Sleep - the yet underappreciated player in cardiovascular diseases: A clinical review from the German Cardiac Society Working Group on Sleep Disordered Breathing.

Patients with a wide variety of cardiovascular diseases, including arterial and pulmonary hypertension, arrhythmia, coronary artery disease and heart failure, are more likely to report impaired sleep with reduced sleep duration and quality, and also, sometimes, sleep interruptions because of paroxysmal nocturnal dyspnoea or arrhythmias. Overall, objective short sleep and bad sleep quality (non-restorative sleep) and subjective long sleep duration are clearly associated with major cardiovascular diseases and fatal cardiovascular outcomes. Sleep apnoea, either obstructive or central in origin, represents the most prevalent, but only one, of many sleep-related disorders in cardiovascular patients. However, observations suggest a bidirectional relationship between sleep and cardiovascular diseases that may go beyond what can be explained based on concomitant sleep-related disorders as confounding factors. This makes sleep itself a modifiable treatment target. Therefore, this article reviews the available literature on the association of sleep with cardiovascular diseases, and discusses potential pathophysiological mechanisms. In addition, important limitations of the current assessment, quantification and interpretation of sleep in patients with cardiovascular disease, along with a discussion of suitable study designs to address future research questions and clinical implications are highlighted. There are only a few randomised controlled interventional outcome trials in this field, and some of the largest studies have failed to demonstrate improved survival with treatment (with worse outcomes in some cases). In contrast, some recent pilot studies have shown a benefit of treatment in selected patients with underlying cardiovascular diseases.

The impact of wearable cardioverter-defibrillator use on long-term decision for implantation of a cardioverter-defibrillator in a semirural acute care hospital.

PURPOSE: Large-scale multi-center studies have reported on efficacy of the wearable cardioverter-defibrillator (WCD). However, outcomes focused on WCD patients treated at community-based acute care centers are lacking. METHODS: Patients with cardiomyopathy were included when left ventricular ejection fraction (LVEF) at baseline was ≤ 35%. There were 120 patients meeting the criteria who also had LVEF measured at baseline and after 90 days of WCD use. RESULTS: After 90 days of WCD use, there were 44 (37%) patients in whom LVEF improved to > 35%. Comparison of patients, by whether LVEF improved or not, indicated that median days of WCD wear and hours of daily use were similar as well as characteristics, such as gender, age, and starting LVEF; and diagnoses leading to WCD prescription were similar between groups as were symptom-based prescription of medications. At the end of WCD use, improved LVEF > 35% correlated with fewer implantable cardioverter-defibrillator (ICD) implants. There were 4 (3%) episodes of new atrial fibrillation detected during WCD use. The WCD appropriately delivered a shock to 3 (2.5%) patients with VT/VF being terminated by the first shock. All shocked patients survived for at least 24 h post-shock. CONCLUSIONS: During WCD use, ischemic and non-ischemic cardiomyopathy patients manifest improved LVEF by 90 days. Long-term care decisions, such as implantation of an ICD, were influenced by LVEF improvement and occurrence of spontaneous VT/VF. The WCD protected patients from sudden cardiac death (SCD) until patient response to guideline-directed medical therapy could be determined.

Predictors of treatment in acute coronary syndromes in the elderly: impact on decision making and clinical outcome after interventional versus conservative treatment.

BACKGROUND: Management of elderly patients with acute coronary syndromes (ACS) is not standardized and physicians discretion for invasive versus conservative strategies lacks sufficient evidence. The purpose of this analysis was, therefore, to evaluate treatment strategies and outcomes of elderly patients with ACS and to highlight reasons for the treatment decision in a consecutive series of elderly patients. METHODS: This is a retrospective analysis of 1,001 elderly patients (>75 years) presenting with ACS. Patients were identified on the basis of their final discharge diagnosis. Baseline data, past medical history, cardiac and noncardiac concomitant diseases, treatment strategy, and adverse outcomes were evaluated, using patient's charts. Various co-variates were used to determine the association or predictive value of these co-variates to the invasive versus conservative management of the subjects. Thirty-day mortality and long-term survival were assessed either directly or in discharged patients via telephone interview with the patients, the patients' relatives or the primary care physicians. RESULTS: A total of 776 (77.5%) patients were treated invasively and 225 (22.5%) conservatively. Logistic regression analysis revealed that patients with advanced age, Killip class > II, pre-existing coronary artery disease, prior stroke, pre-existing renal failure, obesity, non-ST-elevation myocardial infarction, prior ACS, and the presence of supraventricular arrhythmias were significantly more likely to undergo conservative treatment. In-hospital mortality was significantly higher in conservatively treated patients (P < 0.001). CONCLUSION: In this retrospective analysis, we identified age as the main predictor for a conservative treatment strategy in elderly patients, albeit an invasive strategy was associated with a significantly better outcome.

