Pulmonary vein reconnection and repeat ablation characteristics following cryoballoon-compared to radiofrequency-based pulmonary vein isolation.

BACKGROUND: Despite advances in efficacy and safety of pulmonary vein isolation (PVI), atrial fibrillation (AF) recurrence after PVI remains common. PV-reconnection is the main finding during repeat PVI procedures performed to treat recurrent AF. OBJECTIVE: To analyze pulmonary vein (PV) reconnection patterns during repeat ablation procedures in a large cohort of consecutive patients undergoing radio frequency or cryoballoon-based PVI. METHODS: Retrospective analysis of PV-reconnection patterns and analysis of re-ablation strategies in consecutive index RF- and CB-based PVI and their respective re-ablation procedures during concomitant usage of both energy sources at a single high-volume center in Germany. RESULTS: A total of 610 first (06/2015-10/2022) and 133 s (01/2016-11/2022) repeat ablation procedures after 363 (60%) RF- and 247 (40%) CB-based index PVIs between 01/2015 and 12/2021 were analyzed. PV-reconnection was found in 509/610 (83%) patients at first and 74/133 (56%) patients at second repeat procedure. 465 of 968 (48%) initially via CB isolated PVs were reconnected at first re-ablation but 796 of 1422 initially RF-isolated PV (56%) were reconnected (OR: 0.73 [95% CI: 0.62-0.86]; p < .001). This was driven by fewer reconnections of the left PVs (LSPV: OR: 0.60 [95% CI: 0.42-0.86]; p = .005 and LSPV: 0.67 [0.47-0.95]; p = .026). PV-reconnection was more likely after longer, RF-based index PVI and in older females. Repeat procedures were shorter after CB-compared to after RF-PVI. CONCLUSIONS: Reconnection remains the most common reason for repeat AF ablation procedures after PVI. Our data suggest to preferentially use of the cryoballoon during index PVI, especially in older women.

Spatial correction improves accuracy of catheter positioning during ablation of premature ventricular contractions: differences between ventricular outflow tracts and other localizations.

BACKGROUND: Hybrid activation mapping is a novel tool to correct for spatial displacement of the mapping catheter due to asymmetrical contraction of myocardium during premature ventricular contractions (PVC). The aim of this study is to describe and improve our understanding of spatial displacement during PVC mapping as well as options for correction using hybrid activation mapping. METHODS AND RESULTS: We analyzed 5798 hybrid mapping points in 40 acquired hybrid maps of 22 consecutive patients (age 63 ± 16 years, 45% female) treated for premature ventricular contractions (PVCs). Median PVC-coupling interval was 552 ms (IQR 83 ms). Spatial displacement was determined by measuring the dislocation of the catheter tip during PVC compared to the preceding sinus beat. Mean spatial displacement was 3.8 ± 1.5 mm for all maps. The displacement was 1.3 ± 0.4 mm larger for PVCs with non-outflow-tract origin compared to PVCs originating from the ventricular outflow tracts (RVOT/LVOT; p = 0.045). Demographic parameters, PVC-coupling-interval and chamber of origin had no significant influence on the extent of spatial displacement. CONCLUSION: Ectopic activation of the ventricular myocardium during PVCs results in spatial displacement of mapping points that is significantly larger for PVCs with non-outflow-tract origin. The correction for spatial displacement may improve accuracy of radiofrequency current (RFC)-application in catheter ablation of PVCs.

Synovial osteochondromatosis in a 9-year-old girl: clinical and histopathological appearance.

This article reports the clinical and histopathological appearance of synovial osteochondromatosis in the right knee joint of a 9-year-old girl. Initial symptoms such as monoarticular joint swelling led to further diagnostic procedures with the aid of different imaging techniques including X-ray examination and MRI. The definitive diagnosis was based on histopathological findings after performing arthroscopy of the affected joint and the intraoperative appearance of the synovial lesions. Besides antiphlogistical drug-therapy, the treatment of choice is synovectomy.

[Effects of high-energy shock waves on the structure of the immature epiphysis--a histomorphological study]. / Wirkung hochenergetischer extrakorporaler Stosswellen auf Wachstumsfugen--Eine histomorphologische Studie.

