Impact of chronic atrial fibrillation in patients with severe heart failure and indication for CRT: data of two registries with 711 patients (1999-2006 and 2007-6/2008).

AIMS: Atrial fibrillation (AF) is a relevant comorbidity in heart failure (HF) patients. In milestone cardiac resynchronization therapy (CRT) studies, patients with AF were excluded. We sought to investigate the influence of chronic atrial fibrillation (AF) on patients with CRT. AV node (AVN) ablation is frequently recommended. Converting AF to sinus rhythm (SR) is not a standard concept. METHODS: A total of 584 consecutive patients with CRT devices were included in a single-center registry from 1999-2006 (retrospective registry) and 127/324 patients from 2007-06/2008 (prospective registry). The impact of persistent AF (group 1) on clinical and echocardiographic improvement compared with patients in SR (group 2) after 12 (6) months follow-up were analyzed. Re-establishing SR after initial cardioversion or need for AVN ablation was examined. RESULTS: In the retrospective registry, 139 (24%) patients presented with AF (group 1) and 445 with SR (group 2). The groups differed in age, gender, and left atrium (LA) size but not in NYHA class, ejection fraction (EF), left ventricular end-diastolic dimension (LVEDD), B-type natriuretic peptide (BNP) levels, QRS width, and underlying disease. After 1 year, CRT improvement of NYHA class and EF was similar with higher mortality in group 1 (12% vs. 7%; OR 1.80; 95% confidence interval 0.95-3.4). The AF group presented with SR in 33/82 (40%) patients and 11% needed AVN ablation. The prospective data showed 27 (21%) patients in AF with conversion to SR in 41% after 6 months. CONCLUSION: Patients with severe HF and chronic AF had a comparable improvement with CRT as those in SR. CRT is a successful treatment option in patients with chronic AF offering the potential to restore SR in a significant number of patients.

[Cardiac resynchronization therapy (CRT) and anodal stimulation]. / Kardiale Resynchronisationstherapie (CRT) und anodale Stimulation.

We describe a biventricular stimulation mode to pace both ventricles with a single electrical stimulus between the tip of the left ventricular electrode and the tip of the right ventricular electrode: one ventricle is stimulated cathodal the other anodal.

[Implantation of a biventricular pacing system via a persistent left-sided superior vena cava]. / Biventrikuläre Schrittmacherimplantation über eine persistierende linke obere Hohlvene.

Cardiac resynchronization therapy by multisite biventricular pacing presents an additive therapeutic option in the treatment of severe heart failure. Biventricular pacemaker implantation is challenging in patients with persistent left superior vena cava. We describe in this case report the implantation of a biventricular pacemaker using a left-sided approach in a patient with persistent left superior vena cava.

[The arrhythmogenic right ventricular cardiomyopathy (ARVC)]. / Die arrhythmogene rechtsventrikuläre Cardiomyopathie (ARVC)Typische Befunde anhand eines Fallbeispieles.

The following report illustrates the case of a 40-year old patient, who was transferred to our hospital because of a symptomatic sustained ventricular tachycardia (VT). The documented VT showed typical left bundle branch block morphology with an inferior axis, which was accompanied by repolarization abnormalities in the right precordial leads, as revealed by the surface ECG. While coronary angiography allowed the exclusion of an obstructive coronary heart disease and confirmed an intact left ventricular function, the right ventricular angiography as well as the MRI demonstrated not only reduced right ventricular function but also regional abnormalities of contraction in the inferior and diaphragmal regions and typical "outpouchings" and "bulgings". The MRI also provided evidence for sporadic fatty infiltrations of the right ventricle. In the electrophysiological study, sustained VT could be reproducibly induced, while showing the typical RVOT configuration, which corresponded to the clinically apparent VT. Since these examination results matched with the criteria of McKenna et al., arrhythmogenic right ventricular cardiomyopathy was diagnosed. The patient underwent implantation of a cardioverter-defibrillator (ICD) and medical treatment with metoprolol. This particular case report was selected because it shows a typical presentation of an ARVC. Furthermore, the present example offers the possibility of demonstrating that in the case of an ARVC in the regions of the right ventricle, arrhythmogenic areals can also be found which seem morphologically inconspicuous.

Acute haemodynamic effects of AV-synchronous pacemaker stimulation in patients with congestive heart failure and left bundle branch block.