Cardio-respiratory exercise testing early after the use of the Angio-Seal system for arterial puncture site closure after coronary angioplasty.

AIMS: The vascular closure device (VCD) Angio-Seal is an easy-to-use system for the closure of arterial puncture sites after percutaneous coronary intervention (PCI), and allows for early mobilisation of the patient. However, little data are available about exercising early after the use of VCD's in PCI patients. METHODS AND RESULTS: A total of 230 consecutive patients were screened. Of these, 45 (20%) were excluded due to the inability to perform exercise testing, or anatomical conditions which prevented the insertion of a VCD. The 185 remaining patients (139 male, mean age 68 ± 12 years) received Angio-Seal after PCI. After four hours, 30 patients (16%) showed a small local haematoma, 11 patients (6%) complained about minor -and one patient (0.5%) about strong- groin pain. There were no major bleeding complications, six pseudo-aneurysmata, and one arterio-venous fistula. Overall, nine patients (6%) showed moderate to severe groin problems. Patients without major complications underwent bicycle cardiopulmonary exercise testing the subsequent day. Exercise testing was performed up to 136 ± 60 W in 176 patients (94%). Maximum workload was 104 ± 33 W, peak oxygen consumption 17.6 ± 5.1 ml/min/kg, and oxygen consumption at the anaerobic threshold 15.4 ± 4.2 ml/min/kg. After exercise testing there were no cardiovascular complications noted. CONCLUSIONS: In patients receiving VCD after PCI, exercise testing above the anaerobic threshold was feasible after Angio-Seal deployment in those patients with no complications after the use of the device.

Fluid status monitoring with a wireless network to reduce cardiovascular-related hospitalizations and mortality in heart failure: rationale and design of the OptiLink HF Study (Optimization of Heart Failure Management using OptiVol Fluid Status Monitoring and CareLink).

AIMS: The Optimization of Heart Failure Management using OptiVol Fluid Status Monitoring and CareLink (OptiLink HF) study is designed to investigate whether OptiVol fluid status monitoring with an automatically generated wireless CareAlert notification via the CareLink Network can reduce all-cause death and cardiovascular hospitalizations in an HF population, compared with standard clinical assessment. Methods Patients with newly implanted or replacement cardioverter-defibrillator devices with or without cardiac resynchronization therapy, who have chronic HF in New York Heart Association class II or III and a left ventricular ejection fraction ≤35% will be eligible to participate. Following device implantation, patients are randomized to either OptiVol fluid status monitoring through CareAlert notification or regular care (OptiLink 'on' vs. 'off'). The primary endpoint is a composite of all-cause death or cardiovascular hospitalization. It is estimated that 1000 patients will be required to demonstrate superiority of the intervention group to reduce the primary outcome by 30% with 80% power. CONCLUSION: The OptiLink HF study is designed to investigate whether early detection of congestion reduces mortality and cardiovascular hospitalization in patients with chronic HF. The study is expected to close recruitment in September 2012 and to report first results in May 2014.

Left atrial lesion formation and volume overload by open irrigation ablation technology during pulmonary vein antrum isolation: acute effects on cardiac hemodynamics.

PURPOSE: Our goal was to evaluate acute effects of left atrial lesion formation and volume overload on hemodynamics during pulmonary vein antrum isolation (PVAI) as it might be a potential cause of acute pulmonary edema. METHODS: In consecutive patients presenting for PVAI, open irrigation ablation was performed (50 W, 48°C, 15 s lesion duration, saline flow rate 30 mL/min). Blood samples were drawn from the left atrium and the pulmonary artery immediately before and 30 min after PVAI. The cardiac output (CO) and stroke volume (SV) were calculated by the method of Fick. RESULTS: We included 61 (27 female, 61 ± 11 years) patients suffering from paroxysmal (px; 33) or persistent (per; 28) atrial fibrillation (AF) in this study. A total of 2,917 ± 242 mL of volume was infused (2,651 ± 223 mL pxAF vs. 3,184 ± 255 mL perAF, (p < 0.01)). Total ablation time was 60 ± 7 min (52 ± 7 min in pxAF vs. 69 ± 8 min in perAF; (p < 0.001)). CO increased from 5.2 ± 1.3 to 6.2 ± 1.5 L/min (p < 0.001) during PVAI (5.7 ± 1.3 to 6.5 ± 1.7 L/min in pxAF; (p < 0.002) and 4.8 ± 1.1 to 5.9 ± 1.2 L/min in perAF; (p < 0.001)). SV increased from 74 ± 24 to 83 ± 21 mL (p < 0.005) during PVAI, and subgroups showed an increase of 82 ± 23 to 88 ± 22 mL in pxAF (p < 0.009) and 62 ± 21 to 76 ± 16 mL in perAF (p < 0.009). CONCLUSIONS: From our preliminary experience, left atrial scarring and volume overload during PVAI do not seem to impact negatively hemodynamics. On the contrary, an improvement in cardiac output was documented acutely independent of type of AF.

