[Show abstract][Hide abstract] ABSTRACT: The aim of this multicentre study was to determine the normal range and the clinical relevance of the myocardial function of the left atrium (LA) analysed by 2D speckle-tracking echocardiography (2DSTE).
[Show abstract][Hide abstract] ABSTRACT: A 79-year-old female patient presented to our outpatient clinic for the first postoperative visit after implantation of a single chamber ICD (Biotronic Iforia 3). The ICD was implanted 6 weeks before for primary prophylaxis. The patient had been diagnosed with ischemic heart disease with an ejection fraction of 30%. The patient's further medical history included persistent atrial fibrillation, hypertension, diabetes and chronic renal insufficiency. This article is protected by copyright. All rights reserved.
Journal of Cardiovascular Electrophysiology 09/2014; · 3.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Catheter ablation of atrial fibrillation has been associated with left-sided phrenic nerve palsy. Knowledge of the individual left phrenic nerve course therefore is essential to prevent nerve injury. The aim of this study was to test the feasibility of an intraprocedural pace mapping and reconstruction of the left phrenic nerve course and to characterize which anatomical areas are affected.
In patients undergoing left atrial catheter ablation, a three-dimensional map of the left atrial anatomical structures was created. The left-sided phrenic nerve course was determined by high-output pace mapping and reconstructed in the map.
In this study, 40 patients with atrial fibrillation or atrial tachycardias were included. Left phrenic nerve capture was observed in 23 (57.5%) patients. Phrenic nerve was captured in 22 (55%) patients inside the left atrial appendage, in 22 (55%) in distal parts, in 21 (53%) in medial parts, and in two (5%) in ostial parts of the appendage. In three (7.5%) patients, capture was found in the distal coronary sinus and in one (2.5%) patient in the left atrium near the left atrial appendage ostium. Ablation target was changed due to direct spatial relationship to the phrenic nerve in three (7.5%) patients. No phrenic nerve palsy was observed.
Left-sided phrenic nerve capture was found inside and around the left atrial appendage in the majority of patients and additionally in the distal coronary sinus. Phrenic nerve mapping and reconstruction can easily be performed and should be considered prior catheter ablations in potential affected areas.
Pacing and Clinical Electrophysiology 05/2014; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Monitoring of cerebral tissue oxygen saturation (SctO2 ) reflects cerebral microcirculation. We sought to characterize the decrease in SctO2 during supraventricular tachycardia (SVT) and ventricular tachycardia (VT) in adults.
Pacing and Clinical Electrophysiology 05/2014; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pulmonary vein isolation (PVI) is the state-of-the-art treatment of atrial fibrillation (AF). Pulmonary vein reconnection is one of the main mechanisms of AF recurrence after ablation. Catheter-tissue contact is essential for effective ablation lesions. The aim of this study was to evaluate the impact of catheter contact monitoring during PVI on AF recurrence rate.
Archives of medical science : AMS. 05/2014; 10(2):266-72.
[Show abstract][Hide abstract] ABSTRACT: Pulmonary vein isolation (PVI) is widely established as a curative treatment option for atrial fibrillation (AF). A wide range of techniques to improve catheter manipulation and steerability has been developed over the past years. A new remote catheter system (RCS) has recently become available (Amigo Remote Catheter System, Catheter Robotics, Budd Lake, NJ, USA). Here, we present a dual-center study on the RCS for left atrial mapping and PVI in patients with paroxysmal AF compared to a control group undergoing conventional PVI.
One hundred nineteen patients who underwent PVI for paroxysmal AF were studied. Forty patients underwent PVI with the use of the RCS. Seventy-nine patients, who underwent conventional PVI, served as control group. Procedural data were compared between the two groups.
PVI was achieved in all patients. In the RCS group compared to standard ablation group, there were no significant differences in procedure duration (159.1 ± 45.4 vs. 146 ± 30.1 min, p = 0.19), total energy delivery (78,146.3 ± 26,992.4 vs. 87,963.9 ± 79,202.1 Ws, p = 0.57), and total fluoroscopy time (21.2 ± 8.6 vs. 23.9 ± 5.4 min, p = 0.15). Operator fluoroscopy exposure was significantly reduced in the RCS group (13.4 ± 6.1 vs. 23.9 ± 5.4 min, p < 0.001).
