Reduction of Radiation Exposure in Atrioventricular Nodal Reentrant Tachycardia Ablations Using an Electroanatomical Mapping System With Fluoroscopy Integration Module.

Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is a common supraventricular tachycardia. Current guidelines recommend electrophysiology study (EPS) and ablation, which have been proven to show high success rates with very low complication rates. Usually, ablation of AVNRT is performed conventionally using only fluoroscopy. Electroanatomical mapping systems (EMS) are widely used in complex arrhythmias. One of their advantages is their potential in decreasing the need of fluoroscopy time (FT). In this study we analyzed patients undergoing either conventional AVNRT ablation or by using an EMS with a fluoroscopy integrating system (FIS). Materials and Methods: We included 119 patients who underwent AVNRT ablation in our study. Eighty-nine patients were ablated conventionally using only fluoroscopy, 30 patients were ablated using EMS + FIS. Results: We found that the use of EMS + FIS led to a significant reduction of FT (449.90 ± 217.21 vs. 136.93 ± 109.28 sec., p < 0.001) and dose-area-product (DAP, 268.27 ± 265.20 vs. 41.07 ± 27.89 µGym2, p < 0.001) without affecting the procedure time (PT, 66.55 ± 13.3 vs. 67.33 ± 13.81 min, p = 0.783). Furthermore, we found no significance with regard to complications. Conclusion: The use of EMS+FIS is safe and feasible. It leads to a significant reduction of both FT and DAP without affecting PT and safety. Hence, EMS + FIS is beneficial for both the operator and the patients by reducing the radiation exposure.

Wearable Cardioverter-Defibrillator Used as a Telemonitoring System in a Real-Life Heart Failure Unit Setting.

BACKGROUND: In patients with reduced left ventricular ejection fraction (LVEF) who are at risk of sudden cardiac death, a wearable cardioverter-defibrillator (WCD) is recommended as a bridge to the recovery of LVEF or as a bridge to the implantation of a device. In addition to its function to detect and treat malignant arrhythmia, WCD can be used via an online platform as a telemonitoring system to supervise patients' physical activity, compliance, and heart rate. METHODS: We retrospectively analyzed 173 patients with regard to compliance and heart rate after discharge. RESULTS: Mean WCD wearing time was 59.75 ± 35.6 days; the daily wearing time was 21.19 ± 4.65 h. We found significant differences concerning the patients' compliance. Men showed less compliance than women, and younger patients showed less compliance than patients who were older. Furthermore, we analyzed the heart rate from discharge until the end of WCD prescription and found a significant decrease from discharge to 4, 8, or 12 weeks. CONCLUSION: WCD can be used as a telemonitoring system to help the involved heart failure unit or physicians attend to and adjust the medical therapy. Furthermore, specific patient groups should be educated more intensively with respect to compliance.

Influence of excess weight and obesity on performance and outcome of pulmonary vein isolation with the cryoballoon.

Pulmonary vein isolation (PVI) has become a cornerstone therapy in the treatment of atrial fibrillation (AF). Patients with overweight or obesity suffer more often from AF, and studies investigating the safety and feasibility of PVI in these patients have shown varying results. In this study we analyzed PVI performed with the 2nd generation cryoballoon (CB) with regard to safety, procedure and fluoroscopy time in patients with normal weight, overweight and obesity. We analyzed 228 consecutive patients treated with CB PVI in our hospital in 2018 and 2019. Fifty nine (25.88%) patients presented with normal weight (body mass index (BMI) of <25), 115 (50.44%) patients with overweight (BMI between 25 and 29.9) and 54 (23.68%) were obese patients (BMI >30). All pulmonary veins (PV) were isolated successfully. Concerning procedural parameters, neither complications, procedural time, nor fluoroscopy time differed significantly. There was a significant increase of dose area product (DAP) in obese patients compared to normal weight and overweight patients (2035.5 ± 1930.1 µGym2 vs. 975.3 ± 814.9 vs. 1325.1 ± 2081.3, p = 0.001) but no significant difference between overweight and normal weight patients (p = 0.611). Our follow-up data of 168 patients (73.68%) observed for 12 months showed no differences in the recurrence of AF in the three BMI groups [80.9% vs. 83.3% (p = 0.733) vs. 86.55% (p = 0.460)]. In conclusion, CB PVI in overweight and obese patients is safe with similar levels of complications and recurrence of AF as patients of normal weight. However, obese patients and operators are exposed to higher radiation doses.

Evasion maneuver for transseptal approach during cryoballoon pulmonary vein isolation.

