European survey on efficacy and safety of duty-cycled radiofrequency ablation for atrial fibrillation.

AIMS: Duty-cycled radiofrequency ablation (RFA) has been used for atrial fibrillation (AF) for around 5 years, but large-scale data are scarce. The purpose of this survey was to report the outcome of the technique. METHODS AND RESULTS: A survey was conducted among 20 centres from seven European countries including 2748 patients (2128 with paroxysmal and 620 with persistent AF). In paroxysmal AF an overall success rate of 82% [median 80%, interquartile range (IQR) 74-90%], a first procedure success rate of 72% [median 74% (IQR 59-83%)], and a success of antiarrhythmic medication of 59% [median 60% (IQR 39-72%)] was reported. In persistent AF, success rates were significantly lower with 70% [median 74% (IQR 60-92%)]; P = 0.05) as well as the first procedure success rate of 58% [median 55% (IQR 47-81%)]; P = 0.001). The overall success rate was similar among higher and lower volume centres and were not dependent on the duration of experience with duty-cycled RFA (r = -0.08, P = 0.72). Complications were observed in 108 (3.9%) patients, including 31 (1.1%) with symptomatic transient ischaemic attack or stroke, which had the same incidence in paroxysmal and persistent AF (1.1 vs. 1.1%) and was unrelated to the case load (r = 0.24, P = 0.15), bridging anticoagulation to low molecular heparin, routine administration of heparin over the long sheath, whether a transoesophageal echocardiogram was performed in every patient or not and average procedure times. CONCLUSION: Duty-cycled RFA has a self-reported success and complication rate similar to conventional RFA. After technical modifications a prospective registry with controlled data monitoring should be conducted to assess outcome.

Pectus excavatum: echocardiography and cardiac MRI reveal frequent pericardial effusion and right-sided heart anomalies.

AIMS: In patients with pectus excavatum (PEX), echocardiographic assessment can be difficult. There are little data on the impact of the chest deformity on echocardiographic findings and comparison of data obtained by echocardiography (echo) with cardiac magnetic resonance imaging (CMR) in PEX. METHODS AND RESULTS: In a prospective study, cardiac anomalies in PEX were analysed by echo and compared with CMR in consecutive patients with PEX referred for echo. If they agreed to participate, the patients were referred for CMR and included if the pectus index was ≥3.0 by CMR. Also, clinical data and electrocardiogram tracings were analysed. There were 18 patients (13 females; 72%), with a mean age of 53±16 years; mean pectus index was 4.7 (range: 3-7.3). Echo showed haemodynamically insignificant pericardial effusion in six patients (33%), tricuspid valve prolapse in five (28%), right ventricular (RV) localized wall motion anomalies (WMA) in five (28%) and diminished RV systolic function in two (11%); no patient had RV dilatation. CMR demonstrated cardiac displacement to the left in 9 patients (50%); minimal pericardial effusion was seen in 10 patients (56%; P value=0.13 compared with echo), RV localized WMA in 6 (44%; P value=1.0), diminished RV systolic function in 8 (44%; P=0.07), and RV dilatation in 5 (28%; P=0.06). A completely normal cardiac examination was found in six patients by echo (33%) and in 2 (11%) using CMR. Although some signs of arrhythmogenic RV cardiomyopathy (ARVC) were present, no patient fulfilled the ARVC criteria. CONCLUSION: In severe PEX, haemodynamically insignificant pericardial effusion, tricuspid valve prolapse and other RV anomalies possibly due to RV displacement are frequent as demonstrated by both CMR and echo. The cardiac assessment by echo and CMR did show discrepancies; however, they were not significant.

[Preoperative assessment of primary varicose veins]. / Präoperative Abklärung der primären Varikose.

