Abnormal pattern of left atrial activation and asynchronous conduction predicted the occurrence of new atrial fibrillation: evidences for Bachmann's bundle block in atrial fibrillation pathophysiology.

AIMS: Evidences suggest that recurrent atrial fibrillation (AF) is associated with left atrial (LA) remodelling. The goal of this study is to establish a method for assessment of LA remodelling and find predictors for the development of AF. METHODS AND RESULTS: This prospective study included patients without a history of AF who were evaluated using pulsed-wave tissue Doppler imaging (PW-TDI). P-wave onset to A'-wave (PA' interval) was measured at the septal, lateral, anterior, and inferior mitral annulus. Abnormal LA activation pattern was defined as an upward LA activation over the coronary sinus and delayed activation anterior. Left atrial asynchrony was measured as (i) the difference between the septal and lateral PA' interval (DLS) and (ii) the standard deviation of all four PA' intervals (SD4-PA'). The follow-up for AF recurrence (AF+) was based on symptoms and 7-day Holter electrocardiograms. Ninety-eight patients (mean age 58 ± 15 years, 47% female) were included. During a follow-up of 28 ± 9 months, AF was documented in 10%. More pronounced LA asynchrony was observed in AF+ group: DLS (AF+) 39 ± 16 vs. DLS (AF-) 20 ± 11 ms; P < 0.001, and SD4-PA' (AF+) 18.6 ± 6.4 vs. SD4-PA' (AF-) 11.7 ± 4.2 ms; P < 0.001. Abnormal LA activation was frequently observed in AF+ patients: 60% vs. 27%; P = 0.033. Electrocardiogram sign of Bachmann's bundle block (BBB) was associated with prolongation of SD4-PA': SD4-PA' (BBB+) vs. SD4-PA' (BBB-) = 18 ± 6 vs. 13 ± 4.5 ms; P = 0.007. CONCLUSIONS: More pronounced LA asynchrony and abnormal LA activation pattern were associated with new-onset AF.

Left atrial activation and asymmetric anatomical remodeling in patients with atrial fibrillation: The relation between anatomy and function.

BACKGROUND: Identifying patients with advanced left atrial (LA) remodeling before catheter ablation (CA) of atrial fibrillation (AF) is crucial. HYPOTHESIS: This study aimed to identify echocardiographic parameters associated with changes in anatomy and conduction properties of the left atrium (LA). METHODS: We examined 75 AF patients prior to CA and measured the intervals from the P-wave-onset to four mitral annulus sites by pulsed-wave tissue Doppler imaging (PW-TDI). Patients were grouped to an upward U-pattern (delayed anterior activation) and a downward D-pattern (earliest LA activation anterior). CT-data were used to measure the LA volume (LAV). LAV was divided into anterior- (LA-A) and posterior-parts by a plane, parallel to the posterior wall and between the veins and the appendage, to calculate the asymmetry index (ASI = LA-A/LAV). RESULTS: Patients with U-pattern (n = 66) had a higher ASI (65 ± 6 vs. 61 ± 3%, p = .014), older age (61 ± 11 vs. 51 ± 11 years, p = .03) and more diastolic dysfunction (71 vs. 22%, p = .008) Multivariate regression showed that age (OR 1.1 per year, CI 1.007-1.199) and diastolic dysfunction (OR 6.36, CI 1.132-35.7, p = .036) were independent predictors of the U-pattern. Diastolic dysfunction (B 4.49, CI 1.61-7.37, p = .003) was the only independent predictor of ASI in linear regression analysis. CONCLUSION: AF patients with a U-pattern have an increased LA asymmetry. Diastolic dysfunction is a common cause of this LA activation and remodeling. Therefore, detection of a U-pattern signifies patients with advanced AF and may facilitate selection for an appropriate ablation strategy.

Oesophageal Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation (OPERA): results from a prospective randomized trial.

