[Long-term outcome of AV node modulation in 387 consecutive patients with AV nodal reentrant tachycardia]. / Langzeitergebnisse nach AV-Knoten-Modulation bei 387 konsekutiven Patienten mit AV-Knoten-Reentry-Tachykardie.

UNLABELLED: Aim of this study was to assess the long-term results of AV-node modulation in patients with AV nodal reetrant tachycardia. METHODS: From December 1991 until September 1999, AV node modulation (ablation of the fast pathway or ablation/modification of the slow pathway) was performed in 387 consecutive patients with clinically apparent AV nodal reentrant tachycardia. Follow-up data was available in 95% of patients with a mean of 41 +/- 26 months after ablation. RESULTS: Acute success rate was 97%. During long-term follow-up recurrence rate was 7.4% without any difference between fast and slow pathway ablation. Recurrence occurred in 23% of patients with persistent dual AV node physiology after ablation (modification of the slow pathway) in contrast to 3% without dual AV node physiology (ablation of the slow pathway) (p = 0.002). The presence of a dual AV node physiology after slow pathway modulation was the only predictor of recurrence during long-term follow-up. The complication rate was 5.7%. The incidence of complete heart block was 1% without any difference between fast and slow pathway ablation. CONCLUSIONS: Catheter modulation of the AV node for the treatment of AV nodal reentrant tachycardia is effective and safe. During long-term follow-up, the recurrence rate was low. Modulation of the slow pathway is associated with a significantly higher recurrence rate than ablation of the slow pathway.

Biventricular pacing in patients with ICD: how many patients are possible candidates?

BACKGROUND: About 80 % of patients receiving an implantable cardioverter-defibrillator (ICD) due to life-threatening episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) have structural heart disease. ICD implantation reduces the risk of sudden cardiac death to less than 2 %. However, the major obstacle in these patients is chronic heart failure (CHF). Biventricular stimulation (BIV) has shown its efficiency as an alternative therapy in drug refractory CHF. METHODS: According to the InSync registry, we predefined possible indications for BIV as follows: complete branch bundle block (> 120 ms), left-ventricular ejection fraction (EF) < 35 % and NYHA class > II. We evaluated the number of patients presenting this indication at time of implant and during follow-up (FU) at our ICD clinic. RESULTS: Between 1992 and 1998, 360 patients were provided with an ICD (mean age 64.6 +/- 5.4 yrs, mean EF 37 +/- 14 % at implant, 82 % of patients with organic heart disease). Mean FU was 34 +/- 21 months. During FU 46 patients (13 %) died, 15 of these (33 %) presenting criteria for BIV. 33 patients died of heart failure, there was 1 sudden death and 12 patients died for non-cardiac reasons. 35 % of the patients who died of heart failure had an indication for BIV. CONCLUSIONS: About 10 % of ICD patients had an indication for BIV at time of implant. Over a mean FU period of 34 months, 16% of all patients presented an indication for BIV. Patients with an indication for BIV had a higher mortality rate and more frequent atrial fibrillation compared to patients without. With this data and the good clinical results after BIV-ICD implantation, we consider the implantation of a BIV-ICD system in every patient with appropriate indications.

[Initial experience with an implantable loop recorder in patients with unexplained syncope]. / Erste Erfahrungen über den diagnostischen Nutzen eines implantierbaren Langzeit-Ereignisrekorders (Endless-Loop-Rekorder, REVEAL((R))) bei Patienten mit unklaren Synkopen.

Patients with recurrent syncope undiagnosed after extensive noninvasive and invasive testing pose a diagnostic and therapeutic dilemma. Holter monitoring is non-diagnostic in 90% of cases. Recent developments in loop recorder technology permit longterm ECG monitoring in patients with recurrent unexplained syncope. The implantable loop recorder monitors a single lead electrogram continuously using 2 sensing electrodes on the device shell. The device was implanted in 20 patients (11 male, 9 female) with the history of recurrent syncope. During a mean follow-up of 12+/-6 months after device implantation, 11 patients (55%) experienced syncope (8 pts) or presyncope (3 pts). In the remaining 9 patients, no syncope occurred. In all 11 patients with syncope or presyncope during follow-up, loop recording definitively determined whether an arrhythmia was the cause of symptoms or not. Diagnosis included bradycardia in one patient, tachycardia in two patients, in one patient two rhythm disturbances were revealed: frequent ventricular premature beats with bigemini and atrial flutter. Two patients had a neurocardiogenic syncope. Syncope was nonarrhythmic in 5 patients. An implantable loop recorder is useful for establishing the diagnosis if symptoms are recurrent but too infrequent for conventional monitoring techniques.

[Lead-related complications in 340 patients with an implantable cardiverter/defibrillator]. / Komplikationen mit Sonden bei 340 Patienten mit einem implantierbaren Kardioverter/Defibrillator.

