Remaining challenges in catheter ablation of accessory pathways: rare entity of coronary sinus diverticulum-associated pathways.

INTRODUCTION: A limited number of case reports of coronary sinus (CS) diverticula complicating catheter ablation have been published. METHODS AND RESULTS: We retrospectively analysed 2245 patients who underwent ablation of an accessory pathway (AP) at our institution between 1/11/1993 and 31/10/2016. Eight patients (0.36%) were found to have a CS diverticulum in venography. APs showed a mean antegrade conduction time of 276 ± 23 ms (range 220-310 ms) and a mean retrograde conduction of 301 ± 45 ms (230-350 ms). Four patients had 1 (n = 2), 2 (n = 1), or 3 (n = 1) previously failed ablation attempts. Pathways could not be ablated with a conventional 4 mm tip catheter in 7 of 8 cases. In seven patients, ablation was successful, in two using an 8-mm ablation catheter, in two using cryoablation, and in the remaining three with an irrigated tip ablation catheter. After failed femoral approach, one 9-year-old female was successfully ablated via the right jugular vein. In one 75-year-old female, ablation was not successful. During a mean follow-up of 8.9 ± 6.4 years, all patients remained free of recurrences. CONCLUSION: In inferoseptal pathways, especially with previous failed ablation attempts, venographies of the CS should be performed. After successful ablation long-term prognosis is excellent.

Device updates successfully reduce T­wave oversensing and inappropriate shocks in subcutaneous ICD patients.

AIMS: To analyse the impact of device and software updates on the prevention of T­wave oversensing (TWOS) and inappropriate shocks (IS) in subcutaneous ICD (S-ICD) patients. BACKGROUND: TWOS is a feared complication after implantation. It may lead to harmful IS. To date, specific strategies to reduce these events are lacking. METHODS: In this retrospective single-centre trial we analysed 146 S­ICD patients who were implanted between 2010 and 2016. In all eligible consecutive patients (n = 139), follow-up of at least 6 weeks was studied. The incidence of TWOS/IS was analysed in patients receiving a 2nd generation S­ICD (Emblem-S-ICD) between 2014 and 2016 (Emblem). Their outcome was compared with a control group (SQ) treated with the SQ1010 device between 2010 and 2014, who were followed up for a maximum of 2 years. Furthermore, to test if the software update SMR8 reduces inappropriate shocks in the SQ1010-S-ICD population, the incidence of TWOS/IS was evaluated before and after update installation. RESULTS: Basic characteristics and indications for S­ICD implantation were similar in both groups. However, the cumulative incidence of TWOS/IS was significantly decreased in Emblem vs. SQ (SQ: 15.4%, n = 14/91 vs. Emblem 4.2%, n = 2/48; p = 0.049). Furthermore, with regards to the SQ population we also observed a trend towards a significant reduction of TWOS/IS after installation of the software update SMR8 in 2014 (before update: 13.4%, n = 11/82 vs. after update: 4.6%, 3/65, p = 0.07). CONCLUSION: 2nd generation devices but probably also the SMR8 software update reduce the incidence of TWOS/IS in S­ICD patients.

Comparing learning curves of two established "single-shot" devices for ablation of atrial fibrillation.

PURPOSE: We compared the contour of learning curves of two "single-shot" devices used for pulmonary vein isolation (PVI) for safety and procedural data. METHODS: We performed a retrospective analysis comparing the first 60 PVI performed at our center using a pulmonary vein ablation catheter (PVAC) array (39 male, mean age 57 years, 42 paroxysmal AF) to the first 60 first PVI using the Cryoballoon (44 male, mean age 59 years, 22 paroxysmal AF). Both groups were further divided into tertiles, where T1 regroups the first 20 ablations, T2 the following 20, and T3 the last 20 ablations. RESULTS: The mean total procedure time was reduced by 24 min between T1 and T3 for the PVAC and 15 min for the Cryoballoon (p = 0.01). Fluoroscopy increased by 5 min, total ablation time was reduced by 7 min for PVAC (p = 0.02), and both times decreased respectively by 7 and 1 min for the Cryoballoon (p = ns). In the PVAC group, a mean rate of 0.16 (T1: n = 5; T2: n = 2; T3: n = 3) complications was observed while a rate of 0.16 (T1: n = 2; T2: n = 3; T3: n = 4) occurred in the CRYO group (p = ns). Severe complications defined as stroke, pericardial tamponade with need of pericardiocentesis and phrenic nerve palsy occurred in n = 4 in both groups (6.6%). CONCLUSIONS: With either of the systems, no significant differences in the effect of the learning curve on the occurrence of adverse events were observed. However, the PVAC array seemed to have a steeper learning curve for procedure, as well as fluoroscopy time.