AIMS: The aim of the study was to determine the incidence of oesophageal lesions after radiofrequency ablation (RFA) of atrial fibrillation (AF) with or without the use of oesophageal temperature probes. METHODS AND RESULTS: Two hundred patients were prospectively randomized into two groups: the OPERA+ group underwent RFA using oesophageal probes (SensiTherm™); the OPERA- group received RFA using fixed energy levels of 25 W at the posterior wall without an oesophageal probe. All patients underwent post-interventional endoscopy and Holter-electrocardiogram after 6 months. (Clinical.Trials.gov: NCT03246594). One hundred patients were randomized in OPERA+ and 100 patients in OPERA-. The drop-out rate was 10%. In total, 18/180 (10%) patients developed endoscopically diagnosed oesophageal lesions (EDEL). There was no difference between the groups with 10/90 (11%) EDEL in OPERA+ vs. 8/90 (9%) in OPERA- (P = 0.62). Despite the higher power delivered at the posterior wall in OPERA+ [28 ± 4 vs. 25 ± 2 W (P = 0.001)], the average EDEL size was equal [5.7 ± 2.6 vs. 4.5 ± 1.7 mm (P = 0.38)]. The peak temperature did not correlate with EDEL size. During follow-up, no patient died. Only one patient in OPERA- required a specific therapy for treatment of the lesion. Cumulative AF recurrence after 6 (3-13) months was 28/87 (32%) vs. 34/88 (39%), P = 0.541. CONCLUSION: This first randomized study demonstrates that intraoesophageal temperature monitoring using the SensiTherm™ probe does not affect the probability of developing EDEL. The peak temperature measured by the thermoprobe seems not to correlate with the incidence of EDEL. Empiric energy reduction at the posterior wall did not affect the efficacy of the procedure.

Extraction of infected cardiac implantable electronic devices and the need for subsequent re-implantation.

BACKGROUND: Little is known about rates of re-implantation and outcomes of patients not implanted with a device after transvenous lead extraction (TLE) in cardiac device related infections (CDRI). METHODS: All patients with CDRI were included in a prospective registry. After TLE, the indication for re-implantation was evaluated according to the patients' history and most recent cardiac examinations. All patients were followed for complications and mortality. In addition, in patients discharged without device the frequency of device implantations was analyzed. RESULTS: Among 302 patients, only 123 (40.7%) met the indication for implantation of the same cardiac implantable electronic device (CIED), 68 (22.5%) received a different device and 111 (36.8%) patients were discharged without CIED. Reimplanted patients were younger (70 ±â€¯11 vs. 73 ±â€¯13 years; p = 0.004), more often male (83 vs. 69%, p = 0.006), had less systemic infection (38 vs. 60%; p < 0.001) and a higher prevalence of complete heart block (28 vs. 7%, p < 0.001). Reasons against re-implantation were: loss of indication (45%), never met indication (27%), patients' preference (17%), persistent infection (8%) and advanced age (3%). During 26 ±â€¯18 months of follow-up, mortality in both groups was similar after adjusting for cofactors (HR 0.79; 95% CI 0.49-1.29; p = 0.352). CONCLUSION: More than one third of patients undergoing TLE for CDRI in our study are not implanted with a new device. Careful evaluation of the initial CIED indication allows for detection of over treated patients and may avoid unnecessary device-related complications.

Exercise-related sudden cardiac death of an American football player with arrhythmogenic right ventricular dysplasia/cardiomyopathy AND sarcoidosis.

This case emphasizes the value of cardiac MRI and genetic testing in the early phase of ARVD/C. It also emphasizes the increased risk of SCD for patients with ARVD/C participating in competitive sports, even with immediate cardiopulmonary resuscitation.

[Telemonitoring of implanted cardiac devices : Clinical necessity or senseless luxury?] / Telemonitoring von implantierten kardialen Devices : Klinische Notwendigkeit oder sinnloser Luxus?

