Electroanatomic visualization of coronary arteries: a case series to elicit safety, feasibility, and diagnostic value in complex ablation procedures.

AIMS: The goal of this case series was to evaluate the feasibility, safety, and advantages of a wire-based approach for the live visualization of coronary arteries (CAs) in an electroanatomic mapping (EAM) system and to assess its diagnostic information. METHODS AND RESULTS: For this single-centre case series, we included procedures in which close proximity of a possible ablation site to any epicardial vessel was suspected. An uncoated-tip guidewire was introduced into the relevant CAs after exclusion of critical CA stenosis by coronary angiography. By connecting this wire to the EAM system using a clip and pin connection, mapping and live visualization of the wire tip is possible, as well as the assessment of the local electrograms within the respective CAs. Procedural wire insertion and intracoronary mapping was performed by EP specialists and was assisted to judge the relevance of CA disease by an interventional cardiologist. A total of nine procedures in nine patients were included in this case series, four ventricular tachycardia ablation procedures and five procedures for the ablation of premature ventricular contractions. The left CAs were mapped in eight cases and the right CA was mapped in one case. In two cases, epicardial mapping was combined with visualization of the right or left CAs. There were no complications attributed to coronary wiring and mapping in this case. CONCLUSION: We demonstrated the feasibility and safety of CA visualization and integration in an EAM. The live visualization of the CAs added valuable information without the need for preprocedural planning or the purchase of separate software. Electroanatomic visualization was achieved intraprocedurally in a safe and straightforward manner, adding critical diagnostic information without excessive costs or risks.

Association of adipocytokines serum levels with left atrial thrombus formation in atrial fibrillation patients on oral anticoagulation (Alert) - A cross-sectional study.

BACKGROUND AND AIMS: Oral anticoagulation is effective for stroke prevention in atrial fibrillation (AF). However, strokes may still occur in high-risk individuals. We conducted a prospective trial to assess the association between adipocytokine serum levels and surrogate parameters for thromboembolic events. METHODS AND RESULTS: In this cross-sectional multicenter trial, we enrolled 189 patients with AF who were on oral anticoagulation. The primary endpoint was defined as either the presence of spontaneous echo contrast (SEC), a left atrial appendage (LAA), or a left atrial (LA) thrombus on transesophageal echocardiography. We investigated the association of adipocytokine serum levels with the combined endpoint using logistic regression analysis. Forty-eight individuals (25%) were assigned to group 1 (G1) due to the occurrence of at least one of the components of the combined endpoint (41 [21.7%] SEC, 3 [1.6%] LA thrombus, 13 [6.9%] LAA thrombus), whereas the remaining patients formed group 2 (G2). The BMI, logarithmized (loge) leptin (G1: 2.0 ± 1.3 µg/ml, G2: 2.0 ± 1.1 µg/ml, p = 0.746) and visfatin serum levels (G1: 3.4 ± 0.3 ng/ml, G2: 3.4 ± 0.5 ng/ml, p = 0.900) did not significantly differ between the groups. Conversely, logarithmized adiponectin (G1: 3.3 ± 0.6 ng/ml, G2: 3.1 ± 0.7 ng/ml, p = 0.036) and resistin levels (G1: 1.8 ± 0.5 ng/ml, G2: 1.6 ± 0.5 ng/ml, p = 0.009) were higher in patients with the primary endpoint. Multivariate logistic regression analysis using a score that combined the individual adiponectin and resistin values in each patient corroborated this association. CONCLUSIONS: Our results suggest that adiponectin and resistin may act as potential biomarkers to identify individuals with AF who are at high thromboembolic risk.

Cardiac arrhythmias in patients with SARS-CoV­2 infection and effects of the lockdown on invasive rhythmological therapy.

