Is there a difference in rhythm outcome between patients undergoing first line versus second line paroxysmal atrial fibrillation ablation?

BACKGROUND: Catheter ablation of atrial fibrillation (AF) is an established second line therapy for patients with symptomatic paroxysmal AF (PAF) and may be considered as a first line therapy in selected patients who are highly symptomatic, considering patient choice, benefit, and risk, according to recent guidelines. Our study investigated whether a first line vs. second line ablation approach may result in improved sinus rhythm maintenance after ablation. METHODS: A total of 153 patients undergoing pulmonary vein isolation for PAF were included in the study (age 55±12 years, 29% female). Seventy-nine patients underwent first line AF ablation and 74 patients underwent second line AF ablation after failed antiarrhythmic drug therapy. There was no significant difference in baseline characteristics such as age, history of AF, left atrial size or LVEF between groups. Success was defined as atrial tachyarrhythmia free survival during a 12-month follow-up by means of serial ECG Holter monitoring. RESULTS: There was no significant difference in cumulative arrhythmia-free survival between those patients who received AF ablation as a first or second line therapy. Single procedure success was 78% in the first line group vs. 81% in the second line group; multiple procedure success was 90 vs. 91%, (n.s.). Complication rate was 1.3% vs. 1.4% (n.s.). CONCLUSION: Success of AF ablation did not differ between patients who receive ablation as first vs. second line therapy. Based on these data, a trial of AAD therapy before AF ablation may be justified in most patients with symptomatic PAF eligible for rhythm control.

A randomized controlled clinical trial of pacemaker follow-up in clinic and by telemedical interpretation of the pacemakers' magnet mode.

We assessed a two-stage follow-up procedure for cardiac pacemakers, where in-clinic follow-ups were partly replaced by telemedical follow-ups. This was compared with the standard follow-up regime (in-clinic follow-up only). The new procedure required an electronic patient record, a telemedical follow-up unit for recording ECGs while the pacemaker was temporarily set to magnet mode, an ECG processing unit, and a reviewing and reporting unit. A total of 177 (86 female) patients were randomized to the control group and 182 (98 female) patients to the telemedicine group. In the telemedicine group, 234 telemedical follow-ups were performed. Out of these, 68 required an additional in-clinic follow-up, while 166 were sufficient for assessing the pacemakers' working status. During the study, there were 19 deaths in the telemedicine group and 20 in the control group. There was no significant difference between the two groups(P = 0.40). The probability that an individual patient's pacemaker would not to be replaced over time was analysed in a similar way to the Kaplan-Meier survival function. Fewer pacemakers were replaced in the telemedicine group (14) than in the control group (18), but the difference was not significant (P = 0.26). We conclude that alternating telemedical and in-clinic follow-ups brings no additional risks for patients. The follow-up procedure is feasible and interpretation of the pacemakers' magnet effect provides an easy-to-use, manufacturer-independent method of assessing the pacemakers' working status. This should reduce the patient load on pacemaker centres and decrease the overall costs of pacemaker therapy.

Feasibility of a telemedicine framework for collaborative pacemaker follow-up.

We propose a telemedicine framework for remote and manufacturer independent pacemaker (PM) follow-up. The main goal is to provide the caregiver at the point-of-care with an efficient screening method to identify possible malfunction of the pacing system in collaboration with the specialist at the PM clinic. The concept was evaluated in a clinical trial on 44 patients (mean age 76 years). A total of 62 electrocardiogram (ECG) recordings were transmitted using a mobile PM follow-up unit. Using the automatic classification algorithm, 32 PMs were classified as 'OK' and eight PMs were classified as 'not OK'. In four cases a prediction regarding the working status of the PM was not possible. The signal processing classification was confirmed by expert classification (manual review of the ECG). The results indicate that the proposed PM follow-up concept has the potential to work as an efficient screening method and may spare a significant number of patients the burden of having to travel to specialized PM clinics.

[The impact of the Multicenter Automatic Defibrillator Implantation Trial II in a university hospital--do all patients with myocardial infarction and reduced left ventricular function need an implantable cardioverter-defibrillator?]. / Die Auswirkungen nach dem Multicenter Automatic Defibrillator Implantation Trial II in einem kardiologischen Schwerpunktzentrum--müssen alle Postinfarktpatienten mit reduzierter Linksventrikelfunktion einen implantierbaren Kardioverter-Defibrillator erhalten?

BACKGROUND AND OBJECTIVES: Patients with coronary artery disease (CAD) and severely compromised left ventricular ejection fraction are at high risk to die from sudden cardiac death. The Multicenter Automatic Defibrillator implantation Trial II (MADIT II) shows a significant benefit of a cardioverter-defibrillator (ICD) therapy compared to standard treatment alone in this selected group of patients. The objective of the present study was to investigate the number of patients who will fulfil the MADIT II criteria and are candidates for prophylactic ICD implantation. METHODS AND MATERIAL: From January to December 2001 a total of 2653 patients underwent coronary angiography at our institution due to angina pectoris, positive exercise stress testing, pathological SPECT myocardial perfusion images, suspected dilated cardiomyopathy or ventricular arrhythmias. According to the MADIT II inclusion criteria patients with significant coronary artery disease (diameter stenosis > 50%), ejection fraction < 0.31% and previous myocardial infarction were included. Exclusion criteria were acute coronary syndromes, patients with ventricular tachyarrhythmias or an existing indication for ICD therapy, and patients with coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty within the past or following three months. RESULTS: Out of 2653 patients 185 (7%) had an ejection fraction less than 0.31, 149 (5.6%) showed significant coronary artery stenosis and 70 (2.6%) patients fulfilled the MADIT II criteria. The mean age of these patients was 68 +/- 9 years, the left ventricular ejection fraction 24 +/- 6. In 37 patients an ICD system was implanted according to the existing guidelines. 70 patients met the MADIT II inclusion criteria, resulting in an increase of 189% of ICD implantations per year. CONCLUSION: 2.6% out of 2653 patients who were referred to coronary angiography fulfilled the criteria of MADIT II. The expanding indication for ICD therapy will result in an annual increase of 70 (189%) prophylactic ICD implantations in our study population.