Three-dimensional coronary sinus reconstruction-guided left ventricular lead implantation based on intraprocedural rotational angiography: a novel imaging modality in cardiac resynchronization device implantation.

AIMS: Rotational angiography (RA) of the coronary sinus (CS) provides more anatomical insights compared with static angiographies. We evaluated intraprocedural three-dimensional (3D) CS reconstruction (RC) based on RA, using syngo(®) DynaCT Cardiac to guide CS lead implantation. METHODS AND RESULTS: In 24 patients with indication for cardiac resynchronization therapy, intraprocedural RA and 3D RC of the CS was performed. Lead placement was guided by 3D image integration into real-time fluoroscopy. Rotational angiography and 3D RCs were evaluated regarding visibility of the CS and tributaries, CS-to-target vein angles, and vessel diameters. The target vein for CS lead implantation, identified by RA, was successfully displayed by 3D RC in 20 (91%) of 22 patients with adequate RA. All lead implantations were guided successfully by 3D image integration into real-time fluoroscopy. Cranial or caudal angulations were used in 95% of the procedures without further angiographies. Rotational angiography displayed a mean of 2.9 ± 1.0 second-order side branches compared with 1.8 ± 1.1 in 3D RCs (P< 0.05). The CS-to-target vein angle estimated from static projections (right anterior oblique 20°, left anterior oblique 40°, and even optimal RA view) differed substantially from 3D RCs. Main vessel diameters did not differ significantly between both techniques. CONCLUSION: Intraprocedural 3D RC of the CS and 3D image integration-guided lead placement is feasible. Coronary sinus-to-target vein angles seemed to be misestimated even by RA views compared with 3D RC. Thus RA and 3D CS RC should be applied routinely for CS lead implantation.

Criteria for patient selection in cardiac resynchronization therapy.

Since the implementation of cardiac resynchronization therapy (CRT) the prognosis of patients with severe heart failure has been improved owing to a reduction in morbidity and mortality rates, as several multicenter trials have shown. However, several patients treated by CRT still lack improvement or even deteriorate during therapy. In some of them, this might be due to the severity and progression of chronic heart failure. In others, the criteria for the indication of CRT and/or optimized device programming might have not been met. Thus, one important option to improve CRT outcome is to improve CRT patient selection. A lot of publications describing various methods identifying a positive or negative prediction of CRT have been released. In summary, decision making based on all these partly contradictory publications indicate a strong need for guidelines for the use of such expensive therapy. The purpose of this article is to give an overview of CRT and summarize the different methods and the limitations of CRT patient selection parameters. With the focus of the different guidelines, this article tries to give an appropriate overview and aid decision making in CRT patients, including a short view of possible new indications.

Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale.

BACKGROUND: Patients with atrial fibrillation (AF) are at increased risk for ischemic stroke. In patients who have suffered a stroke, screening for AF is routinely performed only for a short period after the stroke as part of the evaluation for possible causes. If AF is detected after an ischemic stroke, oral anticoagulation therapy is recommended for secondary stroke prevention. In 25% to 30% of stroke patients, the stroke mechanism cannot be determined (cryptogenic stroke). The incidence of paroxysmal AF undetected by short-term monitoring in patients with cryptogenic stroke is unknown, but has important therapeutic implications on patient care. The optimum monitoring duration and method of AF detection after stroke are unknown. The purpose of this study is to evaluate the incidence of AF and time to AF detection in patients with cryptogenic stroke using an insertable cardiac monitor. STUDY DESIGN: The CRYSTAL AF trial is a randomized prospective study to evaluate a novel approach to long-term monitoring for AF detection in patients with cryptogenic stroke. Four hundred fifty cryptogenic stroke patients (by definition, without a history of AF) will be enrolled at approximately 50 sites in Europe, Canada, and the United States. Patients will be randomized in a 1:1 fashion to standard arrhythmia monitoring (control arm) or implantation of the subcutaneous cardiac monitor (Reveal XT; Medtronic, Inc, Minneapolis, MN) (continuous monitoring arm). OUTCOMES: The primary end point is time to detection of AF within 6 months after stroke. The clinical follow-up period will be at least 12 months. Study completion is expected at the end of 2012.

