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.

Comparing phase and electrographic flow mapping for persistent atrial fibrillation.

BACKGROUND: An increasing number of methods are being used to map atrial fibrillation (AF), yet the sensitivity of identifying potential localized AF sources of these novel methods are unclear. Here, we report a comparison of two approaches to map AF based upon (1) electrographic flow mapping and (2) phase mapping in a multicenter registry of patients in whom ablation terminated persistent AF. METHODS: Fifty-three consecutive patients with persistent AF in whom ablation terminated AF in an international multicenter registry were enrolled. Electrographic flow mapping (EGF) and phase mapping were applied to the multipolar simultaneous electrograms recorded from a 64-pole basket catheter in the chamber (left vs right atrium) where AF termination occurred. We analyzed if the mapping methods were able to detect localized sources at the AF termination site. We also analyzed global results of mapping AF for each method, patterns of activation of localized sources. RESULTS: Patients were 64.3 ± 9.4 years old and 69.8% were male. EGF and phase mapping identified localized sources at AF termination sites in 81% and 83% of the patients, respectively. Methods were complementary and in only n = 2 (3.7%) neither method identified a source. Globally, EGF identified more localized sources than phase mapping (5.3 ± 2.8 vs 1.8 ± 0.5, P < 0.001), with a higher prevalence of focal (compared to rotational) activation pattern (49% vs 2%, P < 0.01). CONCLUSIONS: EGF is a novel vectorial-based AF mapping method, which can detect sites of AF termination, agreeing with, and complementary to, an alternative AF mapping method using phase analysis.

[Electrical isolation of the left atrial appendage : Benefits and risks]. / Elektrische Isolation des linken Vorhofohrs : Nutzen und Risiko.

The left atrial appendage (LAA) is an extension originating from the body of the left atrium. The LAA is derived from the primary atrium and shows anatomical and physiological deviations from the left atrium. Different LAA morphologies exist. The LAA is not only the most frequent origin of intracardiac thrombi, it also frequently shows triggers responsible for the initiation or maintenance of atrial tachyarrhythmia and atrial fibrillation (AF). Isolation of the LAA using radiofrequency energy in addition to isolation of the pulmonary vein has recently gained importance due to the potential for increasing the clinical success rates, particularly in patients with persistent and long-standing persistent AF; however, after LAA isolation the incidence of LAA thrombi and systemic thromboembolisms might be increased even under treatment with oral anticoagulants, depending on the ablation strategy used. Thus, mechanical occlusion of the LAA should be discussed with patients after electrical isolation of the LAA.

[Interventional stroke prophylaxis : endocardial and epicardial left atrial appendage closure]. / Interventionelle Schlaganfallprophylaxe : Endokardialer und epikardialer Vorhofohrverschluss.

Atrial fibrillation (AF) is currently one of the major causes of ischemic stroke with an estimated stroke risk of 5% per year. Oral anticoagulation is an effective treatment for the reduction of stroke risk in patients with AF but is also associated with an increased risk of bleeding. In patients with AF it has been shown that left atrial thrombi can be identified within the left atrial appendage (LAA) in more than 90% of cases. On the basis of these findings LAA closure devices have been developed as an alternative to oral anticoagulation. Besides endocardial LAA occluders, such as the WATCHMAN™ and AMPLATZER™ devices, an epicardial LAA occluder (LARIAT™) has recently been introduced. The following review introduces the various endocardial and epicardial LAA closure devices and assesses the indications, management, advantages and disadvantages of the two approaches according to the current literature.

[Syncope : epidemiology, definition, classification, pathophysiology and prognosis]. / Synkope : Epidemiologie, Definition, Klassifikation, Pathophysiologie und Prognose.

Syncope is a common clinical issue. Around 40 % of the total population experience syncope during their lifetime. Serious injuries and reduced quality of life are often observed after syncope. Furthermore, in some cases syncope can be associated with an unfavorable prognosis. Due to the complex etiology and pathophysiology, syncope provides challenges for doctors both in private and in clinical practices. This review is based on the latest European guidelines for syncope which were formulated by internists, neurologists, emergency physicians and cardiologists and gives an overview of the current epidemiology, definition, classification, pathophysiology and prognosis of syncope.