These initial results suggest that left atrial mapping and PVI are feasible with the use of the Amigo RCS. Acute procedural efficacy is comparable to the standard approach. The use of the Amigo RCS leads to a significant reduction of operator fluoroscopy exposure.
Journal of Interventional Cardiac Electrophysiology 04/2014; · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Catheter ablation is a curative treatment option for ventricular premature contractions (VPC) and ventricular tachycardia (VT). Procedures require different sedation levels, depending on duration, ablation approach and patient characteristics. The aim of our study was to evaluate feasibility of minimal and deep sedation for ablation of VPC/VT.
Patients underwent catheter ablation of VPC/VT under minimal or deep sedation. Events of hypotension, hypoxia, bradycardia, procedural complications and VT inducibility were compared between the groups.
120 patients were included. In 42 patients (53.6±17.1years, 47.6% male) ablation was performed under minimal sedation with midazolam, and in 78 patients (54.2±17.5years, 67.9% male) ablation was performed under deep sedation with propofol/midazolam. There were significantly fewer patients with idiopathic VT (62.8 vs. 88.1%, p=0.011) in the deep sedation group, LVEF was significantly lower (47±14.4 vs. 53.1±11.7) and the procedure duration was significantly longer (201.9±85.9 vs. 137.9±98.7). No significant differences in procedural complications or sedation related events (hypotension: 0 vs. 3.8%, p=0.2, no hypoxia, no bradycardia) were detected.
Minimal sedation and deep sedation are both feasible during VPC/VT ablation procedures. Propofol does not increase complications even in a collective with pre-existing impairment of LVEF. Adequate monitoring and trained personnel should be present.
International journal of cardiology 01/2014; · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The aim of this multicenter study was to determine the normal ranges and the clinical relevance of multidirectional systolic parameters to evaluate global left ventricular (LV) systolic function.
Three hundred twenty-three healthy adult subjects prospectively included at 10 centers and a cohort of 310 patients with hypertension were analyzed. Multidirectional global LV systolic function was analyzed using two-dimensional speckle-tracking echocardiography by means of two indices: longitudinal-circumferential systolic index (the average of longitudinal and circumferential global systolic strain) and global systolic index (the average of longitudinal, circumferential, and radial global systolic strain).
The ranges of values of the multidirectional systolic parameters in healthy subjects were −21.22 ± 2.22% for longitudinal-circumferential systolic index and 29.71 ± 5.28% for global systolic index. In addition, the lowest expected values of these multidirectional indices were determined in this population (calculated as −1.96 SDs from the mean): −16.86% for longitudinal-circumferential systolic index and 19.36% for global systolic index. Concerning the clinical relevance of these measurements, these indices indicated the presence of subtle LV global systolic dysfunction in patients with hypertension, even though LV global longitudinal systolic strain and LV ejection fraction were normal. Moreover, in these patients, functional class (dyspnea [New York Heart Association classification]) was inversely related to both the longitudinal-circumferential index and the global systolic index.
In the present multicenter study analyzing a large cohort of healthy subjects and patients with hypertension, the normal range and the clinical relevance of multidirectional systolic parameters to evaluate global LV systolic function have been determined.
Journal of the American Society of Echocardiography 01/2014; · 4.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF incidence increases with age. AF ablation procedures are routinely performed under deep sedation with propofol. The purpose of the study was to evaluate if propofol deep sedation during AF ablation is safe in elderly patients.
Four hundred one consecutive patients (mean age, 61.4 ± 11.1 years; range, 20-82; 66.3 % men) who were presented to our institution for ablation of symptomatic AF were enrolled. Patients were divided into three groups: Patients in group A were ≤50 years old; patients in group B were 51-74 years old; and patients in group C were ≥75 years old. Procedures were performed under deep sedation with propofol, midazolam, and piritramide. SaO2, electrocardiogram, arterial blood pressure, and arterial blood gas were monitored throughout the procedure. Sedation-related complications, intraprocedural complications, and other adverse events were evaluated. Fisher exact or χ (2) tests were used for comparison of adverse events and complications among groups. Analysis of variance was used to compare sedation- and procedure-related parameters.
