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ABSTRACT: A growing number of patients with advanced heart failure fulfill a primary-prevention indication for an implantable cardioverter-defibrillator (ICD). This study seeks to identify new predictors of overall mortality in a Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)-like collective to enhance risk stratification.
An impaired renal function and severely depressed left ventricular ejection fraction pose relevant risk factors for mortality in primary prevention ICD recipients.
Ninety-four consecutive ICD patients with New York Heart Association class II-III heart failure and depressed left ventricular function (left ventricular ejection fraction [LVEF] ≤35%) with no history of malignant ventricular arrhythmias were followed for 34 ± 20 months.
During this period, 30 patients died (32%). Deceased patients revealed a significantly worse renal function before ICD implantation (1.55 ± 0.7 mg/dL vs 1.1 ± 0.4 mg/dL; P = 0.007), suffered more often from coronary artery disease (53 vs 29; P = 0.006), and were older (69.5 ± 8 y vs 67 ± 12 y; P = 0.0002) than surviving patients. Furthermore, increased serum creatinine at baseline (2 mg/dL vs 1 mg/dL; odds ratio [OR]: 3.96, 95% confidence interval [CI]: 1.2-13.04, P = 0.02), presence of coronary artery disease (OR: 8.6, 95% CI: 1.1-65, P = 0.036), and low LVEF (OR per 5% baseline LVEF deterioration: 1.4, 95% CI: 1-1.8, P = 0.034) represented strong and independent predictors for overall mortality.
Impaired renal function, the presence of coronary artery disease, and reduced LVEF before implantation represent independent predictors for mortality in a cohort of patients with advanced systolic heart failure. These conditions still bear a high mortality risk, even if ICD implantation effectively prevents sudden arrhythmic death. Indeed, in patients suffering from several of the identified "high-risk" comorbidities, primary-prevention ICD implantation might have a limited survival benefit. The possible adverse effects of these comorbidities should be openly discussed with the potential ICD recipient and his or her close relatives. Clin. Cardiol. 2012 doi: 10.1002/clc.22018 The authors have no funding, financial relationships, or conflicts of interest to disclose.
Clinical Cardiology 06/2012; 35(9):575-9. · 2.15 Impact Factor
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ABSTRACT: AIMS: The current study includes all consecutive patients with advanced heart failure and cardiac resynchronization therapy (CRT) with an implantable cardioverter defibrillator (ICD) over a 10-year period in a tertiary referral centre. It aims at identifying independent risk factors for mortality during CRT-defibrillator (CRT-D) treatment.METHODS AND RESULTS: This study includes 239 consecutive patients who had undergone implantation of a CRT-D system (ejection fraction 25.9 ± 8%; 139 patients with ischaemic, 100 patients with non-ischaemic cardiomyopathy). Enrolment took place between 2001 and 2010, resulting in a median follow-up of 43 ± 30 months. During follow-up, 59 patients (25%) died. An impaired baseline kidney function [hazard ratio (HR) 1.98; 95% confidence interval (CI) 1.7-3; P< 0.0001], appropriate ICD therapy during follow-up (HR 2.1; CI 1.1-3.4; P= 0.001), lack of beta-blocker therapy (HR 2.3; CI 1.6-3.8; P= 0.004), and intake of amiodarone (HR 2; CI 1.8-4.1; P< 0.0001) were identified as predictors of overall mortality.CONCLUSION: This study demonstrates the benefit of beta-blocker therapy also in patients on long-term CRT-D treatment. It confirms the prognostic significance of impaired renal function and the occurrence of appropriate ICD therapies also in CRT-D patients. It argues for an intensified follow-up regimen and adjustment of heart failure treatment whenever these prognostic markers are identified in a patient treated with CRT-D.
Europace 05/2012; · 1.98 Impact Factor
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Friedrich Felix Hoyer,
Lars Martin Lickfett,
Erica Mittmann-Braun,
Charlotte Ruland,
Jens Kreuz,
Stefan Pabst, Jan Schrickel,
Uwe Juergens,
Selcuk Tasci,
Georg Nickenig,
Dirk Skowasch
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ABSTRACT: To address the question whether obstructive sleep apnea (OSA) is associated with the recurrence of paroxysmal atrial fibrillation (AF) in patients treated with ≥2 pulmonary vein isolation procedures.