BACKGROUND: Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, various strategies have been taken worldwide to reduce the risk of infection. As part of the amendment to the Infection Protection Act, elective medical interventions were restricted, leading to a change in patient care. However, the consequences of the lockdown on the treatment of rhythmological patients in Germany remains unclear. OBJECTIVES: The aim of this study was to analyze the reduction in rhythmological interventions and the patient care situation using a nationwide survey during the first lockdown period. METHODS: A survey was sent to all electrophysiological centers certified by the German Society of Cardiology. Here, the treatment volume of tachycardia and bradycardia and their invasive therapy were surveyed before and during the lockdown period. Furthermore, the number of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) treated at these centers and the incidence of cardiac arrhythmias was also recorded. RESULTS: Participating centers performed a total of 24,648 ablation procedures/year and represent approximately 34% (24,648/72,548) of the estimated German ablation treatments. The majority of these centers (33/40; 82.5%) were so-called primary COVID-19 hospitals (level-1). Overall, the number of ablations and pacemaker implantations were reduced by 41% and 18% respectively. Due to postponed ablation procedures and pacemaker implantations, 22/40 (55%) centers reported a worsening of clinical symptoms or early re-hospitalization of their patients. CONCLUSION: These results demonstrate a significant decline in elective rhythmological procedures during the lockdown, as required by the German Federal Government. At the same time, however, more than half of the participating centers reported an increase in patient re-hospitalizations due to postponed procedures.

Confirmation of Pulmonary Vein Isolation with High-Density Mapping: Comparison to Traditional Workflows.

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Yet tools and techniques used for confirmation of PVI vary greatly, and it is unclear whether the use of any particular combination of tools and techniques provides greater sensitivity for identifying gaps periprocedurally. It has been suggested the use of a high-density mapping catheter, which enables simultaneous recording of adjacent bipolar EGMs in two directions, may provide improved sensitivity for gap identification. Anonymized, acute procedural data was prospectively collected in AF ablation cases utilizing various workflows for confirmation of PVI. Post-hoc analysis was performed to evaluate the incidence of gaps detected by different diagnostic catheter technologies, including a high-density mapping catheter and circular mapping catheters (CMCs), and common techniques such as pacing the ablation lines. A total of 139 cases were included across three subgroup analyses: 99 cases were included in an indirect comparison of three mapping catheter technologies, revealing gaps in 36.7%, 38.9%, and 81.8% of cases utilizing a 10-pole CMC, 20-pole CMC, and a high-density mapping catheter, respectively; a direct comparison of diagnostic catheter technologies in 18 cryoballoon ablation cases revealed residual gaps in 22.2% of patients identified by high-density mapping which were missed previously with the use of a 3.3F CMC; in 22 cases utilizing a technique of pacing the ablation lines, high-density mapping identified residual gaps in 68.2% of patients. This proof of concept analysis demonstrated that the use of a high-density catheter which records orthogonal bipoles simultaneously, appears to improve acute detection of gaps in PVI lines relative to other commonly utilized techniques and technologies. The long-term impact of ablating these concealed gaps remains unclear. Further study, including direct comparison of diagnostic catheter technologies in a randomized setting with long-term followup, is warranted.

Pacientes con fibrilación auricular y mal pronóstico en el síndrome coronario agudo: ¿qué fue antes, el huevo o la gallina? / A chicken or egg dilemma: patients with atrial fibrillation and poor prognostic outcome in acute coronary syndrome

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Tilt testing and what you should know about it - Experience with 835 consecutive patients with syncope of unknown origin.

BACKGROUND: Numerous tilt testing protocols with and without a preceding passive phase or the administration of nitrates have already been investigated. However, a truely standardized method for the investigation does not yet exist. METHODS AND RESULTS: A total of 835 consecutive patients who underwent tilt testing between January 2005 and March 2015 were included in this study. Results of a passive tilt test (PTT), a nitrate-stimulated tilt test (NSTT) with a preceding passive phase of 20 min, or an early nitrate-stimulated tilt test (ENSTT) without a preceding passive phase were compared and analyzed retrospectively in 735 patients. In addition, a further 100 consecutive patients were prospectively randomized 1:1 to compare NSTT and ENSTT. In the retrospective analysis, 38% of the patients in the ENSTT group had a positive test response compared with 45% in the NSTT group and only 27% in the PTT group (p = 0.0002). In the prospective study, 34% of the patients had a positive test response in the ENSTT group compared with 42% in the NSTT group (p = 0.537). The mean duration to a positive test response was significantly shorter in the ENSTT group (retrospective and prospective p < 0.001). The nitrate-stimulated groups did not differ significantly with respect to the hemodynamic characteristics of a positive test response (retrospective: p = 0.773; prospective: p = 0.086). CONCLUSION: Due to the rate of positive test response being comparable to other protocols and its significantly shorter test duration, nitrate-stimulated tilt testing without a preceding passive tilt test may be favored for use in a busy clinical practice.