Fifty-three (13.2 %) elderly patients were in group C and were compared to 73 (18.2 %) patients in group A and 275 (68.8 %) in group B. No significant differences in sedation-related or intraprocedural complications were seen (group A, 1.4 %; group B, 1.1 %; group C, 3.7 %; p = 0.336). Despite a significantly greater drop in systolic blood pressure in under sedation in group C (group A, 15.5 ± 9.5 mmHg; group B, 18.9 ± 16.3 mmHg; group C, 32.3 ± 15.5 mmHg; p < 0.001), no prolonged hypotension was observed. The rate of other adverse events (delirium, respiratory infection, renal failure) was significantly higher in group C (9.4 %), compared to group A (0 %) and group B (2.2 %; p = 0.004).
Deep sedation with propofol and midazolam during AF ablation did not result in an increased rate in sedation-related complications in elderly patients. Similarly, the rate of procedural complications was not significantly different among the study groups. The rate of respiratory infections and renal failure was significantly higher in the elderly. All adverse events were treated successfully without any remaining sequelae.
Journal of Interventional Cardiac Electrophysiology 09/2013; · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cerebral and microvascular perfusion is reduced in atrial fibrillation (AF). Maintenance of brain perfusion is important in acute disease and long-term course. Assessment of brain perfusion and oxygenation is difficult in clinical practice. Our study aimed to determine changes in cerebral tissue oxygen saturation (SctO2) with bedside near-infrared spectroscopy (NIRS).METHODS AND RESULTS: Twenty patients (mean age 67.7 ± 10.2 years, 50% men) in whom electrical cardioversion (CV) was successful were prospectively studied. Ten patients (mean age 64.2 ± 7.7 years, 80% men) in whom CV was not successful served as control group. Bilateral SctO2, mean arterial pressure (MAP), arterial oxygen saturation (SaO2), and heart rate were recorded and changes of all parameters before and after CV were compared between the groups. Our results show an increase in SctO2 after successful CV that was significantly higher compared with patients who remained in AF (right SctO2 3.25 ± 2.5 vs. -0.13 ± 0.52%, P = 0.001; left SctO2 4.27 ± 3.56 vs. -0.38 ± 2.4%, P < 0.001). Neither arterial blood pressure nor SaO2 changes differed significantly between the two groups. No correlation could be detected between the significant increase of SctO2 after successful CV and arterial blood pressure, SaO2, or heart rate.CONCLUSION: Cerebral tissue oxygen saturation increases significantly after restoration of sinus rhythm. Near-infrared spectroscopy monitoring can identify changes of SctO2 after successful CV of AF independent from standard monitoring parameters (MAP, SaO2). Near-infrared spectroscopy can be used to detect cerebral oxygen saturation deficits in AF patients or patients at high risk for AF. Clinical applications may include monitoring during ablation procedures and in critical care.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Single nucleotide polymorphisms (SNPs) of EPHX2 alter sEH activity and are associated with increased [rs41507953 (K55R)] or reduced [rs751141 (R287Q)] cardiovascular risk via modulation of fibrosis, inflammation or cardiac ion channels. This indicates an effect on development and therapy response of AF. This study tested the hypothesis that variations in the EPHX2 gene encoding human soluble epoxide hydrolase (sEH) are associated with atrial fibrillation (AF) and recurrence of atrial fibrillation after catheter ablation. METHODS AND RESULTS: A total of 218 consecutive patients who underwent catheter ablation for drug refractory AF and 268 controls were included. Two SNPs, rs41507953 and rs751141, were genotyped by direct sequencing. In the ablation group, holter recordings 3, 12 and 24months after ablation were used to detect AF recurrence. No significant association of the SNPs and AF at baseline was detected. In the ablation group, recurrence of AF occurred in 20% of the patients 12months after ablation and in 35% 24months after ablation. The presence of the rs751141 polymorphism significantly increased the risk of AF recurrence 12months (odds ratio [OR]: 3.2, 95% confidence interval [CI]: 1.237 to 8.276, p=0.016) and 24months (OR: 6.076, 95% CI: 2.244 to 16.451, p<0.0001) after catheter ablation. CONCLUSIONS: The presence of rs751141 polymorphism is associated with a significantly increased risk of AF recurrence after catheter ablation. These results point to stratification of catheter ablation by genotype and differential use of sEH-inhibitory drugs in the future.