In this study, we included adults with therapy-resistant symptomatic paroxysmal AF, defined as AF recurring after ≥2 PV-isolation procedures (n = 23). For comparison, we selected another cohort of patients being successfully treated by one PV isolation without AF recurrence within 6 months (n = 23). PV isolation was performed by radiofrequency with an open irrigated tip catheter. Each of the 46 participants completed an overnight polygraphic study. The two groups were matched for age, gender, and ejection fraction. Patients were late middle-aged (65 ± 7 vs 63 ± 10 years, P = 0.23), white (100%), and overweight (BMI 27.3 ± 3.6 vs. 27.2 ± 4.6 kg/m(2), P = 0.97).
The prevalence of sleep apnea, defined as an apnea-hypopnea index (AHI) of >5 per hour of sleep, was 87% in patients with therapy-resistant AF compared to 48% in the control cohort (P = 0.005). In addition, OSA was more severe in the resistant AF group indicated by a significantly higher AHI (27 ± 22 vs 12 ± 16, P = 0.01).
The extraordinarily high prevalence of sleep apnea in patients with recurrent paroxysmal AF supports its presumable role in the pathogenesis of AF and demands further controlled prospective trials. Moreover, OSA should inherently be considered in patients with therapy-resistant AF.
Journal of Interventional Cardiac Electrophysiology 10/2010; 29(1):37-41. · 1.17 Impact Factor
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ABSTRACT: Gelsolin (gsn) is involved in the reorganization of the cytoskeleton, thereby modulating cardiomyocytal L-type Ca(2+) channels. We investigated global cardiac electrophysiological characteristics in a gsn-deficient (gsn(-/-)) mouse strain.
Using transvenous catheterization, atrial and ventricular stimulation were performed in 15 male mice [eight gsn(-/-), seven wild-type (gsn(+/+))]. Surface ECG, standard electrophysiological parameters, and inducibility of atrial fibrillation (AF) were evaluated.
The surface ECG showed shorter PQ (37.8 +/- 4.6 versus 42.9 +/- 2.7 ms; P = 0.02), but longer QRS (16.5 +/- 1.8 versus 13.9 +/- 1.2 ms; P = 0.005) and QT intervals (38.5 +/- 2.2 versus 35.6 +/- 2.4 ms, P = 0.03) in gsn(-/-). Gsn(-/-) exhibited significantly higher susceptibility to induction of prolonged AF episodes > or =60 s [six of eight gsn(-/-) versus one of seven gsn(+/+); P = 0.04]. Sustained AF episodes > or =10 min were observed in 50% of the gsn-deficient animals.
Gsn deficiency results in perpetuation of inducible episodes of atrial fibrillation. Altered L-type Ca(2+) currents and disturbed Ca(2+) handling known to be associated to gsn deficiency likely contribute to this effect.
Journal of Interventional Cardiac Electrophysiology 08/2009; 26(1):3-10. · 1.17 Impact Factor
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ABSTRACT: Echocardiography is an established method to estimate left-ventricular mass (LVM) in mice. Accuracy is determined by cardiac size and morphology and influenced by mathematical models. We investigated accuracy of three common algorithms in three early developmental stages. High-resolution echocardiography was performed in 35 C57/BL6-mice. Therefore, two-dimensional-guided M-mode echocardiography and parasternal short- and long-axis views in B-mode were obtained. LVM was assessed in vivo applying Penn (P), Area Length (AL), and Truncated Ellipsoid (TE) algorithms and validated with histomorphometry. Regression analysis of all mice showed fair estimation of LVM assessed with M-mode-based Penn algorithm (y = 0.6*x - 0.12, r: 0.71). In contrast two-dimensional assessment of LVM revealed close linear relationship with histomorphometry (y(AL)= 1.21*x - 12.1, r: 0.88, y(TE)= 1.38*x - 2.88, r: 0.86). Bias was lowest for LVM-AL at diastole underestimating 3.2%. In concordance with the summarized data, LVM-P revealed lower regression coefficients and significant underestimation in all three subgroups. Small hearts (<50 mg, n = 12) correlated best with LVM-AL at systole. Hearts of adolescent (50-75 mg, n = 13) and adult (75-100 mg, n = 10) mice revealed close linear relationship with LVM-AL and LVM-TE at diastole. Echocardiographic assessment of LVM is feasible in hearts weighting less than 50 mg and can be estimated best in systole. Hearts weighting more than 50 mg are estimated most accurately by means of LVM-AL at diastole.