In addition to the telemedical follow-up at a fixed point in time, there is the possibility of a close-meshed telemetric monitoring in modern devices. By transferring device and patient-specific data, errors in the integrity of the device or electrodes and cardiac arrhythmias can be detected early, in various studies significantly reducing the number of outpatient or inpatient visits and the rate of inadequate implantable cardioverter-defibrillator (ICD) therapies. Measurement of various surrogate parameters allows better clinical assessment of heart failure patients, yet no improvement in outcome with therapy guided by telemetric data has been demonstrated. Retrospective analyzes, a prospective randomized study, and various meta-analyzes identified a reduction in all-cause mortality through the use of remote monitoring. This effect is mainly due to monitoring as closely as possible, timely examination of the findings, accordingly early interventions and specification of clear therapeutic regimens in certain clinical scenarios. Such comprehensive patient care requires the creation of telemonitoring centers with appropriate structural and personal equipment, whereby the creation of such structures has not yet been remunerated in the German healthcare system. In this paper, an overview of remote monitoring and identify possibilities and limitations of device-based telemedical monitoring is provided.

Cardiac resynchronization therapy in the ageing population - With or without an implantable defibrillator?

BACKGROUND: Cardiac resynchronization therapy (CRT) is an effective treatment option for systolic heart failure, but the benefit of an additional implantable cardioverter-defibrillator (ICD) in elderly patients is not well established. The aim of our study was to evaluate the impact of an additional ICD on survival in elderly CRT recipients. METHODS: Patients aged ≥75 years with an indication for CRT and primary preventive ICD therapy, which underwent implantation of either a CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) were included in the study. Patient characteristics, procedural and follow-up data, and subsequent all-cause mortality were analyzed. RESULTS: A total of 775 consecutive patients underwent CRT implantation, whereof 177 patients fulfilled the inclusion criteria. Of these, 80 patients with CRT-P and 97 with CRT-D formed the two study groups. Patients in the CRT-P group were significantly older (82.6 ±â€¯4.5 vs. 77.8 ±â€¯1.9 years, p < 0.001) and more often female (44 vs. 25%; p < 0.001), had a better left ventricular ejection fraction (29.5 ±â€¯5.7 vs. 27.4 ±â€¯6.0%; p = 0.019) and narrower QRS-complex (150 ±â€¯19 vs. 158 ±â€¯18 ms; p = 0.025). During a mean follow-up of 26 ±â€¯19 months, 62 (35%) study patients died, 28 (35%) in the CRT-P and 34 (35%) in the CRT-D group (p = 0.994). The Kaplan-Meier analysis of survival probability showed no significant difference between the two groups (p = 0.562). CONCLUSION: In our study, an additional ICD had no impact on survival in elderly patients undergoing implantation of a CRT device. Randomized controlled trials have to confirm this finding.

Supraventricular arrhythmias in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy associate with long-term outcome after catheter ablation of ventricular tachycardias.

Aims: This study aimed to assess the impact of supraventricular tachycardia (SVT) on long-term results of radiofrequency catheter ablation therapy of ventricular tachycardia (VT) in a large cohort of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). Methods and results: Supraventricular tachycardia occurrence has been studied in patients from our ARVD/C registry (70 patients, 48 male, age 53.2 ± 14.0, 45 patients (64.3%) with previous VT ablation). SVT were diagnosed in 26 of 70 patients (37.1%). Atrial fibrillation (AF) was the most frequent atrial arrhythmia, diagnosed in 17 patients (24.3%). In univariate analysis advanced age, clinical symptoms of heart failure, enlarged right atrium, diagnosis of significant tricuspid regurgitation (TR), and inappropriate implantable cardioverters-defibrillators therapy were associated with SVT. In binary logistic regression analysis only heart failure: hazard ratio (HR) 10.89, 95% confidence interval (95% CI) 1.08-109.96 (P = 0.043) and significant TR: HR 4.79, 95% CI 1.35-16.33 (P = 0.015) remained associated with SVT. In patients with previous VT ablation Cox multiple regression survival analysis revealed older age (≥53 years): HR 4.63, 95% CI 1.51-14.24 (P = 0.008) and SVT: HR 3.01, 95% CI 1.15-7.89 (P = 0.025) as predictors for VT recurrence during the follow-up. Conclusion: SVT and older age are associated with the recurrence of VT after catheter ablation in patients with ARVD/C.

Implanted defibrillators in trouble: initial device misclassification leads to correct diagnosis-a case series.