PURPOSE: Pulmonary vein isolation (PVI) is a cornerstone therapy in patients with symptomatic atrial fibrillation. One current method is performing a PVI using a cryoballoon (CB). The CB is inserted into the left atrium via a steerable sheath. However, at times, passing of the interatrial septum by the sheath is hindered, e.g., due to septal fibrosis. Here we report our experience with an evasion maneuver to facilitate this approach using a 6F multipolar and steerable coronary Sinus catheter (CS) for predilatation of the interatrial septum. METHODS AND RESULTS: We report 10 patients undergoing a CB-PVI, where the investigator experienced difficulties in passing the interatrial septum with the CB sheath. In these cases, after three conventional abortive attempts, we predilated the transseptal puncture site using both the CS catheter and the dilatator of the CB sheath. Thereafter access of the CB sheath to the left atrium could be achieved instantly and without further resistance. CONCLUSION: We report a safe and feasible maneuver to facilitate transseptal access with the CB steerable sheath in cases complicated by excessive interatrial resistance.

Percutaneous retrieval of a shard of metal from the right ventricular apex after an industrial accident.

A 29-year-old man suffered from an industrial accident as a piece of metal of a die-cutter burst and shards of metal penetrated his right upper arm. One shard was localized via x-ray and computer tomography within the apex of the right ventricle. Here we report on a successful retrieval of this shard of metal by aspirating it via a 6F multipurpose (MP) catheter.

Electromagnetic Interference Between Left Ventricular Assist Device and a Three-Dimensional Mapping System Overcome by "Hot Mapping".

The number of patients with implanted left ventricular assist devices is constantly increasing. Numerous patients suffer from drug-resistant ventricular tachycardias. Only a few studies and reports about ablation therapy in this cohort of patients are available. Electromagnetic interferences between the left ventricular assist device and the three-dimensional mapping system which is used for ablation has been described as disabling the investigator to create a proper map of the left ventricle. We observed that this interference is interrupted by "hot mapping" meaning that one pretends an ablation with only 5 W, permitting the creation of a clear map in areas of interference.

Endostatin a Potential Biomarker for Heart Failure with Preserved Ejection Fraction / Endostatina é um Potencial Biomarcador para a Insuficiência Cardíaca com Fração de Ejeção Preservada

Abstract Background: Endostatin is a circulating endogenous angiogenesis inhibitor preventing neovascularization. Previous studies demonstrated the prognostic value of Endostatin among patients with heart failure with reduced ejection fraction (HFrEF). However, the role of Endostatin among patients with heart failure with preserved ejection fraction (HFpEF) remains unclear. Objective: This study aimed to investigate the association between serum Endostatin levels, natriuretic peptide levels and the severity of left ventricular diastolic dysfunction and the diagnosis of HFpEF. Methods: Endostatin serum concentrations were measured in 301 patients comprising 77 HFpEF patients, 169 patients with asymptomatic left ventricular diastolic dysfunction (ALVDD), and 55 controls with normal cardiac function. Results: Endostatin serum levels were significantly elevated in patients with HFpEF (median/interquartile range 179.0 [159-220]) and ALVDD (163.8 [145.4-191.3]) compared to controls (149.1 [130.6-176.9]), p < 0.001 and p = 0.004, respectively) and significant correlated with N-terminal pro B-type natriuretic peptide (NT-proBNP). Conclusions: This hypothesis-generating pilot study gives first evidence that Endostatin correlates with the severity of diastolic dysfunction and may become a novel biomarker for HFpEF. We hypothesize a rise in Endostatin levels may reflect inhibition of adaptive angiogenesis and adverse cardiac remodeling.

Resumo Fundamentos: A Endostatina é um inibidor circulante endógeno da angiogênese que previne a neovascularização. Estudos anteriores demonstraram o valor prognóstico da Endostatina em pacientes com insuficiência cardíaca com fracção de ejeção reduzida (ICFEr). No entanto, o papel da Endostatina entre os pacientes com insuficiência cardíaca com fração de ejeção preservada (ICFEp) permanece incerto. Objetivo: Investigar a associação entre os níveis séricos de Endostatina, níveis de peptídeos natriuréticos e a gravidade de disfunção ventricular esquerda e diastólica e o diagnóstico de ICFEp. Métodos: Mediu-se a concentração sérica de Endostatina em 301 pacientes, compreendendo 77 pacientes com ICFEp, 169 pacientes com disfunção ventricular esquerda assintomática diastólica (DVEAD) e 55 controles com a função cardíaca normal. Resultados: Os níveis de Endostatina no soro foram significativamente elevados em pacientes com ICFEp (mediana / intervalo interquartil 179,0 [159-220]) e DVEAD (163,8 [145,4-191,3]) em comparação com os controles (149,1 [130,6-176,9]), p < 0,001 e p = 0,004, respectivamente) e correlação significativa com o terminal do pro-peptídeo natriurético tipo B (NT-proBNP). Conclusões: Este estudo piloto gerador de hipótese fornece a primeira evidência de que a Endostatina se correlaciona com a gravidade da disfunção diastólica e pode tornar-se um novo biomarcador para ICFEp. Nossa hipótese é de que um aumento nos níveis de Endostatina pode refletir inibição da angiogênese adaptativa e remodelação cardíaca adversa.

