients (23%) underwent ventricular tachycardia (VT) ablation while 27/64 patients (42%) received intensified medical treatment. Baseline BiVP was 88.1% ± 10.9%. An overall increase in BiVP percentage points of 8.8% (range - 5 to + 47.6%) at 6-month follow-up was achieved. No changes in left ventricular function were observed but improvement in BiVP led to an improvement in NYHA class in 24/64 patients (38%). PVC ablation led to a significantly better improvement in BiVP [9.9% (range 4 to 22%) vs. 3.2% (range - 5 to + 10.7%); p = < 0.001] and NYHA class (12/22 patients vs. 4/27 patients; p = 0.003) than intensified medical therapy. All patients with VT and reduced BiVP underwent VT ablation with an increase of BiVP of 16.3 ± 13.4%. CONCLUSION: In this evaluation of ventricular arrhythmia treatment aiming for CRT optimization, both medical therapy and catheter ablation were shown to be effective. Compared to medical therapy, a higher increase in BiVP was observed after PVC ablation, and more patients improved in NYHA class. CLINICAL TRIAL REGISTRATION: The study was registered at clinical trials.org in August 2019: NCT04065893.

Dipole Density Guided Catheter Ablation versus Conventional Substrate Modification for Repeat Catheter Ablation of Persistent Atrial Fibrillation.

AIMS: The optimal ablation strategy for recurrent persistent atrial fibrillation (persAF) after initially successful catheter ablation (CA) remains debatable. Dipole density (DD) guided CA using the AcQMap system has been proven to be feasible and effective in patients with persAF. So far, long-term outcome data for DD-guided CA in patients with recurrence of persAF are sparse. This study sought to assess long-term outcome data in patients undergoing a DD-guided CA for recurrence of persAF after previous CA in comparison to conventional repeat CA. METHODS AND RESULTS: Patients undergoing DD-guided CA for recurrence of persAF after previous ablation were compared to patients undergoing conventional substrate modification (CSM). A total of 64 patients (32 DD-guided and 32 CSM) were included in this analysis. Procedure duration (DD: 236 ± 61 min; CSM: 198 ± 59 min; p = 0.004) and fluoroscopy time (DD: 36 ± 15 min; CSM: 20 ± 11 min; p = 0.0001) were significantly longer in the DD group. After a long-term median follow-up (FU) of 27 months (interquartile range 12.8-34.3), DD-guided CA was inferior to CSM regarding overall arrhythmia-free survival (DD: 6 patients (19%), CSM: 11 patients (34%); HR 1.47; p = 0.04). Freedom from AF did not differ between both groups (DD: 16 patients (50%); CSM: 18 patients (56%), HR 0.99, p = 0.47). During FU, more patients underwent repeat CA after DD-guided ablation (DD: 16 patients (50%), CSM: 7 patients (22%), p = 0.04). No major complications occurred overall. CONCLUSIONS: Dipole density-guided CA is equally safe but associated with longer procedure duration compared to conventional substrate modification for treatment of recurrent persAF after previous CA. Of note, long-term arrhythmia-free survival is significantly worse after DD-guided ablation, and more patients undergo redo procedures.

[Anatomy for ablation of ventricular extrasystoles and tachycardia in the right ventricle]. / Anatomie für die Ablation ventrikulärer Extrasystolen und Tachykardien im rechten Ventrikel.

BACKGROUND: Catheter ablation of ventricular tachycardias (VTs) is one of the most complex tasks in interventional electrophysiology. It is complicated by the fact that VT can recur during treatment which can affect the hemodynamic stability of the patient. In addition, navigation with the ablation or mapping catheter through the valvular apparatus and the trabecularization of the ventricle can be challenging. MATERIALS AND METHODS: In most cases, a three-dimensional mapping system is used to facilitate orientation and the search for the site where the tachycardia originates. Access to the right ventricle is usually via the tricuspid valve, but in exceptional cases it may also be necessary to use the epicardial venous system. The structures most commonly responsible for an arrhythmia from the right ventricle are the right ventricular outflow tract, the moderator band and the tricuspid valve annulus. The right ventricle is adjacent to vulnerable neighboring structures in many places: In the right ventricular outflow tract, the sinus valsalva, the pulmonary artery and the left ventricular endocardial transition between the aortic and mitral valves must be considered. When ablating along the tricuspid valve annulus, the proximity to the septum and thus to the specific conduction system is particularly important. CONCLUSION: Knowledge of the surrounding structures helps, on the one hand, to draw the right conclusions about the point of origin in the surface ECG, and, on the other hand, to carry out the ablation successfully and safely.

Procedural and outcome impact of obesity in cryoballoon versus radiofrequency pulmonary vein isolation in atrial fibrillation patients.