International journal of cardiology 05/2013; · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Cardiac troponin I (cTnI) is highly specific for myocardial damage and for the diagnosis of acute coronary syndrome. We investigated cTnI utility and predictive value in patients with atrial fibrillation (AF) in the acute setting. METHOD: We studied 354 consecutive patients with the primary diagnosis of AF and clinical symptoms suggestive of myocardial ischemia presenting to our emergency department. cTnI was obtained on presentation. Patients with ST-segment elevation myocardial infarction were excluded. Coronary angiography was performed in 100 patients. RESULTS: cTnI was elevated (>0.09μg/L) in 51 of 354 (15%) patients. The mean cTnI in these patients was 0.37μg/L (0.09-3.14). In 23 of 100 patients undergoing coronary angiography, cTnI was elevated. Only 6 of these 23 patients (26%) had significant stenosis. In 77 of 100 patients undergoing coronary angiography, cTnI was normal, revealing significant stenosis in 25 patients (33%). The positive predictive value of elevated cTnI for a coronary intervention was 26% and the negative predictive value was 68%. Using multivariate logistic regression, we found that heart rate on presentation, the presence of angina pectoris, left ventricular ejection fraction, serum creatinine, and hemoglobin independently predicted elevated cTnI level. CONCLUSION: These data are the first to show that AF in the acute setting is frequently associated with cTnI elevations. AF patients with high heart rate and/or angina pectoris often show false elevated cTnI levels. These findings are relevant for clinicians evaluating patients with acute AF and myocardial ischemia symptoms. Appropriate clinical guidelines must be established that also consider AF-related elevations in cTnI.
International journal of cardiology 04/2013; · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The economic impact of drug-eluting stent (DES) in-stent restenosis (ISR) is substantial, highlighting the need for cost-effective treatment strategies. HYPOTHESIS: Compared to plain old balloon angioplasty (POBA) or repeat DES implantation, drug-coated balloon (DCB) angioplasty is a cost-effective therapy for DES-ISR. METHODS: A Markov state-transition model was used to compare DCB angioplasty with POBA and repeat DES implantation. Model input parameters were obtained from the literature, and the cost analysis was conducted from a German healthcare payer's perspective. Extensive sensitivity analyses were performed. RESULTS: Initial procedure costs amounted to €3488 for DCB angioplasty and to €2782 for POBA. Over a 6-month time horizon, the DCB strategy was less costly (€4028 vs €4169) and more effective in terms of life-years (LYs) gained (0.497 versus 0.489) than POBA. The DES strategy incurred initial costs of €3167 and resulted in 0.494 LYs gained, at total costs of €4101 after a 6-month follow-up. Thus, DCB angioplasty was the least costly and most effective strategy. Base-case results were influenced mostly by initial procedure costs, target lesion revascularization rates, and the costs of dual antiplatelet therapy. CONCLUSIONS: DCB angioplasty is a cost-effective treatment option for coronary DES-ISR. The higher initial costs of the DCB strategy compared to POBA or repeat DES implantation are offset by later cost savings.
