Impact of compression stockings on leg swelling after arthroscopy - a prospective randomised pilot study.

BACKGROUND: Post-operative limb swelling may negatively affect the outcome of arthroscopic surgery and prolong rehabilitation. The aim of this pilot study was to evaluate the effect of compression stockings versus no compression on post-operative swelling and pain in the early post-operative phase. METHODS: A single-centre, randomised controlled trial was performed. Patients who underwent minor knee arthroscopy were randomised to wear class II compression stockings (23-32 mmHg) (CS) or no compression stockings (NCS) immediately post-operatively for ten days. All patients received low molecular weight heparin (LMWH) at prophylactic dosage. The primary outcome variable was post-operative swelling of the limb, quantified by using an optical 3D measurement system (Bodytronic© 600). Pain was rated on a visual analogue scale (VAS). From a total of 76 patients assessed, 19 patients were eligible for final analysis. The trial followed the CONSORT criteria, was registered at clinicaltrial.gov and approved by the local ethics committee. RESULTS: The circumference at the middle thigh (cF) was significantly different between groups at day 10 (p = 0.032; circumference - 1.35 ± 2.15% (CS) and + 0.79 ± 3.71% (NCS)). Significant differences were also noted around the knee (cD) at day 10 (p = 0.026) and a significant trend at cD and at the mid lower leg (cB1) at day 4. The volume of the thigh was also different with marked difference between days 1 and 4 between the two groups (p = 0.021; volume + 0.54 ± 2.03% (CS) and + 4.17 ± 4.67 (NCS)). Pain was lower in compression group (not statistically significant). CONCLUSIONS: Post-operative limb swelling can be reduced significantly by wearing compression stockings in the early post-operative phase when compared to not wearing stockings. This may improve the rehabilitation process after arthroscopic surgery. The optimal duration of compression therapy seems to be between three and ten days. TRIAL REGISTRATION: clinicaltrials.gov ( NCT02096562 , date of registration 11.11.2013).

Prevalence and Progression of Cognitive Impairment in Atrial Fibrillation Patients after Treatment with Catheter Ablation or Drug Therapy.

PURPOSE: In atrial fibrillation (AF) patients, the effect of catheter ablation or drug therapy on cognition is currently not well investigated. Therefore, we prospectively evaluated AF patients who were either treated 'with drug therapy or underwent catheter ablation for the prevalence and progression of cognitive impairment (CI). METHODS: Randomized participants of the CABANA trial (catheter ablation versus antiarrhythmic drug therapy for atrial fibrillation) and the CASTLE-AF (catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation) study were assessed twice within 6 months by Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in our institution. RESULTS: Forty-five patients from both trials were investigated, and twenty-eight patients received catheter ablation, whereas seventeen patients received drug therapy for rhythm or rate control. The mean age of the twenty-one CABANA trial patients (AF group) was 68.8 ± 7.0 years and of the twenty-four CASTLE-AF study patients (AF/HF group) was 66.8 ± 8.1 years, respectively. Mean time from ablation/randomization to the first interview was 16.8 ± 11 months in the AF group and 28.3 ± 18.4 months in the AF/HF group, respectively. All patients investigated were classified as cognitively impaired with mean cutoff scores <24 by MoCA. Overall, we could not detect significant differences in medically treated versus catheter ablation patients within both groups in mean MMSE or MoCA scores between the first and the second interview (p > 0.09). Moreover, patients who received catheter ablation did not show statistically significant differences in the prevalence or progression of cognitive impairment compared to patients who were treated medically, neither within the two groups nor between AF and AF/HF patients (p > 0.05). CONCLUSIONS: Prevalence of cognitive impairment in AF patients with comorbidities is substantial. However, in this preliminary prospective study, no apparent impact of AF pretreatment on the prevalence and course of cognitive impairment could be observed.

Neointimal fibrotic lead encapsulation - Clinical challenges and demands for implantable cardiac electronic devices.

Every tenth patient with a cardiac pacemaker or implantable cardioverter-defibrillator implanted is expected to have at least one lead problem in his lifetime. However, transvenous leads are often difficult to remove due to thrombotic obstruction or extensive neointimal fibrotic ingrowth. Despite its clinical significance, knowledge on lead-induced vascular fibrosis and neointimal lead encapsulation is sparse. Although leadless pacemakers are already available, their clinical operating range is limited. Therefore, lead/tissue interactions must be further improved in order to improve lead removals in particular. The published data on the coherences and issues related to lead associated vascular fibrosis and neointimal lead encapsulation are reviewed and discussed in this paper.

Prevalence of atrial fibrillation and the HATCH score: Intensified monitoring of patients with high HATCH score.