PURPOSE: Cryoballoon (CB) ablation and radiofrequency (RF) ablation are the most common techniques for pulmonary vein isolation (PVI) in patients with symptomatic atrial fibrillation (AF). An increasing number of patients undergoing PVI are obese. To address the paucity of data on outcomes of CB- vs. RF-based PVI in relation to body mass index (BMI) of AF patients. METHODS: All patients undergoing de novo PVI between 01/2018 and 08/2019 at University Hospital Cologne were included in this retrospective analysis. Patients of each group (CB-PVI vs. RF-PVI) were analyzed based on their BMI. Hereafter, procedural characteristics and AF recurrence rate were compared regarding different BMI groups. RESULTS: A total of 526 patients (62% male, 65±11 years) underwent successful de novo PVI (320 CB and 206 RF). In obese patients, two differences in procedural characteristics were noted: A significantly increased contrast medium volume in CB group and a lower fluoroscopy dose in RF group: contrast medium: CB 50 [40-80] vs. RF 20 [20-30], p<0.001; fluoroscopy dose: CB 392.4 [197.9-995.9] vs. RF 282.5 [139.8-507.2], p<0.001. The complication rate was equal throughout all BMI groups, regardless of CB or RF usage. For obese patients, a trend toward a higher AF recurrence rate was revealed after RF-PVI as compared to CB-PVI. In line with previous studies, the overall procedure time was significantly shorter with CB-PVI regardless of BMI. CONCLUSION: For obese patients, CB-PVI is similarly safe and effective as RF-PVI. The significantly shorter procedure time for CB-PVI may minimize potential obesity-related complications. However, the lower contrast medium quantity and fluoroscopy dose in RF-PVI must be considered. AF recurrence rates were comparable between CB-PVI and RF-PVI.

Validation of seven risk scores in an independent cohort: the challenge of predicting recurrence after atrial fibrillation ablation

Purpose@#Several predictive scores for atrial fibrillation (AF) recurrence after AF ablation have been developed. We compared the predictive value of seven previously described risk scores ((CHADS 2 and ­CHA 2 DS 2 -VASC, HATCH, APPLE, CAAP-AF, BASE-AF2, MB-LATER) for prediction of AF recurrence risk at 12 months after AF ablation in our patient cohort. Further, we aimed to identify additional variables to predict recurrences after AF ablation. @*Methods@#We used data from our digital AF ablation registry to compare the previously published scores in an independent cohort (n = 883, 50.8% with paroxysmal AF). The scores were chosen based on earlier publications and availability of relevant data. @*Results@#The BASE-AF2 (AUC 0.630, p < 0.001), MB-LATER (AUC 0.612, p < 0.001), CAAP-AF (AUC 0.591, p < 0.001), APPLE (AUC 0.591, p < 0.001) and CHA2DS2-VASC (AUC 0.547, p = 0.018) scores had a statistically significant but modest pre‑ dictive value for 12-month AF recurrence. None of the scores were significantly superior. Other analyzed scores had no predictive value. There was no difference in the predictive value for 12-month recurrence of AF between first pro‑ cedure vs. redo procedure and RF ablation vs. cryoablation. Unlike other scores, MB-LATER showed better predictive value for paroxysmal vs. persistent AF (AUC 0.632 vs. 0.551, p = 0.038). In the multivariate logistic regression, only age (p = 0.006), number of prior electrical cardioversions (p < 0.001) and early AF recurrence (p < 0.001) were independent predictors of AF recurrence. @*Conclusion@#Despite numerous available scores, predicting recurrences after AF ablation remains challenging. New predictors are needed, potentially based on interventions, as well as novel genetic, functional and anatomic parameters.

[A patient with second-degree AV block-further work-up and treatment]. / Ein Patient mit AV Block II°­ weitere Diagnostik und Therapie.

We present the case of a 64-year-old man who presented to our outpatient clinic with intermittent palpitations and presyncopal events. In 2009, he underwent dual chamber pacemaker implantation in another institution for 2nd degree heart block. Pharmacological treatment attempts with ß­blocker, calcium channel antagonists and ivabradine remained clinically unsuccessful. Up to this point in time, no documentation of clinical tachycardia, which was reported to result in a heart rate of around 160 beats/minute, was obtained. The patient presented to our clinic for further electrophysiological evaluation.

Supervised Obesity Reduction Trial for AF ablation patients: results from the SORT-AF trial.