AIM: Extracorporeal shock wave treatment of infantile skeleton diseases is theoretical reasonable. The aim of this study was to investigate if extracorporeal shock wave therapy (ESWT) may cause damage to the epiphysis within the energy range of human application doses. METHOD: 18 rabbits were treated with 800 extracorporeal shock waves (Philips lithotripter LDM-E, energy density 0.32 mJ/mm(2)) at the proximal tibia epiphysis. At 72 hours, 14 days and 4 weeks each after shock wave application 6 rabbits were sacrificed. RESULTS: Histological examination showed no damage to the epiphysis in all treated subjects. CONCLUSION: This experimental study demonstrates that, under the conditions used in human shock wave therapy, no damage to the rabbit epiphysis occurs.

[Guidelines in orthopedics. Alliance of German Orthopedists. University Clinic of Orthopedics, Heidelberg]. / Leitlinien in der Orthopädie. Ein erster Schritt.

Guidelines are systematically developed statements of the actual knowledge in order to assist doctors and patients by the decision of appropriate health care. Since 1998 the DGOT has published 22 well structured guidelines, 20 guidelines are under construction. The AWMF as the coordinator of guideline constructing of all scientific medical societies has published 629 guidelines since 1995. The publication of guidelines of the DGOT and the BVO is the first step for dissemination, next steps should be implementation und evaluation. Then it will be evident whether change in medical practice will occur.

[Quality management. Concepts and application in orthopedics]. / Qualitätsmanagement. Konzepte und Umsetzungsmöglichkeiten im orthopädischen Kontext.

A growing number of Health Care Systems have introduced Quality Management Systems to manage both quality in medicine and financial resources of the society. These Systems have been developed successfully for manufacturing and service business. Service Quality Management Systems can be modified for the purpose of non-profit-systems, such as Health Care. The view of quality differs among institutions and persons acting within this system. The focus of the customer is most important for any service offer to the patient. The variety of external, internal and total Quality Management Systems is discussed with regard to the adoption in elective orthopaedic surgery. Strong process orientation may favour the DIN ISO System, as the definition of processes in medicine should be enforced. Once the processes are clearly defined, elaborated (total) systems may be introduced easily. The process of the implantation of a total hip prothesis has been designed to DIN ISO conformity by a project team of experienced surgeons and is given here as an example for process orientation in elective surgery.

[Evaluation of standardized routine documentation with implementation of the requirements of multicenter studies. Presentation on the example of a knee endoprosthesis]. / Evaluation einer standardisierten Routinedokumentation mit Implementierung der Anforderung multizentrischer Studien. Darstellung am Beispiel der Knieendoprothetik.

In 1988 we did develop an EDP-System for data collection of daily routine documentation, which allows on the one hand a complete registration and on the other hand only offers entire and plausible data because of the logical program structure. The registered data are saved in a data bank structure as well as in report form for routine documentation. The substitution of routine documentation by such a system essentially depends on the content of interrogation which has to reflect the user's individual indication and operative technique. First doubts about reflection of the high variation of the individual operative technique could be disproved with help of the evaluation of this system of documentation. None of the 200 registered cases had to be documented without the help of the standardized system. The use in a prospective multicenter study for endoprosthesis of the knee was the starting point of the evaluation for the system's efficiency and acceptance. It had been analyzed the expressiveness of the study's documentation. As there was no standard in free dictated operation records the information content seemed to be reduced and with regard to scientific aspects unqualified. The analysis of the EDP-system especially checked three aspects: the general suitability to represent medical facts by standardized evaluation as well as the user's and patient's acceptance. All in all this system is an instrument for standardized daily routine documentation in a clinic which seems able to establish a quality management because of the high data quality, the differentiated registrations of multiple parameters and timeneutral application.

Guidelines in orthopaedic surgery. A first step.

Guidelines are systematically developed statements of the actual knowledge in order to assist doctors and patients by the decision of appropriate health care. Since 1998 the DGOT has published 22 well structured guidelines, 20 guidelines are under construction. The AWMF as the coordinator of guideline constructing of all scientific medical societies has published 629 guidelines since 1995. The publication of guidelines of the DGOT and the BVO is the first step for dissemination, nexts steps should be implementation und evaluation. Then it will be evident whether change in medical practice will occur.