Relation of recurrence of atrial fibrillation after successful cardioversion to renal function.

Angiotensin II exerts proinflammatory effects leading to atrial fibrosis that is associated with persistence of atrial fibrillation (AF). Renal function plays a major role in activation of the renin-angiotensin-aldosterone system. We examined whether the level of impaired renal function, defined by glomerular filtration rate (GFR), would influence the maintenance of sinus rhythm after successful external electric cardioversion (ECV). One hundred two consecutive patients with persistent AF underwent successful ECV. Patients were prospectively followed for recurrence of AF by telephone interviews, Holter electrocardiograms, and electrocardiograms sent by primary care providers. Repeated GFR assays were performed before and 1 month after ECV. Patients were divided into 4 groups according to baseline GFR (I >90 ml/min, II 60 to 90 ml/min, III 30 to 59 ml/min, IV <30 ml/min). AF recurrence rate was significantly higher in patients with moderately or severely decreased renal function (GFR <60 ml/min, p = 0.003). Patients with moderately (GFR 30 to 59 ml/min, p = 0.02) or only mildly (GFR 60 to 90 ml/min, p = 0.01) decreased renal function showed an increase in GFR if sinus rhythm was maintained at 1 month follow-up. In conclusion, impaired renal function was associated with an increased risk of AF recurrence after successful ECV.

A new angiographic method to assess coronary flow reserve-validation in humans.

BACKGROUND: Coronary flow reserve (CFR) is defined as the ratio between coronary artery flow during maximal hyperemia and rest. It is considered as a marker for the integrity of the epicardial coronary circulation and the microcirculation. CFR measurement typically requires the introduction of a guide wire into a diseased coronary artery. We tested a new algorithm, which allows to estimate CFR by analysis of coronary angiograms without the need for direct intracoronary measurements. METHODS: Twenty seven patients (10 female, mean age 64 +/- 11 years) underwent diagnostic cardiac catheterization for the evaluation of chest pain. A Doppler wire was introduced into the diseased coronary artery and CFR(doppler) was calculated by the flow velocity ratio between rest and maximal hyperemia, induced by intravenous administration of 140 microg of adenosine per kg bodyweight. This was compared to the angiographically determined CFR (CFR(angio)) under the same conditions (rest and induced maximal hyperemia) by densitometry. CFR(angio) was based on the creation of two time density curves representing the disappearance of contrast over time. CFR(angio) was the resulting ratio between the density values during hyperemia and rest. RESULTS: An excellent correlation was found between CFR(doppler) and CFR(angio): CFR(angio) = 1 x CFR(doppler) (r = 0.87; P < 0.0001). The average absolute difference between both indeces was 0.36 +/- 0.31. CONCLUSION: Measurement of CFR(angio) by densitometry is feasible and provides results, which are comparable to Doppler-derived intracoronary flow velocity measurements.

Multislice computed tomography for comprehensive assessment of the heart in acute chest pain: a case report.

INTRODUCTION: Over the last decade cardiac computed tomography emerged as a non-invasive imaging modality for the assessment of the heart and the coronary arteries. Only recently its use for patient management in the emergency department was suggested. CASE PRESENTATION: We present an 84-year old male patient with concomitant early in-stent restenosis after coronary artery stent placement, myocardial infarction, left and right ventricular thrombi and aortic valve stenosis. Diagnoses were made on emergency cardiac computed tomography. All findings were confirmed by catheter coronary angiography, echocardiography and cardiac magnetic resonce imaging. CONCLUSION: The comprehensive emergency work-up by cardiac computed tomography, illustrates the potential value of cardiac computed tomography in the emergency setting.

Three-dimensional reconstruction allows accurate quantification and length measurements of coronary artery stenoses.