From February 1991 to May 1998, 340 patients had a cardioverter/defibrillator (ICD) implanted. Mean age was 64 +/- 9 years, 278 male and 62 female. 60% of patients had coronary artery disease and 31% dilatative cardiomyopathy. Ejection fraction was 38 +/- 14%. The indication for an implantable cardioverter/defibrillator was in 57% of patients ventricular tachycardia, in 43% ventricular fibrillation. 298 patients had a single-chamber cardioverter/defibrillator implanted, 42 patients a dual-chamber cardioverter/defibrillator. In 25 patients additional subcutaneous patch or array electrodes and in 2 patients additional epicardial patch electrodes were implanted. Implantation site was in 92 patients abdominal and in 248 pectoral. Over a period of 7 years 34 lead-related complications occurred in 33 patients (9.7%), after a median of 2 months after implantation. Diagnosis was made by routine chest x-ray in about 55% of lead-related complications, by clinical presentation (inadequate therapy, pain) in 24%, and by electrical parameters in 21%. In patients with an abdominal implantation site, lead-related complications occurred in 20%, in contrast to 6% in patients with a pectoral implantation site. Regarding patients with pectoral implantation site, lead-related complications were observed in 12% of patients with a dual-chamber ICD vs 4% with a single-chamber ICD (p = 0.05), due to dislocation of atrial electrodes with dual-chamber ICD. There were no differences in clinical parameters between patients with pectoral vs abdominal and between single vs dual-chamber ICD. There were no deaths due to lead-related complications.

[Clinical experience with the implantable atrial defibrillator (atrioverter) in patients with atrial fibrillation. Metrix Investigators]. / Klinische Erfahrungen mit dem implantierbaren atrialen Defibrillator (Atrioverter) bei Patienten mit Vorhofflimmern. Metrix Investigators.

Due to the limited efficacy of drug therapy in atrial fibrillation and the high rate of recurrence, strong efforts were made to find non-pharmacological strategies. For three years now, the implantable atrial defibrillator Metrix from InControl has been available as an alternative therapy. From October 1995 to the present the atrial defibrillator was implanted in 179 patients worldwide. The sensitivity of the system and its algorithms to detect atrial fibrillation is 90%; the specificity to detect sinus rhythm is 100%. In 121 of 179 patients, 748 episodes of spontaneous atrial fibrillation were treated with 2.4 shocks per episode. No proarrhythmic event or stroke was seen. A cardioversion to sinus rhythm could be achieved in 95% of patients; the overall clinical success rate was 88%. In 7% of all patients, early recurrence of atrial fibrillation (ERAF) occurred that could not be converted into stable sinus rhythm after further cardioversions and antiarrhythmic therapy. In 4.1% there were lead-related complications, in 4 patients the device had to be explanted because of ineffective therapy, and in 3 patients the device had to be changed because of loss of telemetry or early depletion of battery. In 8 patients, postoperative complications were seen (infections, pneumothorax and thrombosis of the subclavian vein). Overall, the implantable atrial defibrillator Metrix is an effective and safe alternative in treating atrial fibrillation.

Importance of preimplantation procedures in candidates for an implantable atrial defibrillator.

INTRODUCTION: Due to the limited efficacy of antiarrhythmic drugs for the treatment of atrial fibrillation, several nonpharmacologic therapeutic options have been developed. One of these options is an implantable atrial defibrillator for patients with severe symptoms and infrequent drug-refractory episodes of atrial fibrillation. The purposes of this study were: (1) to evaluate how many patients with atrial fibrillation are possible candidates for an implantable atrial defibrillator; and (2) to report the results and findings of preimplantation testing in a single center. METHODS AND RESULTS: From our atrial fibrillation outpatient clinic, we evaluated the number of possible candidates for an atrial defibrillator using the following criteria: (1) recurrent persistent atrial fibrillation; (2) long-lasting but infrequent episodes; (3) refractory to antiarrhythmic drugs; (4) capability of maintaining normal sinus rhythm; and (5) no factors increasing proarrhythmic risk. In those patients eligible for an atrial defibrillator, a separate preimplantation test was performed to evaluate atrial defibrillation limits and patient acceptance. Thirty-one of 196 patients were possible candidates for an atrial defibrillator. Fourteen of these 31 patients agreed to participate in the METRIX clinical study phase I on atrial defibrillators. Six of these patients met implantation criteria; two patients refused permanent implantation because of intolerable pain. Implantation was performed in four patients; however, one patient could not be cardioverted intraoperatively despite a successful preimplantation test. CONCLUSION: About 16% of selected patients with atrial fibrillation are possible candidates for an atrial defibrillator. However, successful preimplantation testing does not exclude implantation failure.

[Double pylorus (author's transl)]. / Doppelpylorus.

Smith and Tuttle described in 1969 for the first time a double pylorus; since then this anomaly has been found repeatedly. The pathogenesis is still discussed; the anomaly may be congenital or acquired. A case report is given of a patient with double pylorric ulcer.