AIMS: Supraventricular tachycardia, mistakenly diagnosed as ventricular tachycardia, may lead to inappropriate ICD therapy. Inappropriate ICD therapy associates with increased morbidity and mortality. A reduction of inappropriate therapy is therefore desired. METHODS AND RESULTS: We present three different cases that beautifully illustrate the diagnostic possibilities of stored electrograms. Initial differential diagnoses in all three patients included ventricular tachycardia, focal atrial tachycardia, atrio-ventricular re-entry tachycardia, and atrio-ventricular nodal re-entry tachycardia. The first case was diagnosed as atrio-ventricular nodal re-entry tachycardia. In the second case, atrio-ventricular re-entry tachycardia was revealed. Ectopic atrial tachycardia was the reason for inappropriate therapy in the third patient. CONCLUSION: Thorough analysis of stored electrograms yielded correct diagnosis in all cases, which subsequently was confirmed by electrophysiological study.

Should all patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergo epicardial catheter ablation?

BACKGROUND: Epicardial radiofrequency catheter ablation is currently considered as the therapeutic option of choice in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) and recurrent ventricular tachycardia (VT). We hypothesised that inducibility of VT may guide the ablation strategy and thereby affect long-term results. Additional epicardial ablation was only performed if VT were still inducible after thorough endocardial ablation. METHODS: The objective was to examine an inducibility-guided ablation approach by comparing the long-term results between endocardial and epi-endocardial radiofrequency catheter ablation of VT in a large cohort of patients with ARVD/C. RESULTS: We studied from our ARVD/C registry (70 patients in total, 48 males, age 53.2 ± 14.0) 45 patients (64.3% of all patients) who underwent catheter ablation of VT. All patients received endocardial VT ablation. After endocardial ablation, 24 patients (53.3%) remained inducible. Additional epicardial ablation was performed in 22 patients (48.9%). After ablation, non-inducibility was achieved in overall 38 patients (84.4%). During a mean follow-up of 31.1 ± 27.4 months, 13 patients in each group (59.1% after endo- and epicardial ablation, 56.5% after endocardial ablation) remained free from VT recurrence (P = 0.862). CONCLUSIONS: An inducibility-guided catheter ablation strategy of VT in patients with ARVD/C prevents unnecessary epicardial ablation and may therefore be considered as an alternative to primary combined endo- and epicardial ablation.

Patterns of left atrial activation and evaluation of atrial dyssynchrony in patients with atrial fibrillation and normal controls: Factors beyond the left atrial dimensions.

BACKGROUND: Left atrial (LA) remodeling causing slower and asynchronous conduction is crucial for the maintenance of atrial fibrillation (AF). OBJECTIVE: We propose a simple and quick method to evaluate the LA asynchrony. METHODS: One hundred thirty patients with AF (AF group) and 70 patients without a history of AF (controls) were examined prospectively using pulsed-wave tissue Doppler imaging. The time intervals from the onset of the P wave to the onset of the A' wave (P-A' intervals) were measured at 4 sites at the mitral annulus: septal, lateral, anterior, and posterior. To assess the LA asynchrony, the differences between the longest and the shortest P-A' interval as well as the standard deviation of all 4 P-A' intervals were calculated. RESULTS: Both groups were matched for the baseline characteristics. The AF group had longer differences between the longest and the shortest P-A' than did controls (37 ± 16 ms vs 28 ± 13 ms; P = .0001). The standard deviation of all 4 P-A' intervals was also higher in the AF group (17 ± 7 ms vs 13 ± 5 ms; P = .0001). Furthermore, distinct patterns of LA activation were observed with most patients with AF showing upward LA activation (86.5%) whereas normal controls were showing downward LA activation (65.5%). Receiver operating characteristic analysis revealed that P-A' anterior successfully discriminated patients with AF from controls (area under the curve 0.85; P < .0001). Furthermore, P-A' anterior > 55 ms discriminated between patients with AF and controls with a sensitivity of 85% a specificity of 81%, a positive predictive value of 0.898, and a negative predictive value of 0.707. CONCLUSION: Patients with AF showed greater LA asynchrony in pulsed-wave tissue Doppler imaging, upward LA activation, and a prolonged activation time at the anterior mitral annulus. Prolongation of P-A' anterior discriminated between patients with AF and controls with high sensitivity and specificity.