Refinement of detecting atrial fibrillation in stroke patients: results from the TRACK-AF Study.

BACKGROUND AND PURPOSE: Detection of occult atrial fibrillation (AF) is crucial for optimal secondary prevention in stroke patients. The AF detection rate was determined by implantable cardiac monitor (ICM) and compared to the prediction rate of the probability of incident AF by software based analysis of a continuously monitored electrocardiogram at follow-up (stroke risk analysis, SRA); an optimized AF detection algorithm is proposed by combining both tools. METHODS: In a monocentric prospective study 105 out of 389 patients with cryptogenic stroke despite extensive diagnostic workup were investigated with two additional cardiac monitoring tools: (a) 20 months' monitoring by ICM and (b) SRA during hospitalization at the stroke unit. RESULTS: The detection rate of occult AF was 18% by ICM (n = 19) (range 6-575 days) and 62% (n = 65) had an increased risk for AF predicted by SRA. When comparing the predictive accuracy of SRA to ICM, the sensitivity was 95%, specificity 35%, positive predictive value 27% and negative predictive value 96%. In 18 patients with AF detected by ICM, SRA also showed a medium risk for AF. Only one patient with a very low risk predicted by SRA developed AF revealed by ICM after 417 days. CONCLUSIONS: A combination of SRA and ICM is a promising strategy to detect occult AF. SRA is reliable in predicting incident AF with a high negative predictive value. Thus, SRA may serve as a cost-effective pre-selection tool identifying patients at risk for AF who may benefit from further cardiac monitoring by ICM.

[Current status and problems of the entirely subcutaneous ICD (S-ICD®)]. / Gegenwärtiger Stand und Probleme vollständig subkutaner ICD-Systeme (S-ICD®).

Prevention of sudden cardiac death is one of the most important tasks of cardiology. Transvenous ICD-systems have impressively proven their effectiveness in numerous randomized trials. Transvenous systems have their limitations due to frequent long-term lead complications. Having been available for a few years, the entirely subcutaneous ICD-system (S-ICD®, Boston Scientific, USA, former Cameron Health, USA) seems to be a promising alternative despite the lack of prospective data. The implantation of the SICD® can be performed easily; lead complications are rare because of the totally subcutaneous implantation. The detection and therapy of life-threatening tachyarrhythmias seems to be safe, although inappropriate therapies are a common problem in cases of insufficient ECG screening. S-ICD® is no alternative to the transvenous system due to limited programming options and the lack of stimulation, but it is an interesting supplement of ICD therapy.

[Totally subcutaneous cardioverter-defibrillator (S-ICD®) : recent experience and future perspectives]. / Komplett subkutaner Kardioverter-Defibrillator (S-ICD®) : Aktuelle Erfahrungen und Ausblick.

The implantable cardioverter defibrillator (ICD) is an established therapy for patients at risk of sudden cardiac death. Nevertheless the endocardial electrode in conventional systems plays a major role in long-term complications (difficult removal, risk of endocarditis, etc.). The totally subcutaneous ICD (S-ICD®, Cameron Health, San Clemente, CA, USA) represents a new and particularly significant development in ICD therapy which, since it requires no electrode in or on the heart, results in significantly fewer perioperative and long-term complications (e.g., thromboembolism and endocarditis risk). Although we see an indication for primary and secondary prevention, patients need to be informed about the limited data from randomized trials with the S-ICD®. As there is no permanent pacing option, patients in whom a pacemaker is indicated are not appropriate candidates for S-ICD®. In addition, patients with ventricular tachycardias that can be terminated by antitachycardic pacing are not recommended for the device. In the present article, we report our initial experience with the 18 patients implanted with the S-ICD® to date, comment on the available studies and offer a critical perspective.

Diastolic filling pattern and left ventricular diameter predict response and prognosis after cardiac resynchronisation therapy.