INTRODUCTION: The therapeutical limits of drug and surgical therapy for severe chronic heart failure make the research for adjunctive treatment options necessary. After the positive effects of AV-synchronous pacemaker stimulation in patients with dilatative cardiomyopathy and 1st degree AV-block, this study was to evaluate the benefit of transient pacemaker stimulation in patients with dilated cardiomyopathy and left bundle branch block. METHODS AND PATIENTS: 19 patients (14 male, 5 female, age 60 +/- 8 yrs) were included in the study. Inclusion criteria were congestive heart failure, stage NYHA III or greater and left bundle branch block. Transient stimulation of the myocardium was applied via two electrodes (right atrium and right ventricle) in VDD mode, whereby a series of AV-delay-times between 80 and 180 ms was tested. Thermodilution was used to determine cardiac output, pulmonary capillary pressure and pulmonary arterial pressure. RESULTS: In 16 patients, pacemaker stimulation led to a significant increase of cardiac output (3.8 +/- 0.5 l/min to 4.6 +/- 0.5 l/min; p < 0.002), cardiac index (1.90 +/- 0.20 l/min/m2 to 2.3 +/- 0.2 l/min/m2; p < 0.002) and of stroke volume (51 +/- 8 ml to 62 +/- 6 ml; p < 0.002) as well as a significant reduction of mean pulmonary capillary pressure (19 +/- 1 mmHg to 15 +/- 1 mmHg; p < 0.01). The mean pulmonary arterial pressure remained unchanged. Three patients did not benefit from the treatment. CONCLUSION: AV-sequential pacemaker-stimulation (right ventricular electrode placement) can be a valuable adjunctive therapy in selected patients with late stage congestive heart failure and left bundle branch block.

[Effect of body mass index on success rate of external and internal cardioversion]. / Einfluss des Body-Mass-Index auf die Erfolgsrate der externen und internen Kardioversion.

Atrial fibrillation is due to complications a frequent clinical problem. Internal cardioversion shows a high effectiveness with conversion rates from up to 85%. Aim of this study was to evaluate the influence of body weight (body-mass-index [BMI]) on the effectiveness of different cardioversion procedures.

Prevalence of Helicobacter pylori infection in coronary artery disease and effect of its eradication on coronary lumen reduction after percutaneous coronary angioplasty.

BACKGROUND: Gastric infection caused by Helicobacter pylori has recently been associated with increased risk of coronary artery disease. AIM: To: 1) determine seroprevalence of Helicobacter pylori and its cytotoxin associated gene A in patients with/without coronary artery disease (group A), 2) assess influence of Helicobacter pylori eradication on coronary artery lumen reduction after percutaneous coronary angioplasty (group B) and 3) determine influence of Helicobacter pylori eradication on plasma cytokines, lipids and coagulation factors in patients subjected to percutaneous coronary angioplasty (group B). PATIENTS AND METHODS: Group A included 100 patients with coronary artery disease (subgroup 1) and 100 patients without (subgroup II). For Helicobacter pylori seroprevalence, plasma anti-Helicobacter pylori and anti-cytotoxin associated gene A IgG were examined. Group B included 40 patients with significant single-vessel coronary arterial disease and Helicobacter pylori infection confirmed by 13C-urea breath test and serologically using anti-Helicobacter pylori and anti-cytotoxin associated gene A IgG. Six months after percutaneous coronary angioplasty and triple anti-Helicobacter pylori therapy, the Helicobacter pylori status reassessed by urea breath test was negative in all but two patients of subgroup I subjected to Helicobacter pylori therapy. Coronary angiography and laboratory tests were repeated in both subgroups of group B included in the trial and reduction in coronary artery lumen in these subgroups was compared to baseline after percutaneous coronary angioplasty considered as 100%. RESULTS: Helicobacter pylori seropositivity reached 81.5% of coronary artery disease (subgroup I) and was significantly higher than that in controls without coronary artery disease (subgroup II) (51%), the odds ratio being 4.3 for Helicobacter pylori in coronary artery disease. Cytotoxin associated gene A IgG detection was also significantly higher (47.3%) in coronary artery disease than in controls (28%) giving the odds ratio about 2.3. Mean coronary artery lumen reduction in patients undergoing percutaneous coronary angioplasty + Helicobacter pylori eradication therapy (subgroup I) was significantly (p<0.05) smaller compared to percutaneous coronary angioplasty + placebo-treated subgroup II (22% vs 41%). CONCLUSIONS: 1) There is a significant link between coronary artery disease and infection with Helicobacter pylori, especially expressing CagA proteins, 2) Helicobacter pylori eradication significantly attenuates reduction in coronary artery lumen in coronary artery disease patients after percutaneous coronary angioplasty possibly by elimination of chronic inflammation and decline in proinflammatory cytokine release, and 3) Infection of Chlamydia pneumoniae in these percutaneous coronary angioplasty patients is not affected by eradication therapy.

[A simple method for AV-delay determination in dual chamber pacemakers]. / Eine einfache Methode zur Bestimmung des AV-Intervalls bei Zweikammerschrittmachern.