Echocardiography 11/2006; 23(10):900-7. · 1.24 Impact Factor
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ABSTRACT: Echocardiography is an established method to estimate left-ventricular mass (LVM) in mice. Accuracy is determined by cardiac size and morphology and influenced by mathematical models. We investigated accuracy of three common algorithms in three early developmental stages. High-resolution echocardiography was performed in 35 C57/BL6-mice. Therefore, two-dimensional-guided M-mode echocardiography and parasternal short- and long-axis views in B-mode were obtained. LVM was assessed in vivo applying Penn (P), Area Length (AL), and Truncated Ellipsoid (TE) algorithms and validated with histomorphometry. Regression analysis of all mice showed fair estimation of LVM assessed with M-mode-based Penn algorithm (y = 0.6*x − 0.12, r: 0.71). In contrast two-dimensional assessment of LVM revealed close linear relationship with histomorphometry (yAL= 1.21*x − 12.1, r: 0.88, yTE= 1.38*x − 2.88, r: 0.86). Bias was lowest for LVM-AL at diastole underestimating 3.2%. In concordance with the summarized data, LVM-P revealed lower regression coefficients and significant underestimation in all three subgroups. Small hearts (<50 mg, n = 12) correlated best with LVM-AL at systole. Hearts of adolescent (50–75 mg, n = 13) and adult (75–100 mg, n = 10) mice revealed close linear relationship with LVM-AL and LVM-TE at diastole. Echocardiographic assessment of LVM is feasible in hearts weighting less than 50 mg and can be estimated best in systole. Hearts weighting more than 50 mg are estimated most accurately by means of LVM-AL at diastole.
Echocardiography 10/2006; 23(10):900 - 907. · 1.24 Impact Factor
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Lars Lickfett,
Matthias Hackenbroch,
Thorsten Lewalter,
Stephanie Selbach,
Jörg O Schwab,
Alexander Yang,
Osman Balta, Jan Schrickel,
Alexander Bitzen,
Berndt Lüderitz,
Torsten Sommer
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ABSTRACT: Cerebral embolism and stroke are feared complications of left atrial catheter ablation such as pulmonary vein (PV) ablation. In order to assess the thrombogenicity of left atrial catheter ablation, knowledge of both clinically evident as well as silent cerebral embolism is important. The aim of the current study was to examine the use of diffusion-weighted magnetic resonance imaging (DW-MRI) for detection of cerebral embolism, apparent as well as silent, caused by PV catheter ablation.
Twenty consecutive patients without structural heart disease undergoing lasso catheter-guided ostial PV ablation using an irrigated-tip ablation catheter were studied. Cerebral MRI including DW single-shot spin echo echoplanar, turbo fluid attenuated inversion recovery, and T2-weighted turbo spin echo sequences were performed the day after the ablation procedure. Ten patients also underwent preprocedure cerebral MRI. All ablation procedures were performed without acute complications. A mean of 3.2 +/- 0.6 PVs were ablated per patient. No patient had neurological symptoms following the procedure. In 2 of 20 patients (10%), DW-MRI revealed new embolic lesions, which were located in the right periventricular white matter in one and in the left temporal lobe in the other patient. There was no statistically significant difference in age, history of hypertension, left atrial volume, and procedure duration between the 2 patients with and the 18 patients without cerebral embolism following AF ablation.
This is the first study using highly sensitive DW-MRI of the brain to detect asymptomatic cerebral embolism after left atrial catheter ablation. Even small, clinically silent, embolic lesions can be demonstrated with this technique. DW-MRI can be used to monitor and compare the thrombogenicity of different AF ablation approaches.