Endostatin a Potential Biomarker for Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Endostatin is a circulating endogenous angiogenesis inhibitor preventing neovascularization. Previous studies demonstrated the prognostic value of Endostatin among patients with heart failure with reduced ejection fraction (HFrEF). However, the role of Endostatin among patients with heart failure with preserved ejection fraction (HFpEF) remains unclear. OBJECTIVE: This study aimed to investigate the association between serum Endostatin levels, natriuretic peptide levels and the severity of left ventricular diastolic dysfunction and the diagnosis of HFpEF. METHODS: Endostatin serum concentrations were measured in 301 patients comprising 77 HFpEF patients, 169 patients with asymptomatic left ventricular diastolic dysfunction (ALVDD), and 55 controls with normal cardiac function. RESULTS: Endostatin serum levels were significantly elevated in patients with HFpEF (median/interquartile range 179.0 [159-220]) and ALVDD (163.8 [145.4-191.3]) compared to controls (149.1 [130.6-176.9]), p < 0.001 and p = 0.004, respectively) and significant correlated with N-terminal pro B-type natriuretic peptide (NT-proBNP). CONCLUSIONS: This hypothesis-generating pilot study gives first evidence that Endostatin correlates with the severity of diastolic dysfunction and may become a novel biomarker for HFpEF. We hypothesize a rise in Endostatin levels may reflect inhibition of adaptive angiogenesis and adverse cardiac remodeling.

Chronic total coronary occlusion recanalization: Current techniques and new devices.

Percutaneous coronary intervention (PCI) of total chronic coronary occlusion (CTO) still remains a major challenge. The prevalence of a CTO has been reported to be up to 30% among patients with a clinical indication for coronary angiography. Progress has been made with further advanced interventional techniques and continuously sophisticated interventional tools. Nevertheless the number of interventions carried out to recanalize a CTO is less than 10% of all procedures. Benefits of a successful CTO recanalization include relief of angina pectoris and ischemia-related dyspnea, substantial improvement in left ventricular function and, avoidance of surgery treatment. A vast variety of new CTO PCI techniques and materials has been introduced into clinical practise and pushed success rates of reopening a CTO up to around 90% in experienced hands. Particulary the introduction of the retrograde technique was a milestone. New developed microcatheters and special polymer coated wires allow to recanalize via small collaterals and vessels. Other tools such as intravascular ultrasound (IVUS) and multislice computertomography (MSCT) help to identify the anatomy and the characteristic of the lesions. Any invasive cardiac center should adopt CTO PCI procedures as standard therapy. OBJECTIVE: This review wants to assess and describe the latest development in CTO recanalization strategies.

Relation of global longitudinal strain to left ventricular geometry in aortic valve stenosis.

BACKGROUND: In patients with aortic stenosis (AS), increased afterload induces changes in left ventricular (LV) geometry to preserve a normal ejection fraction (EF). Nevertheless, myocardial dysfunction may occur in spite of a normal EF. Global longitudinal strain (GLS) analysis can detect subtle contractile dysfunction at a pre-clinical stage. The aim of our study was to assess LV function deteriorations with GLS analysis and the association with geometric changes in patients with AS and normal EF. METHODS: Forty four patients with moderate to severe AS and 40 controls were enrolled. All patients underwent echocardiography, including two-dimensional strain imaging. The relative wall thickness and LV muscle mass measurements were performed with magnetic resonance imaging and patients were subdivided into four groups: Group 1 with normal LV, Group 2 with concentric remodeling, Group 3 with eccentric hypertrophy, and Group 4 with concentric hypertrophy. RESULTS: The total group of patients with AS showed a GLS of -15.3 ± 3.6% while the control group reached -18.9 ± 3.2% (p < 0.001). GLS was lower in the hypertrophy Groups 3 and 4 compared to Groups 1 and 2 (12.9 ± 3.4% vs 17.2 ± 2.5%, p < 0.05, respectively). Splitting the patients into Groups 1 to 4, the GLS was -17.2 ± 2.4%, -17.2 ± 2.7%, -12.4 ± 3.8% and -13.1 ± 3.3, respectively (p = 0.002). CONCLUSIONS: In subjects with AS, lower GLS is related to LV hypertrophy, but not to the presence of concentric remodeling. Assessment of GLS can identify subtle contractile dysfunction independent of a preserved EF, and might be useful in identifying patients at high risk for the transition from compensatory to pathological remodeling. (Cardiol J 2011; 18, 2: 151-156).