Differences in clinical and echocardiographic parameters between paroxysmal and persistent atrial flutter in the AURUM 8 study: targets for prevention of persistent arrhythmia?

PURPOSE: Cavotricuspid isthmus-dependent atrial flutter (AFL) can occur in a paroxysmal or persistent pattern. The aim of this study was to identify clinical, echocardiographic, and electrophysiological risk factors independently associated with persistence of AFL. METHODS: Patients of the recently published AURUM 8 study with paroxysmal versus persistent AFL were compared with respect to clinical and echocardiographic baseline characteristics as well as procedural parameters. The AURUM 8 study is a randomized, multicenter clinical trial comparing the efficacy and safety of gold versus platinum-iridium 8-mm-tip ablation. AFL was paroxysmal in 218 patients and persistent in 210 patients. RESULTS: Univariate analysis revealed that patients with persistent AFL had higher New York Heart Association class (P = 0.002), shorter time since 1st AFL episode (median 0.18 vs 0.34, P = 0.037), a higher prevalence of previous coronary artery bypass grafting surgery (17% vs 9%, P = 0.02), left ventricular hypertrophy (17% vs 8%, P = 0.005), dyspnea during AFL (P < 0.001), mitral regurgitation (P = 0.002), tricuspid regurgitation (P = 0.049), and pulmonary hypertension (P = 0.01). Palpitations during AFL were less frequent in patients with persistent AFL (P = 0.001). Multivariate analysis revealed that age, weight, AFL diagnosis after initiation of class IC or III antiarrhythmic drugs for atrial fibrillation, history of left ventricular hypertrophy, dyspnea during AFL and mitral regurgitation on echocardiography were significant independent variables associated with persistent AFL. A history of atrial fibrillation and palpitations during AFL were independently associated with paroxysmal AFL. CONCLUSIONS: We were able to identify clinical and echocardiographic risk factors associated with persistence of typical AFL. Treatment of these risk factors can potentially not only prevent the transition from paroxysmal to persistent AFL, but maybe also the development or initiation of AFL in general.

"Largest amplitude ablation" is the optimal approach for typical atrial flutter ablation: a subanalysis from the AURUM 8 study.

INTRODUCTION: The recently proposed "maximum voltage-guided" (MVG) technique for radiofrequency catheter ablation of atrial flutter targets high-voltage electrograms along cavotricuspid isthmus (CTI) to ablate the functionally important anatomic muscle bundles alone, without drawing a complete anatomic line across the CTI. This innovative approach may shorten ablation time and procedure duration. METHODS AND RESULTS: Within the multicenter AURUM 8 study, which compared 8-mm gold- and Pt-Ir-tip catheters in atrial flutter ablation, we made a post hoc comparison of procedural data from 72 patients treated with MVG technique with data from 281 patients undergoing anatomic CTI ablation (unmatched) and with data from 72 patients selected from among those 281 patients such that they were matched with the MVG group with respect to selected baseline parameters and catheter type (matched). The MVG technique markedly reduced (P < 0.001) ablation time (mean 6.9 minutes vs 10.9/9.7 minutes [unmatched/matched]), number of lesions (8.3 vs 13.7/12.9), fluoroscopy time (9.5 minutes vs 20.6/17.9 minutes), procedure duration (59 minutes vs 93/86 minutes), and energy delivered (19 kJ vs 34/30 kJ) compared with anatomic CTI ablation. The incidence of charring was higher for MVG than for anatomic ablation technique (31.9% vs 18.5/15.3%, P < 0.05), where Pt-Ir tip catheters were 6-fold more susceptible to charring than gold-tip catheters (P < 0.001), likely because of a lower thermal conductivity of the Pt-Ir material. The acute success rate was slightly better for MVG than for anatomic ablation technique (97.2% vs 92.2/91.7%, P = n.s.). CONCLUSION: Major procedural parameters are remarkably improved with MVG technique. Gold-tip catheters are substantially less susceptible to charring and may therefore be preferred over Pt-Ir-tip catheters for MVG ablation technique.

Incidence of lead erosion in a real-world cohort and a case of successful treatment with an antimicrobial mesh.