Quality management. Concepts and applications in orthopaedics.

A growing number of Health Care Systems have introduced Quality Management Systems to manage both quality in medicine and financial ressources of the society. These Systems have been developed successfully for manufactoring and service business. Service Quality Management Systems can be modified for the purpose of non-profit-systems, such as Health Care. The view of quality differs among institutions and persons acting within this system. The focus of the customer is most important for any service offer to the patient. The variety of external, internal and total Quality Management Systems is discussed with regard to the adoption in elective orthopaedic surgery. Strong process orientation may favour the DIN ISO System, as the definition of processes in medicine should be enforced. Once the processes are clearly defined, elaborated (total) systems may be introduced easily. The process of the implantation of a total hip prothesis has been designed to DIN ISO conformity by a project team of experienced surgeons and is given here as an example for process orientation in elective surgery.

Evaluation of standardized routine documentation with implementation of the requirement of multicenter studies. : Presentation with knee endoprosthetics as an example.

In 1988 we did develop an EDP-System for data collection of daily routine documentation, which allows on the one hand a complete registration and on the other hand only offers entire and plausible data because of the logical program structure. The registered data are saved in a data bank structure as well as in report form for routine documentation. The substitution of routine documentation by such a system essentially depends on the content of interrogation which has to reflect the user's individual indication and operative technique. First doubts about reflection of the high variation of the individual operative technique could be disproved with help of the evaluation of this system of documentation. None of the 200 registered cases had to be documented without the help of the standardized system. The use in a prospective multicenter study for endoprosthesis of the knee was the starting point of the evaluation for the system's efficiency and acceptance. It had been analyzed the expressiveness of the study's documentation. As there was no standard in free dictated operation records the information content seemed to be reduced and with regard to scientific aspects unqualified. The analysis of the EDP-system especially checked three aspects: the general suitability to represent medical facts by standardized evaluation as well as the user's and patient's acceptance. All in all this system is an instrument for standardized daily routine documentation in a clinic which seems able to establish a quality management because of the high data quality, the differentiated registrations of multiple parameters and timeneutral application.

[Late hip dislocation--treatment results of 1193 hips in attenuated abduction (Hanausek position)]. / Späte Hüftluxation--Behandlungsergebnisse von 1193 Hüften in der abgeschwächten Beuge-Spreizstellung (Hanausekposition).

Results of 1193 dislocated and dysplastic hips in 695 children of a consistent treatment by skin traction and splinting in a mitigated abduction device (Hanausek position) are given with regard to the acetabular development and avascular head necroses. The acetabular development depends on the initial acetabular dysplasia and is overall satisfactory through final acetabular angles (Hilgenreiner) between 22 and 25 degrees even in highly dysplastic acetabula in late cases. The procedure is non-aggressive proven by low rate of femoral head necroses of 3.4%. Factors contributing to higher rates and degrees of iatrogenic damage to the femoral head are short time or no preceding longitudinal traction, low initial acetabular pathology and prolonged splinting.

[Synovial hemangioma as a rare differential diagnosis of juvenile hemarthrosis. Therapy by laser ablation]. / Das synoviale Hämangiom als seltene Differentialdiagnose des juvenilen Hämarthros. Therapie durch Laserablation.

We report the case of multiple hemangiomas in the left knee of a young female. The hemangiomas were ablated by holmium yag-laser. Arthroscopic versus open surgery procedures in the therapy of synovial hemangiomas will be discussed. Haemarthros in childhood can be caused by hemangiomas.

[Osteochondral fracture of the lateral tibial pilon]. / Osteochondrale Fraktur des lateralen Pilon tibial.

In this paper we report a case of osteochondral fracture of the lateral tibial pilon. A young man fell while he was playing soccer. In the following months the ankle was swollen and painful. Later the reason for his ankle pain was clearly visible on the X-ray pictures, which revealed a severe osteochondral fracture of the lateral tibial pilon. We describe the arthroscopic and X-ray grading of osteochondral fractures of the ankle and their treatment.

Non-invasive treatment of long-bone pseudarthrosis by shock waves (ESWL).