Baroreceptor stimulation in a patient with preexisting subcutaneous implantable cardioverter defibrillator.

BACKGROUND: Many patients with severe heart failure (HF) have an indication for baroreflex activation therapy (BAT) and an implantable cardioverter-defibrillator (ICD). Concerns about device-device interactions were addressed in a study with small sample size that concluded combined BAT and ICD therapy is safe. There are no published data, however, concerning device-device interactions between BAT and a subcutaneous ICD (S-ICD). Since BAT frequently interferes with surface electrocardiogram recordings, there are doubts about compatibility of BAT and S-ICD devices. CASE DESCRIPTION: A 54-year-old male patient with dilated cardiomyopathy and severely reduced left ventricular ejection fraction received an S-ICD after recurrent systemic infections due to a diabetic foot syndrome, ultimately associated with infective endocarditis. Since medical HF therapy could not be further optimized and the patient presented with persistent cardiac decompensations, he was evaluated for BAT. Preoperatively, the barostim was epicutaneously placed on the patient's thorax with conductive gel in order to evaluate a possible interference with the S-ICD. Positioning of the barostim in loco typico did not affect the S-ICD's sensing in any vector. Only positioning of the carotis sinus lead directly upon the S-ICD lead, which is beyond clinical relevance, lead to missensing. Subsequently, BAT was implanted with successful perioperative testing of the S-ICD: there was accurate detection of ventricular fibrillation and immediate termination via first shock delivery under maximum barostim output. CONCLUSIONS: To our knowledge, there are no other reports in which a barostim was safely implanted in a patient with a preexisting S-ICD. Until data with large patient numbers are available, individual perioperative testing is highly recommended.

Safety of the Wearable Cardioverter Defibrillator (WCD) in Patients with Implanted Pacemakers.

BACKGROUND: The wearable cardioverter defibrillator (WCD) is an important approach for better risk stratification, applied to patients considered to be at high risk of sudden arrhythmic death. Patients with implanted pacemakers may also become candidates for use of the WCD. However, there is a potential risk that pacemaker signals may mislead the WCD detection algorithm and cause inappropriate WCD shock delivery. The aim of the study was to test the impact of different types of pacing, various right ventricular (RV) lead positions, and pacing modes for potential misleading of the WCD detection algorithm. METHODS: Sixty patients with implanted pacemakers received the WCD for a short time and each pacing mode (AAI, VVI, and DDD) was tested for at least 30 seconds in unipolar and bipolar pacing configuration. In case of triggering the WCD detection algorithm and starting the sequence of arrhythmia alarms, shock delivery was prevented by pushing of the response buttons. RESULTS: In six of 60 patients (10%), continuous unipolar pacing in DDD mode triggered the WCD detection algorithm. In no patient, triggering occurred with bipolar DDD pacing, unipolar and bipolar AAI, and VVI pacing. Triggering was independent of pacing amplitude, RV pacing lead position, and pulse generator implantation site. CONCLUSION: Unipolar DDD pacing bears a high risk of false triggering of the WCD detection algorithm. Other types of unipolar pacing and all bipolar pacing modes do not seem to mislead the WCD detection algorithm. Therefore, patients with no reprogrammable unipolar DDD pacing should not become candidates for the WCD.

Barostim Implantation with Ipsilateral Carotid Endarterectomy as a One-Stage Procedure.