Cardiac implantable electronic device (CIED)-related infections are a major complication of CIED therapy and associated with high morbidity and mortality. The aim of the present study was to evaluate the incidence of lead erosion as one cause of the CIED-related infections and to provide detailed information about the therapy of two cases of lead erosion. We retrospectively screened the database of a large clinic specialized on patients with CIED (HIZ BERLIN Herzschrittmacher- und ICD-Zentrum, Berlin, Germany) for cases of lead erosion between 2015 and 2020. A total of 5971 outpatients were treated at the HIZ BERLIN - including 4782 patients with a one- or two-chamber pacemaker, 837 patients with an implantable cardioverter defibrillator (ICD) and 352 patients with a biventricular device for cardiac resynchronization therapy (CRT). The incidence of lead erosion was 0.033%. As one of the two patients, who suffered from lead erosions, had no signs of systemic infection, the patient received local therapy with an antimicrobial mesh and intravenous antibiotics. After twelve months, he showed a good clinical outcome without ongoing or recurring infection. In conclusion, the incidence of lead erosion is low. In case of lead erosions without signs of systemic infection, an antimicrobial mesh might be implanted as an off-label use in patients that decline complete device removal.

[Acute rheumatic fever (ARF) in an adult male]. / Akutes rheumatisches Fieber (ARF) bei einem erwachsenen Mann.

Acute rheumatic fever (ARF) results from an autoimmune reaction following Streptococcus pyogenes-induced tonsilitis. It is a disease that has become uncommon in Germany and is rare in adults. Treatment recommendations are controversial in this age group. The case of a 29-year-old male with ARF following tonsillitis due to S. pyogenes treated with penicillin and amoxicillin/clavulanic acid in the setting outpatient is reported. After 6 weeks, the patient presented to hospital with elevated body temperature, painless red-livid skin lesions, and polyarthritis. Laboratory results showed elevated inflammatory parameters and antistreptolysin O titers. The Jones criteria for ARF were met. Symptoms improved rapidly under therapy with nonsteroidal anti-inflammatory drugs. Antibiotic prophylaxis was not given, but regular echocardiographic controls remained non-pathologic over 12 months.

Comparison of skin adhesive and absorbable intracutaneous suture for the implantation of cardiac rhythm devices.

AIMS: Wound healing is a major determent in the post-surgical course of patients (pts) after pacemaker (PM) and implantable cardioverter defibrillator (ICD) implantation. Insufficient closure may lead to serious complications with pocket infections leading to the device's explantation as the worst case scenario. In addition to the different types of suture and suture clips, a novel topical skin adhesive containing 2-octyl-cyanoacrylate is commercially available. METHODS AND RESULTS: Over a period of 18 months, we prospectively assigned all cases of PM, ICD, and loop recorder implants either to skin adhesive (Group 1) or to absorbable intracutaneous polydioxanon suture (Group 2). Data were analysed with respect to operation time, wound infections, and healing disorders. One hundred and eighty-three pts were randomized into Group 1 [71 PMs, 60 ICD, 15 cardiac resynchronization therapy (CRT), 11 loop recorders, and 26 generator replacements]. One hundred and eighty-five pts were assigned to Group 2 (62 PMs, 70 ICD, 30 CRT, 7 loop recorders, and 16 generator replacements). There were no differences regarding sex, diabetes, renal insufficiency, corticosteroid therapy, oral anticoagulants, and acetylsalicylic asa/clopidogrel (P = n.s.). For the significantly higher amount of CRT devices (P < 0.05) in Group 2, the procedure times are given for surgeries except CRT. It was 49.1 ± 27.7 min for Group 1 and 53.4 ± 31.9 min for Group 2 (P = n.s.). Adverse events as insufficient closure, major and minor bleeding, pocket haematoma, erythema, incrustation, dehiscence, keloid, and explantation due to infection occurred significantly more often in the adhesive group (P = 0.02). The greatest impact on this result had early adverse events as insufficient closure, wound incrustation, and inflammation (9.3 vs. 6.0%; P = 0.02). We did not find any difference in long-term adverse events, infections in particular (2.7 vs. 1.6%; P = 0.47). CONCLUSION: This study shows no benefit using skin adhesive in comparison to absorbable intracutaneous suture regarding surgery times for the implantation of cardiac rhythm devices. The rate of early adverse events after wound closure is higher after skin adhesive but no difference in long-term adverse events occurred.

