Case Report: Living on the Edge-Transcatheter Mitral Valve Repair Related Infective Endocarditis.

Background: Infective endocarditis (IE) following mitral valve edge-to-edge repair is a rare complication with high mortality. Case summary: A 91-year-old male patient was admitted to intensive care unit with sepsis due to urinary tract infection after insertion of a urinary catheter by the outpatient urologist. Two weeks ago, the patient was discharged from hospital after successful transcatheter edge-to-edge mitral valve repair (TEER) using a PASCAL Ace device. The initially withdrawn blood revealed repeatedly Proteus mirabilis bacteremia as causal for the sepsis due to urinary tract infection. An antibiotic regime with Ampicillin/Sulbactam was initiated and discontinued after 7 days. During the clinical course the patient again developed fever and blood cultures again revealed P. mirabilis. In transesophageal echocardiography (TOE), IE of the PASCAL Ace device was confirmed by a vegetation accompanied by a mild to moderate mitral regurgitation. While the patient was stable at this time and deemed not suitable for cardiac surgery, the endocarditis team made a decision toward a prolonged 6-week antibiotic regime with an antibiotic combination of Ampicillin 2 g qds and Ciprofloxacin 750 mg td. Due to posterior leaflet perforation severe mitral regurgitation developed while PASCAL Ace vegetations were significantly reduced by the antibiotic therapy. Therefore, the patient underwent successful endoscopic mitral valve replacement. Another 4 weeks of antibiotic treatment with Ampicillin 2 g qds followed before the patient was discharged. Discussion: P. mirabilis is able to form biofilms, resulting in a high risk for endocarditis following transcatheter mitral valve repair especially when device endothelization is incomplete. Endoscopic mitral valve replacement could serve as a bailout strategy in refractory Clip-endocarditis.

Cardiac adaptations in elite female football- and volleyball-athletes do not impact left ventricular global strain values: a speckle tracking echocardiography study.

Cardiac adaptations to exercise on an elite level have been well studied. Strain analysis by speckle tracking echocardiography has emerged as a tool for sports cardiologists to assess the nature of hypertrophy in athletes' hearts. In prior studies, strain values generally did not change in physiological adaptations to exercise but were reduced in pathological hypertrophy. However, research in this field has focused almost solely on male athletes. Purpose of the present study is to investigate strain values in the hearts of female elite athletes in football and volleyball. In this cross-sectional study echocardiography was performed on 19 female elite football-players, 16 female elite volleyball-players and 16 physically inactive controls. Conventional echocardiographic data was documented as well as left ventricular longitudinal, radial and circumferential strain values gained by speckle tracking echocardiography. The hearts of the female athletes had a thicker septal wall, a larger overall mass and larger atria than the hearts in the control group. Global longitudinal, radial and circumferential strain values did not differ between the athletes and controls or between sporting disciplines. No correlation between septal wall thickness and global strain values could be documented. Cardiac adaptations to elite level exercise in female volleyball and football players do not influence global strain values. This has been documented for male athletes of several disciplines. The present study adds to the very limited control-group comparisons of left ventricular strain values in elite female athletes. The findings indicate that global strain values can be used when assessing the cardiac health in female athletes.

Long-term impact of a bonus freeze on clinical outcome: Analysis of effective and non-effective bonus freezes in cryoballoon ablation.

PURPOSE: Data on bonus freeze characteristics and their impact on complication rates and long-term clinical outcome are limited. METHODS: Pulmonary vein isolation (PVI) using a 28 mm 2nd-generation cryoballoon (CB) was performed in 169 patients (pts). The isolation temperatures, time to isolation and minimal temperatures of the cryoapplications were documented. RESULTS: The study included 92 pts who received one bonus freeze after PVI in group I and 77 pts who did not receive a bonus freeze in group II. After a mean follow-up time of 19.0±8.6 months in group I and 16.4±7.5 months in group II, 67 of 92 pts (72.8%) and 49 of 75 pts available to follow up (65.3%; p = 0.221) were free of atrial tachyarrhythmia, respectively. Phrenic nerve palsy occurred in 5.4% of the pts in group I (5/92 pts) and 1.3% of the pts in group II (1/77 pts; p = 0.22). Both the mean nadir temperatures of the bonus freezes and mean nadir temperatures of the isolation freezes differed significantly between the recurrent and non-recurrent pts in group I. The predilection sites of the reconduction for both groups were the inferior aspect of the inferior pulmonary veins. CONCLUSION: The impact of a bonus freeze on long-term clinical outcome was not significant for two reasons: 1) The necessity of a bonus freeze was low because the long-term clinical success rate without a bonus freeze was high; and 2) the majority of bonus freezes, especially at the predilection sites, such as the inferior PV, appeared to be ineffective.