Clinical trials have demonstrated significant and lasting reductions in arterial pressure from baroreflex activation therapy (BAT), resulting from electrical stimulation of the carotid sinus in patients with resistant arterial hypertension. Significant carotid atherosclerosis, however, has been a contraindication for ipsilateral implantation due to a potentially increased risk of periprocedural stroke and uncertain antihypertensive efficacy. Here, we describe the first case in which BAT was applied safely and effectively in a patient with distinct cerebral arteriosclerosis after ipsilateral carotid endarterectomy as a one-stage procedure without neurologic complications. BAT resulted in satisfactory blood pressure levels despite distinct cerebral atherosclerosis after an 18-month follow-up period.

Rescue baroreflex activation therapy after Stanford B aortic dissection due to therapy-refractory hypertension.

Clinical trials have demonstrated significant and durable reduction in arterial pressure from baroreflex activation therapy (BAT) in patients with resistant arterial hypertension. There is a lack of data, however, concerning the use of BAT in a rescue approach during therapy-refractory hypertensive crisis resulting in life-threatening end-organ damage. Here, we describe the first case in which BAT was applied as a rescue procedure in an intensive care setting after ineffective maximum medical treatment. A 34-year-old male patient presented with Stanford B aortic dissection and hypertensive crisis. The dissection membrane extended from the left subclavian artery down to the right common iliac artery, resulting in a total arterial occlusion of the right leg. After emergency thoracic endovascular aortic repair and femorofemoral crossover bypass, the patient developed a compartment syndrome of the right lower limb, ultimately leading to amputation of the right leg above the knee. Even under deep sedation recurrent hypertensive crises of up to 220 mm Hg occurred that could not be controlled by eight antihypertensive drugs of different classes. Screening for secondary hypertension was negative. Eventually, rescue implantation of right-sided BAT was performed as a bailout procedure, followed by immediate activation of the device. After a hospital stay of a total of 8 weeks, the patient was discharged 2 weeks after BAT initiation with satisfactory blood pressure levels. After 1-year follow-up, the patient has not had a hypertensive crisis since the onset of BAT and is currently on fourfold oral antihypertensive therapy. The previously described bailout procedures for the treatment of life-threatening hypertensive conditions that are refractory to drug treatment have mainly comprised the interventional denervation of renal arteries. The utilization of BAT is new in this emergency context and showed a significant, immediate, and sustained reduction of blood pressure levels after activation. To our knowledge, we report the first case of an immediate activation of a barostim while the device is usually not activated before 2 to 4 weeks after implantation to allow time for the surgical site to heal. During the follow-up period, the healing process was not impaired, and a significant, immediate, and sustained reduction of blood pressure levels after activation could be observed. This treatment option offers maximum adherence to antihypertensive therapy to avoid future cardiovascular end-organ damage and possibly reduce antihypertensive medication and undesirable side effects.

Atrial Fibrillation and Renal Disease.

Co-incidence of atrial fibrillation and renal dysfunction in general population is described in many epidemiological studies. Major issue is optimal anticoagulation in patients with atrial fibrillation and renal disease warranting balance between risks of ischemic stroke and hemorrhages. The second issue is catheter ablation of AF patients with renal dysfunction. Both issues are discussed in this paper.

Multi-detector computed tomography is equivalent to trans-oesophageal echocardiography for the assessment of the aortic annulus before transcatheter aortic valve implantation.

OBJECTIVES: In transcatheter aortic valve implantation (TAVI), assessment of the aortic annulus is mandatory. We sought to investigate the correlation between trans-oesophageal echocardiography (TEE) and multi-detector computed tomography (MDCT) for annulus diameter assessment before TAVI. METHODS: A total of 122 patients (67 male, mean age 84 ± 6 years) underwent MDCT and TEE for TAVI planning. In TEE annulus diameters were obtained in a long-axis view at diastole. MDCT data were evaluated using MPR images, and corresponding projections were adjusted for MDCT and TEE. Patients were classified by the predominant localisation of aortic valve calcifications, and annulus diameters between TEE and MDCT were correlated. Additionally, the eccentricity of the aortic annulus was calculated. RESULTS: Mean eccentricity of the aortic annulus determined by MDCT was 0.34 ± 0.17, with no difference according to valve calcification. Regarding the aortic annulus diameter, the mean values measured were 24.3 ± 2.1 mm in MDCT and 24.0 ± 2.5 mm in TEE (P < 0.0001 for agreement). CONCLUSIONS: Independent of the pattern of aortic valve calcification, close correlation is found between CT and TEE measurements of the aortic annulus diameter. In addition, CT demonstrates the non-circular shape of the aortic annulus. KEY POINTS: Accurate assessment of aortic annulus before transcatheter aortic valve implantation is crucial. Trans-oesophageal echocardiography has been the preferred method for aortic annulus assessment. We demonstrated a strong correlation between TEE and CT for annulus dimensions. CT reliably demonstrates the non-circular shape of the aortic annulus. CT could therefore be generally used for aortic annulus assessment before TAVI.