AIMS: Weight management seems to be beneficial for obese atrial fibrillation (AF) patients; however, randomized data are sparse. Thus, this study aimed to investigate the influence of weight reduction on AF ablation outcomes. METHODS AND RESULTS: SORT-AF is an investigator-sponsored, prospective, randomized, multicentre, and clinical trial. Patients with symptomatic AF (paroxysmal or persistent) and body mass index (BMI) 30-40 kg/m2 underwent AF ablation and were randomized to either weight-reduction (group 1) or usual care (group 2), after sleep-apnoea-screening and loop recorder (ILR) implantation. The primary endpoint was defined as AF burden between 3 and 12 months after AF ablation. Overall, 133 patients (60 ± 10 years, 57% persistent AF) were randomized to group 1 (n = 67) and group 2 (n = 66), respectively. Complications after AF-ablation were rare (one stroke and no tamponade). The intervention led to a significant reduction of BMI (34.9 ± 2.6-33.4 ± 3.6) in group 1 compared to a stable BMI in group 2 (P < 0.001). Atrial fibrillation burden after ablation decreased significantly (P < 0.001), with no significant difference regarding the primary endpoint between the groups (P = 0.815, odds ratio: 1.143, confidence interval: 0.369-3.613). Further analyses showed a significant correlation between BMI and AF recurrence for patients with persistent AF compared with paroxysmal AF patients (P = 0.032). CONCLUSION: The SORT-AF study shows that AF ablation is safe and successful in obese patients using continuous monitoring via ILR. Although the primary endpoint of AF burden after ablation did not differ between the two groups, the effects of weight loss and improvement of exercise activity were beneficial for obese patients with persistent AF demonstrating the relevance of life-style management as an important adjunct to AF ablation in this setting. TRIAL REGISTRATION NUMBER: NCT02064114.

Mapping strategies for premature ventricular contractions-activation, voltage, and/or pace map.

A high premature ventricular contraction (PVC) burden is associated with an increase in cardiovascular mortality and may become clinically apparent through palpitations, reduced physical capacity or PVC-induced cardiomyopathy. Catheter ablation has been shown to be a more effective tool to treat patients with a high PVC burden than medical therapy alone. Current recommendations list catheter ablation as a class I option in patients with symptomatic idiopathic outflow tract PVCs as well as in patients with suspected PVC-induced cardiomyopathy. Careful planning is necessary to maximize efficiency and outcome of the ablation procedure. Prediction of the most likely PVC origin by studying the 12-lead electrocardiogram (ECG) is important. A high burden of spontaneous PVCs is associated with a better outcome during and after the procedure; pharmacological provocation can be performed. Developments in high density mapping systems have greatly advanced accuracy and efficiency of arrhythmia mapping in recent years. Different systems are now available that allow the simultaneous use and integration of different mapping information in an automated manner. Voltage mapping, activation mapping and pace mapping are used in clinical practice today. Activation mapping is used to visualize the area of earliest activation. While it is a very accurate tool, it relies on a high burden of spontaneous PVCs. Pace mapping aims to find the target area by means of stimulation and comparison of paced QRS complexes with the clinical PVC. Today, mostly a combination of both methods is used to maximize procedure outcome and efficiency. While voltage mapping plays a primary role in the mapping of substrate-based sustained arrhythmias in patients with underlying structural heart disease, activation and pace mapping are the methods of choice for PVC mapping.

ICD therapy in the elderly: a retrospective single-center analysis of mortality.

BACKGROUND: Current implantable cardioverter-defibrillator (ICD) guidelines do not impose age limitations for ICD implantation (IMPL) and generator exchange (GE); however, patients (pts) should be expected to survive for 1 year. With higher age, comorbidity and mortality due to non-sudden cardiac death increase. Thus, the benefit of ICD therapy in elderly pts remains unclear. Mortality after ICD IMPL or GE in pts ≥ 75 years was assessed. METHODS: Consecutive pts aged ≥ 75 years with ICD IMPL or GE at the University Hospital Cologne, Germany, between 01/2013 and 12/2017 were included in this retrospective analysis. RESULTS: Of 418 pts, 82 (20%) fulfilled the inclusion criteria; in 70 (55 = IMPL, 79%, 15 = GE, 21%) follow-up (FU) was available. The median FU was 3.1 years. During FU, 40 pts (57%) died (29/55 [53%] IMPL; 11/15 [73%] GE). Mean survival after surgery was 561 ± 462 days. The 1­year mortality rate was 19/70 (27%) overall, 9/52 (17%) in pts ≥ 75 and 10/18 (56%) in pts ≥ 80 years. Deceased pts were more likely to suffer from chronic renal failure (85% vs. 53%, p = 0.004) and peripheral artery disease (18% vs. 0%, p = 0.02). During FU, seven pts experienced ICD shocks (four appropriate, three inappropriate). In primary prevention (n = 35) mortality was 46% and four pts experienced ICD therapies (two adequate); in secondary prevention (n = 35) mortality was 69% (p = 0.053) with three ICD therapies (two adequate). CONCLUSION: Mortality in ICD pts aged ≥ 80 years was 56% at 1 and 72% at 2 years in this retrospective analysis. The decision to implant an ICD in elderly pts should be made carefully and individually.