Cryoballoon ablation for pulmonary vein isolation in patients with atrial fibrillation: preliminary results using novel short-tip cryoballoon.

PURPOSE: In this study, we aimed to report our preliminary experience regarding the impact of the novel short-tip (ST) cryoballoon (CB) on procedural efficacy and signal quality during pulmonary vein (PV) isolation for both paroxysmal and persistent atrial fibrillation. METHODS: Between March, 2015, and August, 2015, we enrolled a total of 64 patients (47 patients male, 73 %) with a mean age of 60 ± 11 years. In the study population, 31 patients (48 %) underwent PVI using Advance (ADV) CB and 33 (52 %) patients with ST CB. In all patients, a 28-mm balloon was used. RESULTS: Acute procedural success rates were 100 % for the entire study population. A statistically insignificant increase in the percentage of PV signal recordings was observed with ST CB in all PVs compared to ADV CB [88 vs. 81 % for left superior PV (LSPV), 82 vs. 78 % for left inferior PV (LIPV), 85 vs. 84 % for right superior PV (RSPV), 82 vs. 71 % for right inferior PV (RIPV), p < 0.05]. Additionally, the difference in minimum temperature reached during the procedure per PV was not statistically significant between ST CB and ADV CB except the LIPV (LSPV -44.2 ± 5.9 vs. -45.6 ± 5.3 °C, p = 0.970; LIPV -38.7 ± 4.6 °C vs -44.6 ± 6.8 °C, p < 0.001; RSPV -45.6 ± 7.4 °C vs.-47.2 ± 6.1 °C, p = 0.168; RIPV -41.4 ± 5.1 °C vs.-43.7 ± 6.3 °C, p = 0.360). Time to isolation for each PV was similar between ST and ADV CB (p > 0.05). CONCLUSION: Our preliminary findings indicated similar acute procedural success for the novel ST CB compared with second generation ADV CB. The increase in the ratio of PV signal recordings obtained during the PVI using the novel ST CB was not significant.

Characterization of Electrical Reconnection Following Pulmonary Vein Isolation Using First- and Second-Generation Cryoballoon.

BACKGROUND: Second-generation cryoballoon (CB-2) is associated with improved outcomes for pulmonary vein isolation (PVI) compared to first generation (CB-1). However, data regarding the predictors of pulmonary vein (PV) electrical reconnection are limited. In this study, we aimed to characterize the predilection sites and predictors of reconnection in patients with recurrent atrial tachyarrhythmia (ATa) after PVI using CB-1 and CB-2. METHODS: A total of 59 patients (mean age: 62 ± 11 years and 66% male) with recurrent ATa after previous CB-PVI, using either a 28-mm CB-1 or CB-2, underwent repeat ablation. PV reisolation was performed by irrigated radiofrequency ablation using three-dimensional electroanatomical mapping systems. RESULTS: Electrical PV reconnection was detected in 10 of 11 (91%) of CB-1 patients compared to 41 of 48 (85%) of CB-2 patients. Time to redo procedure after index CB-1 was 8.9 ± 10.2 months and 11.2 ± 7.0 months in CB-2. Bonus freeze was applied in all patients with CB-1 and 41% of the patients with CB-2. Superior quadrants of both superior PVs and inferior quadrants of the both inferior PVs exhibited higher predilection for conduction compared to other quadrants (P < 0.001). Multivariate binary logistic analysis revealed that right inferior PV (RIPV; odds ratio [OR]: 1.52, 95% confidence interval [CI]: 1.09-2.13, P = 0.014) and minimum temperature (OR: 1.09, 95% CI: 1.03-1.15, P = 0.004) were the independent predictors of electrical reconnection after CB-2 ablation. CONCLUSION: Conduction gaps after CB-1 and CB-2 were higher in inferior PVs compared to superior PVs. The RIPV and minimum CB temperature were independent predictors of PV electrical reconnection after CB-2.

The Total Incidence of Complications and the Impact of an Anticoagulation Regime on Adverse Events After Cryoballoon Ablation of Atrial Fibrillation: A Single-Center Study of 409 Patients.