[Show abstract][Hide abstract] ABSTRACT: AIMS: Propofol is commonly used as an anaesthetic during catheter ablation. Bradycardia and termination of supraventricular tachycardia (SVT) under propofol are reported. Ketamine is used for cardiac catheterization procedures and increases heart rate and blood pressure. Our study aimed to determine the effects of propopfol and ketamine on atrial electrophysiology.METHODS AND RESULTS: Thirty-one patients undergoing electrophysiological study prior to SVT ablation were enrolled. Patients received a combination of propofol/midazolam (n = 10), ketamine/midazolam (n = 9), or midazolam alone (n = 12). Electrophysiological study was performed before and after administration of the anaesthetic agents. Blood pressure, corrected sinus node recovery time, Wenckebach cycle length, and atrial conduction time were measured. We found a significant increase in heart rate, systolic, and diastolic blood pressure and a significant shortening of atrial conduction time after administration of ketamine compared with propofol and the control. Results for ketamine, propofol and the control, respectively: mean (SD) change in heart rate was 12.4 (8.3), -1.4 (8), and 1 (7.5) b.p.m. (P = 0.002); mean (SD) change in systolic blood pressure was 19.2 (8.1), -22 (9), and 0.1 (5.7) mmHg (P < 0.001); mean (SD) change in diastolic blood pressure was 6.6 (9.7), -7.8 (2.9), and 2.3 (4.5) mmHg (P = 0.001); and mean (SD) change in atrial conduction time was -13.7 (16.4), 4.5 (11.1), and -0.3 (3.8) ms (P = 0.008). No significant affection of sinus node or antrioventricular node function was seen.CONCLUSION: Our results show stimulatory effects of ketamine on heart rate, atrial conduction, and blood pressure. Ketamine, therefore, may be beneficial in patients with pre-existing hypotension and bradycardia.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine the clinical significance of the assessment of the diastolic and systolic myocardial function of the left atrium in patients with paroxysmal atrial fibrillation (AF) and low CHADS(2) scores treated with catheter ablation therapy. In a cohort of 84 symptomatic patients with paroxysmal AF and low CHADS(2) scores (≤1), the clinical significance of the systolic and diastolic myocardial function of the left atrium (assessed using 2-dimensional speckle-tracking echocardiography) were studied to predict the risk for recurrence of AF after catheter ablation therapy in the course of a follow-up period of ≥1 year. During a mean follow-up period of 19.2 ± 5.4 months, patients with left atrial (LA) myocardial diastolic dysfunction (LA strain <18.8%) had a significantly higher rate of recurrence of AF (42.4% vs 9.8%, p <0.05) compared to those without LA diastolic dysfunction. In line with this finding, patients with impaired LA myocardial systolic function (LA strain rate >-0.85 s(-1)) had worse outcomes after catheter ablation therapy than those with normal LA systolic function (rate of recurrence of AF 42.9% vs 12.5%, respectively, p <0.05). In relation to these results, in a logistic regression analysis including co-morbidities, left ventricular dysfunction, LA enlargement, and LA myocardial alterations, diastolic and systolic LA myocardial dysfunction were the principal variable associated with the recurrence of AF (odds ratios 6.8 and 5.2, respectively). In conclusion, in symptomatic patients with paroxysmal AF and low CHADS(2) scores, these findings suggest that the assessment of diastolic and systolic LA myocardial function using 2-dimensional speckle-tracking echocardiography could be of great utility to distinguish those patients with high or low risk for recurrence of AF after catheter ablation therapy.
The American journal of cardiology 01/2013; · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: AimsRecent studies have demonstrated the safety and efficacy of catheter-based renal sympathetic denervation (RDN) for the treatment of resistant hypertension. We aimed to determine the cost-effectiveness of this approach separately for men and women of different ages.Methods and resultsA Markov state-transition model accounting for costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness was developed to compare RDN with best medical therapy (BMT) in patients with resistant hypertension. The model ran from age 30 to 100 years or death, with a cycle length of 1 year. The efficacy of RDN was modelled as a reduction in the risk of hypertension-related disease events and death. Analyses were conducted from a payer's perspective. Costs and QALYs were discounted at 3% annually. Both deterministic and probabilistic sensitivity analyses were performed. When compared with BMT, RDN gained 0.98 QALYs in men and 0.88 QALYs in women 60 years of age at an additional cost of €2589 and €2044, respectively. As the incremental cost-effectiveness ratios increased with patient age, RDN consistently yielded more QALYs at lower costs in lower age groups. Considering a willingness-to-pay threshold of €35 000/QALY, there was a 95% probability that RDN would remain cost-effective up to an age of 78 and 76 years in men and women, respectively. Cost-effectiveness was influenced mostly by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN non-responders, and the procedure costs of RDN.Conclusion
Renal sympathetic denervation is a cost-effective intervention for patients with resistant hypertension. Earlier treatment produces better cost-effectiveness ratios.