OBJECTIVE: To investigate predisposing factors for cardiac resynchronisation therapy (CRT) response. DESIGN: Single-centre study. SETTING: University hospital in Germany. PATIENTS: 122 consecutive patients with heart failure (mean (SD) age 65 (11) years; ischaemic/non-ischaemic 41%/55%; New York Heart Association (NYHA) class 3.1 (0.3); left ventricular ejection fraction 24.4 (8.1)%; QRS width 170 (32) ms, quality of life (QoL) 43.5 (19.2)) with an indication for CRT and demonstrated left ventricular dyssynchrony by echocardiography including tissue Doppler imaging. INTERVENTIONS: Besides laboratory testing of clinical variables, results of ECG, echocardiography including tissue Doppler imaging, invasive haemodynamics, measures of QoL and of exercise capacity were obtained before CRT implantation and during follow-up. MAIN OUTCOME MEASURE: Responders were predefined as patients with improvement by one or more NYHA functional class or reduction of left ventricular end-systolic volume by 10% or more during follow-up. Mean (SD) follow-up was 418 (350) days. RESULTS: Overall, 70.5% of patients responded to CRT. Responders had a significantly improved survival compared with non-responders (96.2% vs 45.5%, log-rank p<0.001). On univariate analysis, left ventricular end-diastolic diameter, left ventricular end-systolic diameter (LVESD), E/A ratio, a restrictive filling pattern, mean pulmonary artery pressure, pulmonary capillary pressure, N-terminal pro-brain natriuretic peptide and Vo(2)max were significant predictors of outcome. On multivariate analyses, LVESD (p = 0.009; F = 7.83), pulmonary capillary pressure (p = 0.015, F = 6.61) and a restrictive filling pattern (p = 0.026, F = 5.707) remained significant predictors of response. CONCLUSIONS: Despite treatment according to present guidelines nearly 30% of patients had no benefit from CRT treatment in a clinical setting. On multivariate analyses, patients with an increased left ventricular end-systolic diameter and concomitant diastolic dysfunction had a significantly worse outcome.

[Public health service as cooperative partner in prevention]. / Der öffentliche Gesundheitsdienst als Kooperationspartner in der Prävention.

As resources become scarce there is increasing demand on the public health services to create a system of community-based and jointly used health protection services. Cohort surveys that are currently more and more reduced contribute to both primary and secondary prevention. They enable third parties to implement further prevention projects. In addition, due to continuous quality assessment and standardization process, they yield valid data for developing target-group-specific prevention strategies as well as for evaluating preventive measures. In this respect public health services already fulfil the demand for prevention in the social environment as outlined in the forthcoming Prevention Act. Preventive measures in the field of dental health, atopic diseases and vaccination are presented as examples. The integration of data from continuous cohort surveys into a health reporting system as a basis for developing and evaluating health targets and prevention projects at the state level is demonstrated.

EORTC Early Clinical Studies Group early phase II trial of S-1 in patients with advanced or metastatic colorectal cancer.

Cancer of the colon and rectum is one of the most frequent malignancies both in the US and Europe. Standard palliative therapy is based on 5-fluorouracil/folinic acid combinations, with or without oxaliplatin or irinotecan, given intravenously. Oral medication has the advantage of greater patient convenience and acceptance and potential cost savings. S-1 is a new oral fluorinated pyrimidine derivative. In a nonrandomized phase II study, patients with advanced/metastatic colorectal cancer were treated with S-1 at 40 mg m-2 b.i.d. for 28 consecutive days, repeated every 5 weeks, but by amendment the dose was reduced to 35 mg m-2 during the study because of a higher than expected number of severe adverse drug reactions. In total 47 patients with colorectal cancer were included. In the 37 evaluable patients there were nine partial responses (24%), 17 stable diseases (46%) and 11 patients had progressive disease (30%). Diarrhoea occurred frequently and was often severe: in the 40 and 35 mg m-2 group, respectively, 38 and 35% of the patients experienced grade 3-4 diarrhoea. The other toxicities were limited and manageable. S-1 is active in advanced colorectal cancer, but in order to establish a safer dose the drug should be subject to further investigations.

Safe administration of irinotecan, oxaliplatin and raltitrexed in a DPD-deficient patient with metastatic colon cancer.

Dihydropyrimidine dehydrogenase deficiency is diagnosed more frequently and is now generally accepted as a potentially life-threatening condition. It predisposes patients receiving treatment with fluoropyrimidines such as 5-fluorouracil (5-FU) to severe and, in case of complete dihydropyrimidine dehydrogenase deficiency, often fatal toxicity. A patient who had severe side effects following standard dose adjuvant 5-FU exposure was diagnosed of having hereditary partial dihydropyrimidine dehydrogenase deficiency. When the patient relapsed with liver metastases, we treated him with the non-fluoropyrimidine cytotoxic agents irinotecan, oxaliplatin and raltitrexed in sequential manner, and were able to show that these drugs can be safely applied in patients with this metabolic defect.

Cardiac aneurysm complicated by E. coli abscess.

An E. coli myocardial abscess developed in the region of an old aneurysmal myocardial scar. In spite of vigorous antibiotic therapy fever and positive blood cultures persisted. A combination of In-111 WBC scanning and Tc-99m RBC gated heart imaging located the infection in the aneurysmal scar. The abscess was resected and the patient survived.