Gold vs. platinum-iridium tip catheter for cavotricuspid isthmus ablation: the AURUM 8 study.

AIMS: Gold electrodes have the theoretical advantage of creating bigger lesions than platinum-iridium (Pt-Ir) electrodes. We performed a prospective randomized study to compare the clinical efficacy of standard 8 mm Pt-Ir tip catheter (control) and 8 mm gold-tip catheters in the ablation of the cavotricuspid isthmus (CTI)-dependent atrial flutter. METHODS AND RESULTS: A total of 463 patients undergoing CTI ablation in 19 clinical centres were randomized to receive the treatment by gold-tip or control catheter. The primary endpoint was cumulative radiofrequency (RF) application duration until achieving bidirectional CTI block. It did not differ significantly for the two catheters. The gold-tip catheter was, however, associated with a higher ablation success rate (94.3 vs. 89.0%, P = 0.042) and a substantially lower incidence of char and coagulum formation (4.8 vs. 37.9%, P < 0.001), which required exchange of 1 gold-tip (0.4%) and 10 control catheters (4.6%, P = 0.005). The gold-tip catheter delivered more mean power (52 ± 12 W) than the control catheter (48 ± 13 W, P < 0.001). Both mean and maximum temperatures measured by the thermocouple integrated in the catheter tip were statistically significantly lower in the gold (mean: 53.2 ± 4.7°C, max: 68.7 ± 6.6°C) than in the control catheter (54.3 ± 5.2 and 70.2 ± 7.0°C, respectively, P < 0.05). Fluoroscopy time, procedure duration, procedural-related complications, and arrhythmia recurrence during 6 months of follow-up did not differ between the two catheters. CONCLUSION: Owing to a higher primary ablation success rate and reduced incidence of char/coagulum formation, gold may be preferred over Pt-Ir as electrode material for 8 mm tip catheters for CTI ablation. ClinicalTrials.gov: NCT00326001 (http://clinicaltrials.gov/ct2/show/NCT00326001).

Ventricular fibrillation and Takotsubo cardiomyopathy triggered by media panic on COVID-19: A case report.

Takotsubo cardiomyopathy has potentially lethal complications and can be caused by a media-induced diffuse atmosphere of life threatening and panic in preconditioned patients.

Polymorphisms associated with ventricular tachyarrhythmias: rationale, design, and endpoints of the 'diagnostic data influence on disease management and relation of genomics to ventricular tachyarrhythmias in implantable cardioverter/defibrillator patients (DISCOVERY)' study.

Implantable cardioverter-defibrillator (ICD) therapy is effective in primary and secondary prevention for patients who are at high risk of sudden cardiac death. However, the current risk stratification of patients who may benefit from this therapy is unsatisfactory. Single nucleotide polymorphisms (SNPs) are DNA sequence variations occurring when a single nucleotide in the genome differs among members of a species. A novel concept has emerged being that these common genetic variations might modify the susceptibility of a certain population to specific diseases. Thus, genetic factors may also modulate the risk for arrhythmias and sudden cardiac death, and identification of common variants could help to better identify patients at risk. The DISCOVERY study is an interventional, longitudinal, prospective, multi-centre diagnostic study that will enrol 1287 patients in approximately 80 European centres. In the genetic part of the DISCOVERY study, candidate gene polymorphisms involved in coding of the G-protein subunits will be correlated with the occurrence of ventricular arrhythmias in patients receiving an ICD for primary prevention. Furthermore, in order to search for additional sequence variants contributing to ventricular arrhythmias, a genome-wide association study will be conducted if sufficient a priori evidence can be gathered. In the second part of the study, associations of SNPs with ventricular arrhythmias will be sought and a search for potential new biological arrhythmic pathways will be investigated. As it is a diagnostic study, DISCOVERY will also investigate the impact of long-term device diagnostic data on the management of patients suffering from chronic cardiac disease as well as medical decisions made regarding their treatment.

Potential role of home monitoring to reduce inappropriate shocks in implantable cardioverter-defibrillator patients due to lead failure.