Arrhythmic death in implantable cardioverter defibrillator patients: a long-term study over a 10 year implantation period.

AIMS: Evaluation of cause-specific mortality in a large cohort of unselected implantable cardioverter defibrillator (ICD) recipients. METHODS AND RESULTS: Causes of death of consecutive ICD recipients implanted over a 10 year period were analysed. Overall 822 patients (age 63 +/- 11 years, 80% male, EF 34 +/- 14%, secondary prevention 65%) were followed for 43 +/- 30 months during which time 225 patients died (annual mortality 7.6%). Causes of death were cardiac arrhythmic in 16%, cardiac non-arrhythmic in 39%, non-cardiac vascular in 4%, non-cardiovascular in 27%, and unknown in 13%. Advanced age [relative risk (RR) 1.23 per decades, 95% confidence interval (CI) 1.06-1.43], NYHA class >II (RR 2.27, 95% CI 1.51-3.41), renal failure (RR 1.57, 95% CI 1.15-2.14), use of amiodarone (RR 2.56, 95% CI 1.91-3.43), digitalis (RR 1.87, 95% CI 1.40-2.49), diuretics (RR 1.89, 95% CI 1.35-2.66) were independent predictors of all-cause mortality. Predictors for arrhythmic mortality were NYHA class >II (RR 12, 95% CI 3.69-37.5), spontaneous or inducible VT as indication for ICD therapy (RR 2.53, 95% CI 1.06-6.05), and use of amiodarone (RR 3.95, 95% CI 2.02-7.75). CONCLUSION: In this unselected group of ICD recipients, at least 16% of patients died from arrhythmic causes. Risk factors associated with arrhythmic mortality were a history of spontaneous or inducible VT, higher NYHA class, and amiodarone use.

Cardiovascular risk factors in idiopathic compared to risk-associated venous thromboembolism: A focus on fibrinogen, factor VIII, and high-sensitivity C-reactive protein (hs-CRP).

There have recently been reports of an increased incidence of arterial cardiovascular events in patients with idiopathic venous thromboembolism (VTE) compared to patients with risk-associated VTE. The aim of our study was to evaluate whether elevated clotting factors, which have been linked to chronic sub-clinical inflammation and arterial thromboembolic disease, have a higher prevalence in idiopathic VTE compared to secondary VTE. Plasma fibrinogen, factor VIII, and high-sensitivity C-reactive protein (hs-CRP) levels were determined in a cohort of sex- and age-matched patients with unprovoked VTE (n=101), patients with secondary VTE (n=101), and controls (n=202). Fibrinogen and hs-CRP levels were higher in patients with idiopathic VTE (fibrinogen: median/range: 331/214-524 mg/dl; hs-CRP: median/interquartile range: 1.8/0.8-3.7 mg/l) than in those with risk-associated VTE (299/162-458 mg/dl, p=0.004; 1.5/0.8-2.2 mg/l, p=0.05) and controls (302/185-644 mg/dl, p=0.001; 1.2/0.5-2.2 mg/l, p=0.02). Fibrinogen levels in the upper tertile of the controls were seen in 53% of patients with unprovoked VTE, compared to 35% of patients with secondary VTE. According to their hs-CRP levels (>3 mg/l), 26% of patients with idiopathic VTE were categorised as being at high risk for cardiovascular disease, as opposed to just 9% of those with risk-associated VTE. Factor VIII activity was significantly higher in patients with both idiopathic and secondary VTE than in controls, with the highest median value in patients with idiopathic VTE. Our data show that markers of inflammation, such as hs-CRP, fibrinogen, and factor VIII, are at higher levels in patients with idiopathic compared to secondary VTE, supporting the hypothesis that idiopathic VTE and arterial thromboembolism share common risk factors.