The first step in the evaluation of a patient with primary varicose veins is a careful personal history and clinical examination. The individual advice should be based on the disturbance suffered due to the actual varicose veins, "heaviness of the legs" and the advantages and disadvantages of various therapies. The aim of an examination in any type of varicose veins is to determine their relationship to the deep and the surrounding superficial venous system. The continuous-wave Doppler method is often sufficient to examine the trunk of the long saphenous vein. Colour-coded duplex sonography is the chosen method for evaluation of the deep venous system with respect to flow feasibility and valve competence, as well as localization of deficient perforants and anatomic variations at the saphenouspopliteal junction. Phlebography is reserved for cases with inconclusive duplex-sonography results or if no duplex is available. The purpose of this exhaustive preoperative evaluation is to indicate in detail the haemodynamic and anatomic situation in the groin and in the popliteal fossa and to detect the relevant insufficient perforators. Such accurate haemodynamic assessment is the basis for an individualized operation with excellent cosmetic and functional results. Whether a reduced recurrence rate after varicose vein surgery can be shown with this extensive examination scheme has not yet been investigated in a prospective study.

Arterial stent placement with use of the Wallstent: midterm results of clinical experience.

Self-expandable stents of the Wallstent type were used in 26 iliac and 15 femoropopliteal artery lesions of 31 patients to treat stenoses or occlusions. The indications were confined to complex lesions, including residual stenoses and dissections after percutaneous procedures or previous surgery in the iliac artery lesions, and long-segment (mean, 13.5 cm) occlusions with inadequate response to percutaneous recanalization in the femoropopliteal artery lesions. In the iliac artery group, after stent placement, 96% of the lesions were patent at a mean follow-up of 16 months (range, 6-30 months). In the femoropopliteal artery group, of 11 patients available for follow-up, only six had patent stents at 7-26 months (mean, 20 months). Four of these six patients required one to three secondary interventions. Self-expanding endoprostheses are of great value in complex iliac artery lesions where simple balloon dilation is insufficient. Stent placement for long femoral artery lesions should be performed with utmost reserve, and the extent of stent placement should be as short as possible.

[Local thrombolysis of acute and subacute forearm, hand and finger artery occlusions. Early and late results]. / Lokale Thrombolyse von akuten und subakuten Unterarm-, Hand- und Fingerarterien-verschlüssen. Früh- und Spätergebnisse.

21 patients with acute or subacute severe ischemia at the digits due to occlusions of forearm, hand and/or finger arteries were treated by local thrombolysis with urokinase. The medicament (0.6-1.1 million units per day during 1-3 days) was applied by the intraarterial route after cannulation of the cubital or radial artery. Simultaneously, heparin (20,000 units/24 hours) was infused by the same intraarterial catheter. Complete recanalization was obtained in 5 out of 21 patients, partial recanalization with significant clinical improvement in 9 additional patients. Therapeutic success was best with mean duration of symptoms lasting less than 4 weeks and in patients with embolic occlusions. After one year half of the patients had no remaining symptoms. There were no patients with acral necrosis.

[Acquired hemophilia A due to factor VIIIC inhibitor: detection of circulating immune complexes containing factor VIIIC but not factor VIIIR]. / Erworbene Hämophilie A durch Faktor-VIIIC-Hemmkörper: Nachweis zirkulierender Immunkomplexe, die nur Faktor VIIIC, nicht aber Faktor VIIIR enthalten.

In a 79-year-old, otherwise healthy woman who had developed multiple hematomas, laboratory tests revealed a factor VIII inhibitor (8.0 Bethesda units) which caused a decrease in factor VIIIC activity to 1%; factor VIIIR antigen and ristocetin cofactor activity were above normal values. Incubation of patient's plasma with a factor VIIIC sepharose immunoadsorbent partially removed the inhibitor, which was again detected in the IgG-containing eluate. In addition, immune complexes were found in the patient's serum. Whereas incubation of the serum with an immunoadsorbent containing rabbit antihuman factor VIIIR antibodies did not influence the titer of the immune complexes, 43% of which were removed by a rabbit antihuman factor VIIIC immunoadsorbent. This suggests that the factor VIIIC part only may be trapped by the inhibitor, leaving the factor VIIIR part of the molecule unchanged in circulation. This hypothesis is further supported by the fact that the amount of factor VIIIR antigen is likewise not diminished by incubation of patient's plasma with Raji cells.