AIMS: Lead dysfunctions in implantable cardioverter-defibrillator (ICD) patients can lead to inappropriate shocks or even complete loss of function of the device. Home monitoring (HM) systems are capable of daily data transmissions regarding the device and the lead integrity as well as information concerning anti-arrhythmic therapies. We therefore analysed the data from the Biotronik HM system whether it enables physicians to react quickly on serious ICD malfunctions and to avoid inappropriate shocks. METHODS AND RESULTS: Fifty-four patients who had to undergo resurgery due to malfunctions of the ICD lead were included. Eleven of them were on HM interrogating the device every night at 3 am. If any adverse event was detected, a fax alert was sent to the clinic and the patients were asked for in-hospital ICD interrogation. The rate of inappropriate shocks and symptomatic pacemaker inhibition due to oversensing was compared with the 43 patients without remote surveillance. HM sent alert messages in 91% of all incidents. All lead failures became obvious because of oversensing of high frequency artefacts. Only in 18%, changes in the pacing impedance were noticed, in all cases preceded by oversensing. Eighty per cent of the patients were asymptomatic at the first onset of oversensing. Only one patient suffered an inappropriate shock as first manifestation of lead failure. Compared with the patients without HM, inappropriate shocks occurred in 27.3% in the HM group vs. 46.5% (P = n.s.). This trend gains statistical significance, if the compound endpoint of symptomatic lead failure consisting of inappropriate shocks and symptomatic pacemaker inhibition due to oversensing is focused: 27.3% event in the HM group vs. 53.4% in the group without HM (P = 0.04). Event messages were despatched in a mean of 54 days after the last ICD interrogation and 56 days before next scheduled visit. Thus, 56 days of reaction time are gained to avoid adverse events. CONCLUSION: In 91% of all lead-related ICD complications, the diagnosis could be established correctly by an alert of the HM system. Mostly, the first incident sent was oversensing of artefacts, falsely detected as ventricular fibrillation-the VF zone. The automatic HM surveillance system enables physicians to detect severe lead problems early and to react quickly; thus, it might have a potential to avoid inappropriate shocks due to lead failure and T-wave oversensing.

Cardiac resynchronization therapy in a patient with a mitral annuloplasty device.

We present a case of a 58-year-old man. Due to high-degree mitral regurgitation an anuloplasty device (MONARCtrade mark) was inserted. During continuous pacing, inter- and intraventricular asynchrony occurred and heart failure worsened. The indication for cardiac resynchronization was established. A biventricular ICD was successfully inserted with the left ventricular approach via the coronary sinus over the MONARCtrade mark device (Edward Lifescience, Irvine, CA, USA). Biventricular pacing significantly shortened the QRS duration and improved the clinical status as well as the 6-minute walking test.

Polymorphisms in the GNAS Gene as Predictors of Ventricular Tachyarrhythmias and Sudden Cardiac Death: Results From the DISCOVERY Trial and Oregon Sudden Unexpected Death Study.

BACKGROUND: Population-based studies suggest that genetic factors contribute to sudden cardiac death (SCD). METHODS AND RESULTS: In the first part of the present study (Diagnostic Data Influence on Disease Management and Relation of Genetic Polymorphisms to Ventricular Tachy-arrhythmia in ICD Patients [DISCOVERY] trial) Cox regression was done to determine if 7 single-nucleotide polymorphisms (SNPs) in 3 genes coding G-protein subunits (GNB3, GNAQ, GNAS) were associated with ventricular tachyarrhythmia (VT) in 1145 patients receiving an implantable cardioverter-defibrillator (ICD). In the second part of the study, SNPs significantly associated with VT were further investigated in 1335 subjects from the Oregon SUDS, a community-based study analyzing causes of SCD. In the DISCOVERY trial, genotypes of 2 SNPs in the GNAS gene were nominally significant in the prospective screening and significantly associated with VT when viewed as recessive traits in post hoc analyses (TT vs CC/CT in c.393C>T: HR 1.42 [CI 1.11-1.80], P=0.005; TT vs CC/CT in c.2273C>T: HR 1.57 [CI 1.18-2.09], P=0.002). TT genotype in either SNP was associated with a HR of 1.58 (CI 1.26-1.99) (P=0.0001). In the Oregon SUDS cohort significant evidence for association with SCD was observed for GNAS c.393C>T under the additive (P=0.039, OR=1.21 [CI 1.05-1.45]) and recessive (P=0.01, OR=1.52 [CI 1.10-2.13]) genetic models. CONCLUSIONS: GNAS harbors 2 SNPs that were associated with an increased risk for VT in ICD patients, of which 1 was successfully replicated in a community-based population of SCD cases. To the best of our knowledge, this is the first example of a gene variant identified by ICD VT monitoring as a surrogate parameter for SCD and also confirmed in the general population. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00478933.