Journal of Cardiovascular Electrophysiology 02/2006; 17(1):1-7. · 3.06 Impact Factor
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ABSTRACT: Several prospective randomized clinical trials have reported that atrial-based "physiological" pacing is associated with a lower incidence of paroxysmal and permanent atrial fibrillation than single-chamber ventricular pacing in patients with conventional pacemaker indication. Whether atrial pacing itself is antiarrhythmic remains still uncertain. By contrast, right ventricular pacing is considered to beget atrial fibrillation, even in preserved AV synchrony during dual-chamber pacing. A number of clinical trials investigated the impact of sitespecific atrial pacing and advanced atrial pacing algorithms on the secondary prevention of atrial fibrillation. Multisite pacing (dual-site right atrial or biatrial pacing) was demonstrated to add only minimal benefit for the prevention of atrial fibrillation. By contrast, in some studies septal pacing and specific atrial pacing algorithms were reported to reduce the recurrence of atrial fibrillation in selected patients. At present, however, it remains unclear how to identify these patients. In clinical practice, the effectiveness of specific atrial pacing algorithms and/or septal pacing has to be tested out in the individual case. These therapeutic options should be considered in patients with a conventional indication for antibradycardia pacing and, additionally, symptomatic atrial fibrillation.
Herz 01/2006; 30(8):733-42. · 0.92 Impact Factor
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ABSTRACT: Eine Reihe prospektiver, randomisierter Studien an Patienten mit konventioneller antibradykarder Schrittmacherindikation hat
gezeigt, dass die Inzidenz von Vorhofflimmern bei der vorhofbeteiligten, sog. „physiologischen“ Schrittmacherstimulation niedriger
als bei der ventrikulären „Demandstimulation“ ist. Ob die atriale Stimulation in diesem Zusammenhang eine eigenständige antiarrhythmische
Wirkung aufweist, ist noch nicht eindeutig geklärt. Als gesichert hingegen gilt, dass die ventrikuläre Stimulation, selbst
bei erhaltener AV-Synchronie, das Auftreten von Vorhofflimmern begünstigt. Die elektrische Sekundärprävention von Vorhofflimmern
basiert auf Variationen des atrialen Stimulationsortes sowie in die Schrittmachersoftware integrierten präventiven Stimulationsalgorithmen.
Die multifokale atriale Stimulation (rechts-bifokal oder biatrial) hat in klinischen Studien nur einen geringen antiarrhythmischen
Effekt gezeigt und spielt daher im klinischen Alltag nur noch eine untergeordnete Rolle. Dagegen war in einigen Studien erkennbar,
dass das Rezidivverhalten von Vorhofflimmern bei bestimmten Patientengruppen durch die septale Vorhofstimulation und/oder
den Einsatz präventiver Stimulationsalgorithmen günstig beeinflusst werden kann. Unklar bleibt zurzeit allerdings, wie diese
Patientengruppen identifiziert werden können. Für die klinische Praxis bedeutet dies, dass die Wirksamkeit von präventiven
Algorithmen und/oder der septalen Stimulation individuell ausgetestet werden muss. Ihr Einsatz sollte insbesondere bei Patienten
mit stimulationsbedürftigen Bradykardien und zusätzlich symptomatischem Vorhofflimmern in Erwägung gezogen werden.
Several prospective randomized clinical trials have reported that atrial-based “physiological” pacing is associated with a
lower incidence of paroxysmal and permanent atrial fibrillation than single-chamber ventricular pacing in patients with conventional
pacemaker indication. Whether atrial pacing itself is antiarrhythmic remains still uncertain. By contrast, right ventricular
pacing is considered to beget atrial fibrillation, even in preserved AV synchrony during dual-chamber pacing. A number of
clinical trials investigated the impact of sitespecific atrial pacing and advanced atrial pacing algorithms on the secondary
prevention of atrial fibrillation. Multisite pacing (dual-site right atrial or biatrial pacing) was demonstrated to add only
minimal benefit for the prevention of atrial fibrillation. By contrast, in some studies septal pacing and specific atrial
pacing algorithms were reported to reduce the recurrence of atrial fibrillation in selected patients. At present, however,
it remains unclear how to identify these patients. In clinical practice, the effectiveness of specific atrial pacing algorithms
and/or septal pacing has to be tested out in the individual case. These therapeutic options should be considered in patients
with a conventional indication for antibradycardia pacing and, additionally, symptomatic atrial fibrillation.