Non-invasive treatment of non-union of diaphyses by application of the shock waves known from lithotripsy has proved successful in three out of four cases. Two thousand shock waves with a single-wave energy of 18 kV were applied by the MFL 5000 and HM3 Lithotripters of the Dornier Medizintechnik Company with manual detection of the lesion. The shock waves induced a kind of callus formation in the non-union soft tissue within about 6 weeks, which was successfully maintained and transformed into bony union in all cases but one by dynamic fixation less rigid than a plaster cast. Four cases are documented and the effects of the shock waves and principles of bony union discussed.

[Prostaglandin and leukotriene release of synovial tissue in various joint diseases]. / Prostaglandin- und Leukotrienfreisetzung aus Synovialgewebe bei verschiedenen Gelenkerkrankungen.

Synovial tissue from 37 patients suffering from osteoarthritis, chondrocalcinosis, active and inactive rheumatoid arthritis was investigated. The tissue was obtained during knee surgery and immediately incubated in tyrode solution. PGE2, 6-keto-PGF1 alpha, LTB4 and LTC4 were measured by radioimmunoassay. Calcium ionophore A 23187 stimulated the eicosanoid release significantly. This effect was more pronounced with LT than with PG. In the four different joint diseases there was no significant difference in the PG release. The LTC4 release was significantly lower in inactive rheumatoid arthritis as compared to the other joint diseases. For LTB4 this effect was significant only when compared to osteoarthritis. Indomethacin 10(-5) and 10(-7)mol/l inhibited the PG release from synovial tissue in all joint diseases significantly (p less than 0.05), there was no significant effect on the LT release. LT as well as PG are pro-inflammatory mediators. Non-steroidal anti-inflammatory drugs inhibit only the PG release. The remaining LT synthesis might thus be partially responsible for the lack of efficacy of these drugs in some patients.

Closed reduction by two-phase skin traction and functional splinting in mitigated abduction for treatment of congenital dislocation of the hip.

A method of a two-phase closed reduction using longitudinal skin traction followed by abduction was employed by the authors for treatment of children with congenital dislocation of the hip (CDH). Longitudinal traction was used for two to four weeks, depending on the child's age and the degree of dislocation. Traction in abduction required two weeks. Splinting after reduction was used with an intermediate abduction device, which allowed immediate hip function and motion without the risk of redislocation. The results of 1178 treated hips, with follow-up examinations in 809 cases, demonstrate the efficacy of this method even for completely dislocated hips. The procedure is nonaggressive, results in a low incidence of femoral head osteonecrosis (3.4%), and is suitable for children with CDH aged six weeks to about 2.5 years.

[Ultrasound control of the repositioning of hip dislocation in a child in the unstable phase of splint retention (Hanausek position)]. / Sonographische Repositionskontrolle kindlicher Luxationshüften in der instabilen Phase der Schienenretention (Hanausekposition).

In CDH ultrasound control of reduction in the unstable period of the first 3 months has to be performed by an inguinal access, as the splint can not be removed for the reason of high risks of redislocation. Controls are possible whenever required, according to anglo-american techniques. Thus treatment within the first year of life may be controlled by ultrasound imaging alone. Criteria for detection of posterior and cranial redislocation as well as for the anterior positioning of the femoral head are given.

[Immunologic methods of study for evaluating the risk of anaphylactic reactions in intradisk chymopapain injections]. / Immunologische Untersuchungsmethoden zur Risikoabschätzung einer anaphylaktischen Reaktion bei der intradiskalen Chymopapain-Injektion.

According to results available to date, skin tests are of limited value in determining the risk of anaphylactic shock. By identifying specific IgE antibodies, e.g. via the Chymo-FAST test or the corresponding RAST, the risk of anaphylactic shock of 0.2%-1% in the total group of patients can be reduced to 0.05% in patients in whom the test was negative, whereas in test-positive patients the risk is above 60%. Previous intolerance reactions among the remaining 0.05% are probably due to a non-testable pseudoallergic reaction, just like the 6% mild late reactions after the injection. For the remaining risk of 0.05% in IgE-negative patients drug prophylaxis with antihistamines or if necessary even steroids will continue to be mandatory. Examination of histamine release from leucocytes, which can be conducted in very few centres only, may possibly be able to clarify in future to what extent reinjection is permissible if a disc on a different level is affected, besides other scientific problems.