European Heart Journal 10/2012; · 14.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background- The aim of this study was to investigate the myocardial systolic and diastolic performance of the left ventricle (LV) in patients with heart failure with normal LV ejection fraction (HFNEF) through novel LV myocardial indices, which assess the systolic and diastolic function of the whole myocardium of the LV. Methods and Results- LV myocardial systolic and diastolic performance were assessed as the average value of peak systolic strain and peak early-diastolic strain rate, respectively, in longitudinal, circumferential, and radial directions from all LV segments using 2-dimensional speckle-tracking echocardiography. We studied patients with HFNEF and a control group consisting of asymptomatic subjects with LV diastolic dysfunction of similar age, sex, and LV ejection fraction. A total of 322 patients were included (92 with HFNEF and 230 with asymptomatic LV diastolic dysfunction). Myocardial systolic and diastolic LV performance were significantly lower in HFNEF (20.13±6.02% and 1.14±0.27 s(-1)) than in patients with asymptomatic LV diastolic dysfunction (25.33±6.06% and 1.37±0.33 s(-1), respectively; all P<0.0001). In addition, patients with HFNEF with low systolic and diastolic LV myocardial performance had significantly higher LV filling pressures (17.1±6.6 and 17.6±6.3 versus 12.0±5.1 and 11.7±4.7, respectively; all P<0.001) and lower cardiac output (4.8±1.0 L/min and 4.9±1.1 L/min versus 5.7±1.2 L/min and 5.8±1.1 L/min, respectively; all P<0.001) than patients with normal LV myocardial performance. In relation to these findings, the symptomatic status (ie, New York Heart Association functional class) was significantly altered in those patients with low systolic and diastolic LV myocardial performance. Conclusions- In patients with HFNEF, both systolic and diastolic LV myocardial performance are impaired, which is associated with increased LV filling pressures, decreased cardiac output, and worse New York Heart Association functional class. Therefore, the measurement of these myocardial parameters could be of great importance in HFNEF because these echocardiographic indices assess the multidirectional function of the whole myocardium of the LV, thereby allowing detection of an alteration of the global function of the LV which is associated with a worse symptomatic status in these patients.
[Show abstract][Hide abstract] ABSTRACT: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiac disorder mainly caused by dominant mutations in several components of the cardiac desmosome including plakophilin-2 (PKP2), the most prevalent disease gene. Little is known about the underlying genetic and molecular mechanisms of missense mutations located in the armadillo (ARM) domains of PKP2, as well as their consequences on human cardiac pathology.
We focused on in vivo and in vitro studies of the PKP2 founder mutation c.2386T>C (p.C796R), and demonstrated in cardiac tissue from 2 related mutation carriers a patchy expression pattern ranging from unchanged to totally absent immunoreactive signals of PKP2 and other desmosomal proteins. In vitro expression analysis of mutant PKP2 in cardiac derived HL-1 cells revealed unstable proteins that fail to interact with desmoplakin and are targeted by degradation involving calpain proteases. Bacterial expression, crystallization, and structural modeling of mutated proteins impacting different ARM domains and helices of PKP2 confirmed their instability and degradation, resulting in the same remaining protein fragment that was crystallized and used to model the entire ARM domain of PKP2.
The p.C796R and other ARVC-related PKP2 mutations indicate loss of function effects by intrinsic instability and calpain proteases mediated degradation in in vitro model systems, suggesting haploinsufficiency as the most likely cause for the genesis of dominant ARVC due to mutations in PKP2.