Incidence of MRI-detected brain lesions and neurocognitive function after electrical cardioversion in anticoagulated patients with persistent atrial fibrillation.

BACKGROUND: After electrical cardioversion (eCV) in patients with atrial fibrillation (AF), the risk for clinically apparent cerebral thromboembolism is increased in the subsequent weeks. To date, there is little evidence on the incidence of acute brain lesions (ABL) detected with cerebral magnetic resonance imaging (MRI) after eCV, in particular in patients treated with the Non-Vitamin K Antagonist oral anticoagulants (NOAC). AIMS: The aim of this pilot study was to evaluate the incidence of MRI-detected ABL, as well as the neuro-cognitive function after eCV in patients with persistent AF using NOACs as compared to phenprocoumon. METHODS AND RESULTS: 50 consecutive patients with persistent AF (mean age 69.6±3.5years, 26 male) were evaluated in this prospective study. Cerebral 3Tesla MRI and neuro-cognitive assessment using the National Institutes of Health Stroke Scale (NIHSS) score and the Montreal Cognitive Assessment Test (MoCA) were performed in all patients within 24h before eCV and after a median follow-up duration of 14days (Q1: 13, Q3: 19days). Patients were treated with an OAC for at least 4weeks after eCV and according to the CHA2DS2-Vasc-score thereafter. Thirty-nine patients were treated with NOACs (Dabigatran 10/50 [20%], Apixaban 21/50 [42%] and Rivaroxaban 8/50 [16]) and 11/50 patients with Phenprocoumon (22%). No patient developed ABL on cerebral MRI at the 2-week follow-up. Neurological as well as cognitive function were similar before and 2weeks after eCV (NIHSS-score: p=0.35; MoCa score: p=0.21). CONCLUSION: Electrical CV in patients with persistent AF, in particular when treated with NOACs, carries a low risk for the development of MRI-detected ABL or neurocognitive decline. CLINICAL TRIALS REGISTRATION: GermanClinicalTrialsRegister number: DRKS00010460.

Structured diabetes therapy and education improves the outcome of patients with insulin treated diabetes mellitus. The 10 year follow-up of a prospective, population-based survey on the quality of diabetes care (the JEVIN Trial).

AIMS/HYPOTHESIS: JEVIN (Jena's St. Vincent Trial) is a prospective, 10 year follow-up, population-based survey of all insulin treated patients with type 1 and type 2 diabetes mellitus aged 16 to 60 years and living in the city of Jena (100,000 inhabitants), Thuringia, Germany. It aims to show the effects of implementation of the St. Vincent Declaration and to evaluate the effect of recent changes in the health care system and new treatment strategies. PATIENTS AND METHODS: 190 patients (83% of the target population), 244 patients (90%) and 261 patients (90%) were studied in 1989/90, 1994/95 and 1999/2000, respectively. RESULTS: Up to 1994/95, the HbA1c of patients with type 1 diabetes mellitus increased (1994/95: 8.50+/-1.80% versus 1989/90: 7.83+/-1.60%, p=0.002). For patients with type 2 diabetes mellitus, it remained constant (9.01+/-2.06% versus 9.17+/-1.60%, n. s.). During the period from 1994/95 to 1999/2000, there was a substantial improvement in the relative HbA1c of both, patients with type 1 (7.62+/-1.55%, p<0.0001), and with type 2 diabetes (7.57+/-1.29%, p<0.0001). Up to 1999/2000, 87.7% of the patients with type 1 (1989/90: 0%, 1994/95: 73.2%) and 96.6% of the patients with type 2 diabetes (1989/90: 0%, 1994/95: 89.7%) participated in TTP's. The incidence of acute and the prevalence of long-term complications remained constant. CONCLUSIONS: Results of the population-based, prospective trial to optimise patients' quality of diabetic control suggest: For patients with insulin treated type 2 diabetes mellitus, excellent treatment can be available by primary care physicians interested, educated and highly engaged in diabetes therapy. Moreover, structured diabetes therapy consisting of treatment and teaching programmes, regular self-monitoring, patients' insulin dose adjustment and patients' empowerment, should be offered to all patients with diabetes mellitus.