AIM: The HATCH score [hypertension, age > 75 years, previous transient ischemic attack (TIA) or stroke (doubled), chronic obstructive pulmonary disease, heart failure (doubled)] has been established to identify patients who are at risk of developing persistent forms of AF. We investigated whether this score is associated with the prevalence of AF in order to guide diagnostic efforts and therapy. PATIENTS AND METHODS: The data of 150,408 consecutive patients who were hospitalized at the University Hospital of Rostock between 2007 and 2012 were analyzed. Factors constituting the HATCH score and the presence of AF were prospectively documented using ICD-10 admission codes. RESULTS: Patients were 67.6 ± 13.6 years of age with a mean HATCH score of 1.48 ± 1.02; 16 % had a history of AF and 4 % suffered a TIA or stroke. The prevalence of AF increased significantly with the HATCH score up to 60.0 % (p < 0.001). In all, 63 % of the patients had a HATCH score of 0 and 1 without any history of stroke. CONCLUSION: The HATCH score correlates with the occurrence of AF, since the prevalence of AF rises with rising score values. Therefore, the HATCH score may be used to select patients for intensified ECG monitoring. Moreover, the score may also be used for stroke risk assessment, as none of the patients with a low HATCH score suffered a stroke.

Electrophysiological studies in patients with paroxysmal supraventricular tachycardias but no electrocardiogram documentation: findings from a prospective registry.

AIMS: A significant proportion of patients presenting with paroxysmal supraventricular tachycardia (PSVT) has no electrocardiogram (ECG) documentation. In these patients an electrophysiological study (EPS) may be performed to facilitate the diagnosis. METHODS AND RESULTS: In a prospective registry we compared the prevalence of inducible arrhythmias and the clinical outcome in 525 patients with and without ECG documentation. Compared with patients with a documented PSVT a smaller but substantial proportion of patients (63.7%) without ECG documentation had inducible supraventricular tachycardias (SVT). Atrio-ventricular nodal reentrant tachycardia was the most common type in both groups. Patients with an inducible SVT and no documentation were significantly younger, had a shorter episode duration and a lower hospitalization rate, which may be the cause for the lacking documentation. Similar to patients with documented PSVTs most of these patients (90.0%) were asymptomatic or clinically improved after the EPS. Even 43% of patients without an inducible tachycardia improved clinically, probably due to a placebo effect of the EPS. In particular, patients between 31 and 60 years of age seemed to benefit from an EPS because they were more likely to have inducible SVTs that could be cured by radiofrequency ablation. CONCLUSION: Our data show that a substantial proportion of patients with suspected paroxysmal tachycardia, but without ECG documentation, have inducible SVTs and obtain a clear clinical benefit from an EPS. Thus, our data provide justification for using EPS for patients in this category. To the best of our knowledge, ours is the first prospective registry that supports this approach.

Reduction of radiation exposure during ablation of atrial fibrillation.

AIMS: Pulmonary vein isolation (PVI) during ablation of atrial fibrillation (Afib) may be associated with long fluoroscopy duration. Although most current publications report on fluoroscopy time (FT), the dose-area product (DAP) may be a more valuable parameter for depicting radiation exposure. The aim of our study was to describe a method to reduce DAP by simple means during ablation of Afib. METHODS: Patients undergoing Afib ablation using a three-dimensional (3D) mapping system were assigned to two fluoroscopy protocols: (1) standard settings with 7.5 pictures/s and collimation to the heart, fluoroscopy as needed for the convenience of the operator (standard group, SG); and (2) strict collimation to the left atrium, a frame rate of 4 pictures/s, shortened pulmonary vein angiography sequences, and maximal orientation by the 3D mapping system (redDAP group). The primary endpoint was DAP. RESULTS: The study comprised 206 patients, who were assigned to the SG (n = 101, 49 %) or to the redDAP group (n = 105, 51 %). Mean FT was significantly reduced from 29.9 ± 11.3 min (SG) to 13.3 ± 8.3 min (redDAP group); mean DAP was reduced by approximately 90 % from 8,690 ± 5,727 to 837 ± 647 cGycm(2). The groups did not differ significantly in body mass index (28.8 ± 4.1 vs. 29.0 ± 5.0). PVI could be achieved in 98 of 101 patients (97 %) from the SG group and in all patients (100 %) from the redDAP group. Procedure time was significantly longer in the redDAP group (160.9 ± 35.7 vs. 138.1 ± 34.3 min). CONCLUSION: Radiation exposure during Afib ablation procedures can be reduced with simple means by strict collimation to the left atrium, a frame rate of 4 pictures/s, shortened pulmonary vein angiography sequences, and maximal 3D orientation.

Pulmonary vein triggers play an important role in the initiation of atrial flutter: Initial results from the prospective randomized Atrial Fibrillation Ablation in Atrial Flutter (Triple A) trial.