Herz 10/2005; 30(8):733-742. · 0.92 Impact Factor
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ABSTRACT: Postextrasystolic acceleration of heart rate (HR), known as HR turbulence (HRT) is attenuated in patients with coronary artery disease at increased risk of adverse events. The influence of age and basic HR on HRT have not been evaluated in a large cohort of persons. In 95 healthy individuals, HRT onset (TO) and slope (TS) were calculated from 24-hour ambulatory electrocardiograms, as well as the turbulence timing (TT). Gender specific differences in TO and TS were compared in simple, linear, weighted regression model. The influence of age and the basic HR preceding ventricular premature contractions on HRT were examined. We found that, in men and women, TO decreases as basic HR increases (P < 0.01). In contrast, in men, TS decreased as basic HR increases, whereas in women, basic HR influenced TS only slightly (P < 0.01). A multiple, linear regression model revealed a decrease in HRT with increasing age in men. In conclusion, physiological acceleration of the HR within the first 11 beats after premature ventricular complex (VPC) was observed in >75% of healthy individuals. An accelerating HR preceding the VPC influenced HRT in men. An increasing age was associated with a decrease in HRT in men and a decrease in TO in women. These results illustrate the importance of physiological modulations of HRT when used for risk stratification, especially in older populations.
Pacing and Clinical Electrophysiology 02/2005; 28 Suppl 1:S198-201. · 1.35 Impact Factor
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ABSTRACT: In this study, we report an intraprocedural incident in patients undergoing ablation for atrial fibrillation. During left atrial manipulation our patients suffered from acute chest pain, showed ECG signs of an acute inferior wall myocardial infarction, and increased levels of cardiac Troponin I (cTnI). We strongly recommend being aware of unexpected reactions during isolating pulmonary veins for focal atrial fibrillation, especially when passing the dorsal part of the left atrium. If pericardial effusion is ruled out and ECG signs as well as symptoms disappear, the ablation procedure should proceed. We think patients undergoing pulmonary vein ablation for atrial fibrillation should be informed of this threatening complication.
Europace 04/2004; 6(2):111-5. · 1.98 Impact Factor
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ABSTRACT: Electrical isolation of pulmonary veins (PV's) is crucial to achieve success in catheter ablation for trigger elimination in focal atrial fibrillation (AF). To guide ostial PV radiofrequency (RF) delivery, it is necessary to identify the electrical breakthrough (EBT) between PV and left atrium. For this purpose, coronary sinus (CS) fixed rate pacing is commonly used. This study evaluated, whether CS extrastimulus pacing is superior in identifying the EBT area as compared to fixed rate pacing.
In 9 patients (51 +/- 10 years) undergoing a left sided electrophysiological study for AF ablation, 25 PV's (10 right and 15 left-sided PV's) were mapped using a 4 French fixed-wire catheter with eight 6 mm coiled Platinum electrodes in a distal looped configuration (Revelation Helix, Cardima Inc.). For mapping and ablation the electrode loop was positioned in the PV ostium rectangular to the longitudinal PV axis. EBT area was identified as those electrodes indicating the earliest PV signals during CS pacing. We measured number of EBT electrodes and time between EBT and the latest activated bipoles at the electrode loop during fixed rate and extrastimulus pacing. The reduction of two or more EBT electrodes was defined as a significant benefit in EBT identification.
In 22 of 25 PV's mapped PV potentials could be observed. Performing fixed rate pacing the EBT area was identified in a mean of 4.2 +/- 1 electrodes, whereas using extrastimulus pacing, EBT area could be significantly reduced to 2.3 +/- 0.8 electrodes. The time between EBT and latest electrode activated increased from 14 +/- 7 ms to 22 +/- 10 ms indicating an intrapulmonary conduction delay during extrastimulus pacing. In 13 of 22 PV's mapped (59%), extrastimulus pacing was beneficial in the identification of the EBT, as the primary target for RF delivery.
CS extrastimulus pacing induces intra-PV decremental conduction properties allowing one to identify a more localised and smaller EBT area as the primary target for RF delivery. Performing PV ablation to treat focal AF, extrastimulus maneuvers allow to unmask the "true" EBT and thus may help to limit intrapulmonary RF delivery.