AIM: Data evaluating the complications of pulmonary vein isolation (PVI) using second-generation cryoballoons (CB) related to different anticoagulation regimes are limited. This study evaluates the total complications and the impact of novel oral anticoagulants (NOACs) compared to phenprocoumon on adverse events in the setting of PVI using CB. METHODS AND RESULTS: PVI was performed using second-generation CB by two experienced investigators. A total of 409 patients (58.9% male; mean age = 61 ± 10 years) with atrial fibrillation were included in this study. In group I, 150/409 (36.7%) patients received phenprocoumon therapy, and in group II, 259/409 (63.3%) patients were treated with NOACs (rivaroxaban: n = 193; dabigatran: n = 48; and apixaban: n = 18). In both groups, the rates of major complications were similar (group I [phenprocoumon]: four pts (2.7%) vs. Group II [NOACs]: seven pts (2.7%); P = 0.999). In this cohort, 275 patients were ablated with the bonus freeze protocol, and 134 patients were ablated without bonus freezes. The procedure duration significantly decreased with the bonus freeze protocol from 102.3 ± 24.6 min to 68.5 ± 16.2 min (P < 0.001). The impact of the bonus freeze on the postprocedural increase of C-reactive protein (CRP) levels was significant compared to the postprocedural CRP levels after procedures without the bonus freeze protocol (postprocedural CRP level+ bonus protocol: 1.6 ± 1.2 mg/L vs. postprocedural CRP level+ nonbonus protocol: 1.3 ± 1.3 mg/L; P = 0.04). CONCLUSION: The incidence of adverse events in PVI using the second-generation CB with the periprocedural administration of NAOCs was not significantly different compared to phenprocoumon. Further, large-scale randomized studies are needed to evaluate the safety of two anticoagulation regimes comparing vitamin K antagonists and NOACs, as well as different NOAC regimes, in patients undergoing PVI using cryoballoon ablation.

Rotational Angiography Based Three-Dimensional Left Atrial Reconstruction: A New Approach for Transseptal Puncture.

AIM: Rotational angiography is a well-known method for the three-dimensional (3-D) reconstruction of left atrium and pulmonary veins during left-sided atrial arrhythmia ablation procedures. In our study, we aimed to review our experience in transseptal puncture (TSP) using 3-D rotational angiography. METHODS: We included a total of 271 patients who underwent atrial fibrillation ablation using cryoballoon. Rotational angiography was performed to get the three-dimensional left atrial and pulmonary vein reconstructions using cardiac C-arm computed tomography. The image reconstruction was made using the DynaCT Cardiac software (Siemens, Erlangen, Germany). RESULTS: The mean age of the study population was 61 ± 10 years. The indications for left atrial arrhythmia ablation were paroxysmal AF in 140 patients (52%) and persistent AF patients in 131 (48%) patients. The success rate of TSP using only rotational guidance was (264/271 patients, 97.4%). In the remaining seven patients, transesophageal guidance was used after the initial attempt due to thick interatrial septum in five patients and difficult TSP due to abnormal anatomy and mild pericardial effusion in the remaining two patients. Mean fluoroscopy dosage of the rotational angiography was 4896.4 ± 825.3 µGym(2). The mean time beginning from femoral vein puncture to TSP was 12.3 ± 5.5 min. CONCLUSION: TSP guided by rotational angiography is a safe and effective method. Our results indicate that integration of rotational angiographic images into the real-time fluoroscopy can guide the TSP during the procedure.

Cryoballoon Ablation for Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation: One-Year Outcome Using Second Generation Cryoballoon.

BACKGROUND: Data regarding the freedom from atrial fibrillation (AF) in the follow-up of persistent AF patients is limited. The second-generation cryoballoon has better cooling properties compared with first-generation cryoballon. In this study, we aimed to assess the medium-term efficacy of second-generation cryoballoon in patients with persistent AF. METHODS AND RESULTS: A total of 100 patients (63±10 years, 80% male) with symptomatic persistent AF, despite ≥1 antiarrhythmic drug(s), who were scheduled for pulmonary vein isolation using second-generation cryoballoon were enrolled in this study. Follow-up was based on outpatient clinic visits, including Holter ECGs. Recurrence was defined as a symptomatic or documented arrhythmia episode of >30 seconds excluding a 3-month blanking period. As a result, 393 pulmonary veins (7 patients with common ostium) were successfully isolated. Mean procedural and fluoroscopy times were 96.2±21.3 and 19.7±6.7 minutes, respectively. Phrenic nerve palsy occurred in 3% (3/100) of the patients. At a mean follow-up duration of 10.6±6.3 months, 67% of the patients were in sinus rhythm. Stepwise multivariable Cox proportional hazard regression analysis showed that early AF recurrence (hazard ratio 3.83, 95% confidence interval 1.91-7.68, P<0.001) was the only independent predictor for late AF recurrence apart from other clinical and echocardiographic variables. CONCLUSIONS: Our findings indicated that second-generation cryoballoon use is associated with favorable outcomes in patients with persistent AF. Recurrence at blanking period was the only predictor of long-term AF recurrence.