AIMS: The aim of this prospective study was to evaluate the feasibility and accuracy of a recently developed 3D system (CardiOp-B; Paieon Medical Ltd., Israel) as compared to a validated quantitative coronary angiography (QCA) system (Siemens Quantcor, Siemens Medical Solutions). METHODS AND RESULTS: In patients scheduled for heart catheterisation, minimal lumen diameter (MLD) and diameter-derived percent stenosis (DPS) were obtained for CAS (>50%) using both QCA and the 3D-system. To estimate stenosis length, a non-inflated balloon was inserted into the stenosis and the distance between balloon markers was measured using both methods and then compared to the known distance between the markers. In 61 patients 79 lesions were analysed. MLD measurements showed a good agreement between QCA and 3D with a mean difference of 0.08+/-0.035 mm. Reference diameter was 2.61+/-0.67 for 3D and 2.42+/-0.61 mm for QCA and 54.79+/-9.20% vs. 58.75+/-8.15% for the %-stenosis range, respectively. The mean true balloon length was 12.8 mm+/-3.8 mm. Lengths determined by the 3D system were 13.0+/-4.0 mm and 11.3+/-3.8 mm by QCA, respectively. CONCLUSIONS: Evaluation of CAS using the novel 3D system was feasible and showed equivalent results to validated QCA measurements. Length measurements seemed to be more accurate by the 3D system as compared to QCA. Therefore, this 3D-system can be used to guide decisions in interventional cardiology.

Left ventricular dyssynchrony from right ventricular pacing depends on intraventricular conduction pattern in intrinsic rhythm.

AIMS: Right ventricular pacing (RVP) prolongs ventricular activation and may induce mechanical dyssynchrony. We hypothesized that the severity of RVP-associated ventricular mechanical dyssynchrony may depend on the intrinsic intraventricular conduction pattern. METHODS AND RESULTS: Sixty-five patients with a single- or dual-chamber RV pacemaker were included. Forty-seven patients with ejection fraction (EF) 35% and no BBB served as a control group. Echocardiographic dyssynchrony parameters [aortic pre-ejection delay (AoPEP), interventricular mechanical delay, delayed posterior left ventricular wall motion, and septal-to-posterior wall motion delay (SPWMD)] were evaluated in all patients with and without RVP. No dyssynchrony was found in patients with no BBB, RBBB, and in the control group, whereas LBBB patients showed significant dyssynchrony in AoPEP and SPWMD. RVP had a significant negative impact on all dyssynchrony parameters in patients with no BBB or LBBB. RVP induced significantly less severe dyssynchrony in RBBB patients. With RVP 100, 94, 56 and 16% of patients with LBBB, without BBB, RBBB, and from the control group, respectively, fulfilled the CARE-HF criteria for ventricular dyssynchrony. CONCLUSION: RVP worsens mechanical ventricular dyssynchrony in patients with reduced EF. These effects are most pronounced in patients with either normal QRS width or LBBB during intrinsic rhythm. In contrast, patients with an RBBB during intrinsic rhythm without RVP evidenced a better preserved haemodynamic function and mechanical synchrony with RVP, despite a comparable extent of pacing-induced QRS prolongation.

Role of left ventricular scar and Purkinje-like potentials during mapping and ablation of ventricular fibrillation in dilated cardiomyopathy.

BACKGROUND: Purkinje-like potentials (PLPs) have been described as important contributors to initiation of ventricular fibrillation (VF) in patients with normal hearts, ischemic cardiomyopathy, and early after-myocardial infarction. METHODS: Of the 11 consecutive patients with VF storm, nonischemic cardiomyopathy (68 +/- 22 years, left ventricular ejection fraction 28 +/- 8%) who were given antiarrhythmic drugs and/or heart failure management, five had recurrent VF and underwent electrophysiology study (EPS) and catheter ablation. RESULTS: At EPS, frequent monomorphic premature ventricular contractions (PVC) and/or ventricular tachycardia did not occur. With isoproterenol, VF was induced in three patients, and sustained monomorphic PVCs were induced in one patient. Three-dimensional electroanatomical mapping using CARTO (Biosense-Webster Inc., Diamond Bar, CA) revealed posterior wall scar in four of the five patients. PLP in sinus rhythm were recorded around the scar border in these four patients, and radiofrequency ablation targeting PLP was successfully performed at these sites. The patient without PLP did not undergo ablation. During follow-up (12 +/- 5 months), only the patient without PLP had four VF recurrences requiring implantable cardioverter-defibrillator (ICD) shocks. CONCLUSION: In patients with VF and dilated cardiomyopathy, left ventricular posterior wall scar in the vicinity of the mitral annulus seems to be a common finding. Targeting PLP along the scar border zone for ablation seems to efficiently prevent VF recurrence in these patients.