Intrinsic clotting factors in dependency of age, sex, body mass index, and oral contraceptives: definition and risk of elevated clotting factor levels.

Elevated clotting factors have been demonstrated to be a risk factor for venous thromboembolism (VTE). The aim of our study was to investigate the impact of age, sex, body mass index, and oral contraceptives on the clotting factor activities of factors VIII, IX, XI, and XII and their impact on the cutoff definition and risk of VTE associated with elevated clotting factors. Factor VIII, IX, XI, and XII activities were measured in 499 blood donors and 286 patients with VTE. Age and body mass index predicted significantly and independently the clotting factor activities of factors VIII, IX, and XI, whereas use of oral contraceptives predicted factor IX, XI, and XII levels. Percentiles of clotting factor activities, which are often used for the cutoff definition of elevated clotting factors, varied due to the effect of age, body mass index, and oral contraceptives. The adjusted odds ratios for VTE were 10.3 [95% confidence interval (CI) 5.1-20.7], 6.1 (95% CI 3.1-12.0), and 3.3 (95% CI 1.9-5.8) for elevated factors VIII, IX, and XI, respectively. Furthermore, our study demonstrates for the first time that elevated factor XII is associated with an increased risk of VTE (adjusted odds ratio 2.9, 95% CI 1.6-5.3).

Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications.

Atrial fibrillation (AF), the most commonly encountered clinical arrhythmia, often complicates acute myocardial infarction (AMI) with an incidence between 6 and 21%. Predictors of the arrhythmia in the setting of AMI include advanced age, heart failure symptoms, and depressed left ventricular function. The bulk of evidence demonstrates that AF in patients hospitalized for AMI has serious adverse prognostic implications regarding in-hospital, but also long-term mortality. This seems to apply for all patient populations studied without significant differences related to the treatment of AMI (i.e. no reperfusion therapy vs. thrombolysis vs. percutaneous coronary intervention). Mortality is particularly high in patients who have congestive heart failure and/or a reduced left ventricular ejection fraction. Finally, there are persuasive data indicating that AF complicating AMI not only increases the risk for ischaemic stroke during hospitalization but also during follow-up. This seems to apply also for transient AF which has reversed back to sinus rhythm at the time of discharge. These observations emphasize the need for prospective studies evaluating optimal therapeutic approaches for patients with AMI complicated by AF.

Complications leading to surgical revision in implantable cardioverter defibrillator patients: comparison of patients with single-chamber, dual-chamber, and biventricular devices.

AIMS: Implantable cardioverter defibrillator (ICD) technology has become more complex, particularly with respect to biventricular resynchronization devices. The incidence of hardware-related complications in single (SC)-, dual (DC)-, and triple (BiV)-chamber devices requiring surgical revision has not been investigated systematically. METHODS AND RESULTS: We analysed data from consecutive ICD recipients implanted between January 2000 and December 2007 with respect to the need of surgical re-intervention for device- or lead-related complications. Generator exchanges due to normal battery depletion were not considered. From 816 patients (81% male, 69% ischaemic cardiomyopathy, 48% secondary prevention ICDs) followed for 31 +/- 24 months (2118 cumulative patient-years), 98 patients underwent 110 revisions (5.2% per patient-year). Complications included lead-related revision procedures in 81 cases and generator-related problems in 29 cases. The annual incidence of surgical revision due to complications was 11.8% in BiV compared with 4.9% in SC and 4.1% in DC patients (P = 0.002). This higher revision rate was mainly caused by lead-related complications. Implantation of a BiV system was an independent risk factor of the need for surgical revision (relative risk 2.37, 95% confidence interval 1.38-4.04). CONCLUSION: Even with long-lasting operator experience, complications requiring surgical revision remain a clinically important problem of ICD therapy. The incidence of complications is significantly higher in BiV resynchronization devices than in SC and DC systems.