Randomized comparison of platelet-leukocyte aggregates and platelet activation in blood: heparin-coated coiled wire stent implantation versus balloon angioplasty in acute myocardial infarction.

INTRODUCTION: Stent implantation has been shown to be superior to balloon angioplasty in patients with acute myocardial infarction (AMI). Newer trials indicate that platelet-leukocyte aggregates are a more sensitive marker for platelet activation than platelet surface marker. Our study examined platelet activation and platelet-leukocyte interaction in blood in patients with AMI randomized to heparin-coated stent implantation versus balloon angioplasty. MATERIALS AND METHODS: Forty-seven patients with AMI were included into our study. Patients were randomized to heparin-coated stent implantation (n=31) or balloon angioplasty (n=16). Platelet activation, total platelet-leukocyte aggregates and aggregate composition in blood were assessed by flow cytometry before, immediately after and 24 h after intervention. RESULTS: No differences in platelet activation, total platelet-leukocyte aggregates and aggregate composition were found between both groups before intervention. Immediately after intervention, platelet activation was comparably increased in both groups. Patients treated with heparin-coated stent showed a decrease in total platelet-leukocyte aggregates 24 h after intervention (3.9% [2.8; 4.7] versus 3.2% [2.4; 4.1]; p<0.01). Platelet-monocyte conjugates decreased 24 h after heparin-coated stent implantation compared to balloon angioplasty alone (0.28% [0.17; 0.42] versus 0.49% [0.45; 0.79]; p<0.05). No difference in total platelet-leukocyte aggregates was found in patients treated with balloon angioplasty alone. CONCLUSIONS: An inhibitory effect of heparin-coated stent implantation on total platelet-leukocyte aggregates and platelet-monocyte conjugates in blood was demonstrated in patients with AMI. This reflects heparin-coated stent implantation to be less thrombogenic than balloon angioplasty alone.

Comparison of a novel, single-lead atrial sensing system with a dual-chamber implantable cardioverter-defibrillator system in patients without antibradycardia pacing indications: results of a randomized study.

BACKGROUND: Supraventricular tachyarrhythmias are the main cause for inappropriate therapy by implantable cardioverter-defibrillators (ICDs). For better rhythm discrimination, an atrial electrogram is helpful and usually obtained from an additional atrial lead, even in the absence of sinus node or atrioventricular nodal disease. An A+-ICD system with integrated atrial sensing rings mounted 15 to 18 cm from the tip of an ICD lead may obviate the need to implant a separate atrial lead. The aim of the study was to compare the novel A+-ICD and a conventional dual-chamber (DR)-ICD. METHODS AND RESULTS: Two hundred forty-nine patients with standard ICD indications but no requirement for antibradycardia pacing were randomized to receive an A+-ICD (n=124) or a DR-ICD (n=125). Implantation details, need for ICD system revision, long-term sensing, documented arrhythmia episodes, and the respective rhythm discrimination during follow-up were analyzed. The implantation time was significantly shorter in the A+-ICD group (67±30 vs 79±30 minutes, P=0.003). Mean P-wave amplitudes were 3.5±0.8 mV (A+-ICD) and 3.2±0.6 mV (DR-ICD) and remained stable during the follow-up period of 12 months. Surgical revision was necessary in 13 patients in the DR-ICD and 10 in the A+-ICD group. All 593 ventricular tachyarrhythmia episodes were correctly discriminated. Sensitivity and specificity of supraventricular tachyarrhythmia discrimination were not different between the study groups. CONCLUSIONS: The novel A+-ICD system can be implanted faster and is equivalent to a standard DR-ICD with regard to the detection of ventricular tachyarrhythmias and supraventricular tachyarrhythmias. It represents a useful alternative to obtain atrial sensing.