Long-term effects of dynamic atrial overdrive pacing on sleep-related breathing disorders in pacemaker or cardioverter defibrillator recipients.

INTRODUCTION: Sleep-related breathing disorders occur in 20-30% of Europeans and North Americans, including 10% of sleep apnea syndrome (SAS). A preliminary study suggested that atrial overdrive pacing with a fixed heart rate might alleviate SAS. However, it is not known whether dynamic atrial overdrive pacing alleviates SAS. METHODS: Patients with indications for a dual chamber pacemaker or implantable cardioverter-defibrillator (ICD) were screened for SAS using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. If PSQI was >5, cardio-respiratory polygraphy was performed before and 4 and 7 months after device implantation. Patients were randomized to algorithm ON-OFF (group A) or OFF-ON (group B) and the apnea-hypopnea index (AHI) was measured. RESULTS: Out of 105 consecutive patients, 46 (44%) had a positive PSQI. This analysis included 12 patients (mean age = 61 +/- 10 years, body mass index 28.9 +/- 6.5 kg/m(2), left ventricular ejection fraction = 38.3 +/- 13.6%; 10 men). All patients suffered from obstructive or mixed SAS. There were no significant differences in PSQI or AHI between baseline and follow-up or between the two study groups. Therefore, the study was terminated ahead of schedule. CONCLUSIONS: The prevalence of obstructive or mixed SAS was high in pacemaker or ICD recipients and reduced left ventricular ejection fraction. In these patients, long-term dynamic atrial overdrive pacing using did not improve PSQI or SAS. Therefore, patients with relevant obstructive or mixed SAS should not be offered atrial pacing therapy.

Esophageal acid levels after pulmonary vein isolation for atrial fibrillation.

BACKGROUND: Pulmonary vein antrum isolation (PVAI) is a potentially curative, nonpharmacologic treatment of atrial fibrillation (AF). Several procedural complications have been described, including esophageal wall lesions ranging from erythema and esophagitis, necrosis and ulcer, to atrio-esophageal fistula. We prospectively studied changes in esophageal acid levels before and after PVAI. METHODS: We performed 24-hour pH-metry before and 1.3 +/- 1.6 days after PVAI, in 25 patients (mean age = 62 +/- 12 years, 17 men) with symptomatic AF. A 2-mm transnasal probe was inserted into the inferior part of the esophagus and into the stomach to measure pH levels at fixed intervals. DeMeester scores, indicating acidic gastro-esophageal reflux, were calculated. RESULTS: The mean number of reflux episodes increased from 89 +/- 80 before to 107 +/- 94 after PVAI. The mean percentage of time with esophageal pH < 4 was shorter after (108 +/- 193 minutes) than before PVAI (159 +/- 245 minutes). The mean DeMeester score decreased from 49 +/- 68 before to 31 +/- 41 after PVAI (P < 0.05). We observed erythema or esophagitis in five patients, necrosis or ulcer in seven, and atrio-esophageal fistula in no patient. CONCLUSIONS: Our hypothesis of increased acid levels caused by stimulation of the right vagal nerve during isolation of the right upper pulmonary vein was not verified.

Atrial flutter ablation in inducible patients during pulmonary vein atrum isolation: a randomized comparison.

BACKGROUND: The incidence of atrial flutter (AFL) post pulmonary vein antrum isolation (PVAI) in patients with atrial fibrillation (AF) is reported to be between 8% and 20%. The need for right or left AFL ablation during the initial PVAI procedure remains controversial. We prospectively compared mapping and ablation versus no ablative treatment of inducible AFL during PVAI. METHODS AND RESULTS: In 220 patients (167 men, mean age 56+/-15 years) with symptomatic AF presenting for PVAI, burst pacing from the high right atrium and coronary sinus was performed to determine AFL inducibility. A total of 25 patients with sustained (17 patients) or reproducible (eight patients) AFL were included in this study. Patients were randomized to mapping and ablation of AFL using the CARTO 3D mapping system (Biosense Webster, Diamond Bar, CA, USA) versus no further ablation. Typical AFL was induced in 48% of the patients. During a follow-up of 12+/-4 months, recurrences were determined by serial 48-h Holter and event monitors. Recurrence rates, time to recurrence, and AFL cycle length differences between both groups were not statistically significant. CONCLUSION: These data suggest that inducibility of AFL post PVAI does not predict long-term incidence of AFL. Moreover, this study demonstrates little benefit to mapping and ablation of these arrhythmias during the PVAI procedures.