Non-invasive determination of the optimized atrioventricular delay in patients with implanted biventricular pacing devices.

BACKGROUND: Biventricular (BiV) is extensively used in the treatment of congestive heart failure but so far no recommendations for optimized programming of atrioventricular-delay (AVD) settings have been proposed. Can AVD optimization be performed using a simple formula based on non-invasive doppler-echocardiography? METHODS: 25 patients (ejection fraction 30+/-8%) received BiV ICDs. Doppler-echocardiographic evaluation of diastolic and systolic flow was performed for different AVDs (30ms to 150ms) and different stimulation sites (left ventricular (LV), right ventricular and BiV). The optimal atrioventricular delay was calculated applying a simple formula based on systolic and diastolic mechanical delays determined during doppler-echocardiography. RESULTS: The mean optimal AVD was calculated to be 112+/-29ms (50 to 180ms) for BiV, 95+/-30ms (65 to 150ms) for LV and 75+/-28ms (40 to 125ms) for right ventricular pacing with wide interindividual variations. Compared to suboptimal AVDs diastolic optimization improved preejection and ejection intervals independent to pacing site. Optimization of the AVD significantly increased ejection time during BiV pacing (279ms versus 266ms; p<0.05). Compared to LV or right ventricular pacing BiV pacing produced the shortest mean pre-ejection and longest ejection intervals as parameters of improved systolic ventricular contractile synchrony. Diastolic filling times were longest during BiV pacing compared to LV or RV pacing. CONCLUSIONS: Individual programming of BiV pacing devices increases hemodynamic benefit when implementing the inter-individually widely varying electromechanical delays. Optimization applying a simple formula not only improves diastolic ventricular filling but also increases systolic functional parameters.

Predicting successful pulmonary vein isolation in patients with atrial fibrillation by brain natriuretic Peptide plasma levels.

BACKGROUND: Catheter ablation for atrial fibrillation is a clinically established treatment by now while success rate varies between 60% and 85%. Interventional treatment of atrial fibrillation is still a challenging technique associated with a long procedure time and risk of major complications in up to 6 % of treated patients. The aim of this study was to investigate the predictive value of plasma brain natriuretic peptide (BNP) in patients undergoing pulmonary vein isolation concerning stable sinus rhythm after ablation. METHODS: In 68 consecutive patients with atrial fibrillation (AF) and normal left ventricular ejection fraction, BNP was measured at baseline before pulmonary vein isolation (PVI). All patients received a 7-days-holter monitoring 3 months after radiofrequency (RF) ablation in order to detect recurrent AF episodes. RESULTS: 48 patients with paroxysmal and 20 patients with persistent AF were enrolled. Baseline BNP was significantly higher in patients with persistent AF compared to patients with paroxysmal AF (145,5 pg/ml vs. 84,4 pg/ml; p<0,05). 3 months after PVI 38 patients (79,1%) with paroxysmal AF had a stable sinus rhythm documented on 7-days-holter monitoring, where as in 10 patients (20,9%) AF episodes were detected. Patients with a successful PVI showed significantly lower BNP plasma levels at baseline compared to patients with AF recurrrence (68,7 pg/ml vs. 144,1 pg/ml; p<0,05). In patients with persistent AF 55% (11 cases) had no recurrence of AF at 3 months 7-days holter and in 9 patients (45%) AF recurred. BNP plasma levels at baseline were lower in patients with stable sinusrhythm after 3 months compared to the group of recurrent AF (105,8 pg/ml vs. 193,3 pg/ml; p=0,11). CONCLUSIONS: Patients with AF and low preprocedural BNP plasma levels showed a better outcome after PVI. Thus BNP may be helpful in patient selection for a successful treatment of AF by PVI.