Limitations of the past and latest evolutions of home monitoring: arrhythmia electrograms transmitted automatically improve the efficacy of remote monitoring.

BACKGROUND: Telemetric surveillance systems are part of a well-accepted and evolving field in the care of cardiac patients. Especially in patients with implanted cardioverter-defibrillators (ICD), they are well established and their usefulness and reliability have been shown in several clinical trials. Currently, three generations of Home Monitoring™ (HM, Biotronik GmbH & Co. KG, Berlin, Germany) are commercially available. METHODS: This paper presents three cases demonstrating the various limitations of the first and second generations of HM and the way they can be overcome by the third generation. RESULTS: In the first case, atrial flutter was misinterpreted by the device and classified as ventricular tachycardia (VT). Thus, in the online IEGM, supraventricular tachycardia was identified, and the short IEGM strip and lack of transmitted atrial signals of the dual-chamber device necessitated an appointment for ICD interrogation, to clarify the diagnosis and propose further treatment. The second case is that of a patient in whom a VT was ineffectively treated by anti-tachycardia pacing (ATP) and continued with longer cycle length, leading to syncope. A second-generation HM device with online- IEGM misleadingly appears to indicate successful treatment. The third case demonstrates correct detection and therapy of a fast VT by an ICD of third-generation HM type. The online IEGM now gives all information needed for complete telemetric assessment. CONCLUSIONS: Home Monitoring (HM) is a helpful remote surveillance tool for the early detection of both arrhythmias and technical problems. As shown, the first two generations had limitations which the patient must take into account when using the system. These limitations have been overcome in the third generation, making Home Monitoring more self-sufficient and reliable.

An unusual cause of oversensing leading to inappropriate ICD discharges.

A 70 year old patient was treated with a cardioverter-defibrillator because of repetitive syncope and sustained ventricular tachycardia. Six months after implantation 49 shocks were delivered by the ICD while she was cleaning her apartment. Upon interrogation p-wave oversensing during sinus tachycardia was found to be responsible for the inappropriate shocks. The cause of the oversensing was a lead dislodgment caused by a Twiddler s Syndrome. As it turned out in the presented case, the main causes for the Twiddler s Syndrome are patients manipulate the devices and surgeons create oversized pockets. Additional predisposing factors are: psychiatric disease, weight loss, obesity, advanced age, female gender and a loop of the lead outside the pocket. The use of subfascial instead of submuscular ICD pockets may reduce the frequency of this complication but it is still crucial to avoid oversized pockets and to instruct the patients not to "play" with their device.

The amount of fibrinogen-positive platelets predicts the occurrence of in-stent restenosis.

AIMS: To determine the value of fibrinogen-positive platelet-analysis in predicting restenosis after stent implantation in acute myocardial infarction patients. METHODS AND RESULTS: Our patient population comprised 50 patients who underwent intravascular ultrasound (IVUS) guided stent implantation for acute myocardial infarction. In all cases, IVUS confirmed a deep vessel wall injury due to a ruptured plaque within the culprit lesion. Flow cytometry quantified the amount of platelets with surface-bound fibrinogen and thrombospondin before and immediately after the intervention. After 5 months, IVUS was repeated to assess the long-term results. In-stent restenosis - defined as a percent diameter stenosis of >50% - was detected in 11 of 45 patients who attended follow-up angiography. The amount of fibrinogen-positive platelets was significantly higher among patients who subsequently developed in-stent restenosis (50.5+/-6.8% fibrinogen-positive platelets immediately after intervention) than among those who did not (39.7+/-12.3% fibrinogen-positive platelets, p<0.005). Receiver operating characteristic curve revealed a 40% cut-off for fibrinogen-positive platelets immediately after the intervention to predict restenosis (p<0.05, sensitivity: 90.9%, specificity: 47.1%). CONCLUSION: The amount of fibrinogen-positive platelets immediately after stent implantation predicts the occurrence of in-stent restenosis, as confirmed by IVUS in acute myocardial infarction patients.