The individual adjustment of the AV intervals is a prerequisite for the hemodynamic advantages of dual-chamber pacing. The methods for the optimization of the AV-Delay (AVD) applied so far are time intensive. A simple and fast method is the approximate adjustment of the AVD with the surface-ECG. The aim of this work is the conception and validation of this new method. The optimal AVD is given if at the end of the atrial contraction the mitral valve is closed by the ventricular increase of pressure. In order to achieve this with pacemaker patients, the individually different atrial and ventricular conduction times must be considered. The different conduction times can be determined from the surface-ECG. Intra- and interatrial conduction times can be defined by the beginning of the atrial spike up to the end of the p-wave. The beginning of ventricular pressure increase corresponds to the peak of the stimulated QRS complex (beginning of the Iso-Volumetric Contraction time, ISVC) and depends on the interventricular conduction time.¶ In the case of 100 patients, who did not receive a cardiac pacemaker, the interval at the end of the p-wave (left atrial excitation, EP) up to the peak of the r-wave (ISVC) during rest and exercise was measured and an age referred average value of 100ms determined; this serves as standard value if no AV-conduction is available. The approximated optimized AVD is given if the interval of the end at the p-wave to the peak of the QRS-Complex amounts to 100ms. By means of a simple algorithm, the optimized AVD can, thus, be calculated:¶ After programming a long AVD, the interval at the end of the native or paced p-wave up to the peak of the stimulated QRS-Complex (EP/ISVC) is determined. This value EP/ISVC is then taken from the long AVD, the 100ms standard value is added and one receives the approximately optimized AVD.¶ In order to validate the described method, 13 consecutive patients (2 female, 11 male, average age 67±7.8 years) were included, and received for different indication (7 sick sinus syndrome, 4 AV block III, 2 binode disease) a DDD pacemaker (Affinity, St. Jude Medical).¶ About 8 weeks after implantation all patients underwent a PA catheter investigation, in order to optimize the AV-/PV-Delay of the pacemaker regarding the maximum cardiac output (CO). For CO measurement the thermo dilution method was applied. Altogether 17 complete hemodynamic measurements (9 times with different PVDs, 8 times with different AVDs) were executed. The patients 10-13 could be examined both in the VDD and in the DDD mode.¶ The minimum determined CO amounted to 3.5 l/min, the maximal CO 7.1 l/min and the average value was 5.62±0.98 l/min. In all patients not only one optimal AVD was found but, moreover, a varied interval of AVDs with which optimal CO results could be obtained. The comparison of surface ECG optimized AVD with the PA catheter optimized AVD showed a statistically significant correlation (0.825PV, 0.982 AV, P<0.01). Sixteen out of seventeen measurements were at an interval which enables hemodynamic optimal CO or stroke volume. Only one AVD determined from the surface ECG was situated slightly (10 ms) outside of a hemodynamic optimal determined AVD. Despite the encouraging test results represented here, further studies should examine the value of the new algorithm in comparison with the other techniques for AVD optimization.

[Hemodynamic indications for DDD mode pacing therapy]. / Hämodynamische Indikationen zur DDD-Schrittmachertherapie.

BACKGROUND AND OBJECTIVE: Because there are limits to the drug treatment or surgical intervention of advanced heart failure, alternative methods are being explored. It was the aim of this study to investigate the extent to which optimal atrioventricular (AV) sequence of dual pacemaker stimulation in patients with advanced dilated cardiomyopathy (DCM) of different aetiology increases their usually much reduced cardiac output. PATIENTS AND METHODS: The study group consisted of 22 patients (five women, 17 men; aged 54-84 years) with heart failure in class I-IV (New York Heart Association classification). Temporary dual electrode stimulations (in the right atrium and ventricle) in the VDD or DDD mode were performed with programmed AV intervals between 80 and 180 ms. Cardiac output (CO), pulmonary capillary and pulmonary arterial pressures were measured via an indwelling catheter. RESULTS: In 17 patients with a 1 degree AV block and/or left bundle branch block in the surface ECG pacing produced a significant increase in CO (from 3.7 +/- 0.75 to 4.6 +/- 0.65 l/min; P < 0.005) and cardiac index (from 2.05 +/- 0.43 to 2.47 +/- 0.37 l/min/m2; P < 0.005). There was no increase in patients with normal PR interval and QRS duration. Mean pulmonary capillary and pulmonary arterial pressures remained unchanged. CONCLUSION: Alteration of AV sequence by pacemaker in selected patients in the late stage of heart failure, particularly if there is also abnormal atrioventricular and/or intraventricular conduction delay, may be an effective complementary method of treatment.

A field study on the immediate effects of exposure to low-altitude flights on heart rate and arrhythmia in patients with cardiac diseases.

Noise from low-altitude military flights differs from most other sources of noise by virtue of its unpredictability in space and time, its very high maximal levels, and the fast increase in noise level at high flight speeds. While this makes low-altitude flights a frightening and annoying experience, the potential immediate health hazards for exposed individuals with preexisting cardiovascular disease are unclear. A field study on the immediate effects of exposure to low-altitude flights on heart rate and arrhythmia was conducted among patients of a rehabilitation clinic for cardiac diseases in the summer of 1990 in Bad Rothenfelde, Germany. Twenty-four hour electrocardiograms of 68 patients taken on days when low-altitude overflights with peak sound pressure levels above 95 dB(A) were registered on the flat roof of the clinic were analyzed for changes in the heart rate or the occurrence of ventricular extrasystoles in four 2-min periods before, around, and after the overflights. Overall, 149 "overflight events" were included in the analysis. No major changes in the heart rate or in the frequency of ventricular extrasystoles were observed, but this could be partly due to problems inherent in the field approach. Nevertheless, the potential effects on heart rate and arrhythmia of low-altitude flights appear to be of limited magnitude compared to the potential effects of other factors, such as psychological or physical exposures, and they are probably too small to be proven under field conditions in an observational epidemiologic study in Germany following the limitations placed on the frequency and altitude of flights in September 1990.