BACKGROUND: The incidence of atrial fibrillation (AF) after ablation of a cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) is high. OBJECTIVE: The purpose of this study was to test the hypothesis that AFL and AF may be initiated by pulmonary vein triggers. This prospective randomized trial tested the efficacy of a standalone pulmonary vein isolation (PVI) in patients with AFL but without AF. METHODS: Patients with AFL but without documented AF were randomly assigned to 1 of 3 treatment groups: (1) antiarrhythmic drugs (AAD), (2) CTI ablation, or (3) circumferential PVI. The primary end-point was defined as any recurrent atrial tachyarrhythmia and the secondary end-point as recurrence of AFL. In case of tachyarrhythmia recurrence in the PVI group, a second PVI was performed to close gaps in the ablation lines. RESULTS: Of the 60 patients, 17 were randomized to AAD, 23 to CTI ablation, and 20 to PVI. During follow-up of 1.42 ± 0.83 years, 14 of 17 patients (82.4%) in the AAD group, 14 of 23 patients (60.9%) in the CTI group, and 2 of 20 patients (10%) in the PVI group reached the primary end-point (P <.001) after a mean of 1.4 PVI procedures per patient. AFL reoccurred in 9 patients (52.9.%) in the AAD group, in 2 patients (8.7%) in the CTI group, and after a single PVI in 3 patients (15%) in the PVI group (P = .003). After closure of gaps, 1 patient (5%) in the PVI group presented with recurrent AFL. CONCLUSION: Pulmonary vein triggers play an important role in AFL. PVI can prevent the recurrence of AFL, even without CTI ablation.

A historical perspective of pacemaker infections: 40-years single-centre experience.

AIMS: The approach to infected cardiac devices has changed during recent decades. Optimal treatment is still a matter of debate, especially in pacemaker-dependent patients. Therefore, we investigated the management and outcome of patients with pacemaker infections in a single centre over four decades. METHODS AND RESULTS: We conducted a retrospective analysis of 4212 patients and extracted those with pacemaker infections admitted to Rostock Heart Center between 1973 and 2012. One hundred and thirty-one consecutive patients (median age 69.6 ± 14.9 years) were admitted for device infections. Two-stage exchange was performed in 42 patients (32.8%). In 72 patients (55%), explantation and implantation on the contralateral side was performed simultaneously. In 17 cases the device was not replaced. Mean follow-up was 63 ± 81 months. Reinfection rate was 12.2%, which declined from 24% (1980s) to 2.6% (after 2000). Complete device removal (in 57.3%) reduced the risk for reinfection by 75% (P = 0.02), as well as increasing age (0.049% per year, P = 0.001). One-stage exchange increased the risk of reinfection six-fold (P = 0.021). Cultured bacteria after initiation of antibiotic therapy predicted a four-fold increase in risk of a recurrent infection (P = 0.01). CONCLUSION: Continuous assimilation of guidelines for pacemaker infection improved the outcome over time: complete extraction of the infected device seems to be highly desirable. A one-stage exchange increased the risk of recurrent device infection and should probably be avoided, but complete extraction seems to be more important than timing.

Prevalence of atrial fibrillation in patients with high CHADS2- and CHA2DS2VASc-scores: anticoagulate or monitor high-risk patients?

BACKGROUND: In patients with known atrial fibrillation (AF) different scores are utilized to estimate the risk of thromboembolic events and guide oral anticoagulation. Diagnosis of AF strongly depends on the duration of electrocardiogram monitoring. The aim of this study was to use established scores to predict the prevalence of AF. METHODS: The CHADS2- (Congestive Heart failure, hypertension, Age >75 years, Diabetes, Stroke [doubled]) and CHA2DS2VASc-score (Congestive Heart failure, hypertension, Age ≥75 years [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74 years, Sex category [female sex]) was calculated in 150,408 consecutive patients, referred to the University Hospital of Rostock between 2007 and 2012. All factors constituting these scores and a history of AF were prospectively documented with the ICD-10 admission codes. RESULTS: Mean age of our study population was 67.6 ± 13.6 years with a mean CHADS2-score of 1.65 ± 0.92 and CHA2DS2VASc-score of 3.04 ± 1.42. AF was prevalent in 15.9% of the participants. The prevalence of AF increased significantly with every CHADS2- and CHA2DS2VASc-score point up to 54.2% in CHADS2-score of 6 and 71.4% in CHA2DS2VASc-score of 9 (P < 0.001). CONCLUSION: The prevalence of AF increases with increasing CHADS2- and CHA2DS2VASc-score. In intermediate scores intensified monitoring may be recommended. In high scores, thromboembolic complications occurred irrespective of the presence of AF and anticoagulant therapy may be initiated irrespective of documented AF.