Journal of Interventional Cardiac Electrophysiology 11/2003; 9(2):269-73. · 1.17 Impact Factor
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Alexander Yang,
Marc Hochhäusler, Jan Schrickel,
Helga Bielik,
Nikolay Shlevkov,
Rainer Schimpf,
Jörg Otto Schwab,
Bahman Esmailzadeh,
Christian Schneider,
Fritz Mellert,
Armin Welz,
Friedhelm Saborowski,
Berndt Lüderitz,
Thorsten Lewalter
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ABSTRACT: Pacing algorithms to prevent PAF are mainly based on the suppression of premature atrial complexes (PACs), which play an important role in its initiation. In contrast to 24-hour ambulatory electrocardiograms, advanced pacemaker (PM) diagnostic features are capable of recording AF episodes during long follow-up periods and of characterizing AF in a detailed fashion. For the specific use of these algorithms, a detailed characterization of AF was performed in 91 dual chamber PM recipients with histories of AF. Fifteen patients with episodes of oversensing due to far-field signals or frequent episodes of "2:1-undersensing" of atrial flutter were excluded. The remaining 76 patients had high recurrence rates of AF (median 0.8 episodes/day), however, the majority of episodes lasted < 7 minutes. Despite frequent PACs (median 10.8/hour) during sinus rhythm, a median of 66.4% of the AF episodes were preceded by < 2 PACs/min before onset. In conclusion, frequent, short-lived AF episodes seem best suited for AF preventive pacing therapies. However, the small number of PACs preceding many AF episodes may limit the efficacy of PAC suppressing algorithms.
Pacing and Clinical Electrophysiology 01/2003; 26(1 Pt 2):310-3. · 1.35 Impact Factor
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ABSTRACT: Atrial fibrillation (AF) can be cured in a subgroup of patients performing catheter ablation and eliminate trigger arrhythmias mainly originating in the pulmonary veins (PV's).
This case report describes the use of a novel catheter design combining both, circumferential mapping and radiofrequency delivery capabilities to perform pulmonary vein ablation in patients with focal AF. It could be demonstrated that this catheter was able to eliminate pulmonary vein potentials in a single left atrial catheter technique without acute evidence for PV stenosis. In two PV's of a second patient, where the Helix catheter was placed in a very ostial position, it was not possible to completely eliminate the PV signal component of the ostial electrogram. Long-term follow-up with AF recurrence documentation will clarify whether ostial PV signal amplitude reduction may serve as an acceptable procedural endpoint.
PV potential elimination is feasible using this novel catheter design; safety and long-term efficacy of this single catheter approach will be evaluated in a multicenter study (BITMAP study: Breakthrough and Isolation Trial: Mapping and Ablation of Pulmonary Veins).
Journal of Interventional Cardiac Electrophysiology 11/2002; 7(2):165-70. · 1.17 Impact Factor
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ABSTRACT: Pacing therapy is well established in all cases of symptomatic bradyarrhythmic atrial fibrillation. In paroxysmal or persistent atrial fibrillation, the implanted dual chamber pacemaker device should incorporate an automatic mode switching algorithm. Mode switch in case of atrial fibrillation detection avoids pacemaker mediated rapid ventricular pacing during an atrial tachyarrhythmia and allows to perform dual chamber pacing during phases of sinus rhythm which is the preferable mode due to improved hemodynamics, rate adaptation, lower progress in atrial fibrillation burden and a lower rate of thromboembolic events as compared to ventricular pacing. PERSPECTIVE: The possibility to prevent from atrial fibrillation recurrencies by pacing is currently under investigation. Various methodological approaches, for example multisite or alternate single site pacing, preventive pacing algorithms or hybrid- and even triple-therapy concepts are used for that purpose. Due to the theoretical point of view, that all these pacing interventions may reduce atrial fibrillation but also have the potential to act in a proarrhythmic manner, the data from adequately designed trials is of major importance: Septal pacing and preventive pacing algorithms seem to have a beneficial effect in a limited number of so far available studies. CONCLUSION: In clinical practice, preventive pacing and/or placement of the atrial lead in a septal position should therefore be available in those patients with a conventional pacing indication in addition to symptomatic recurrent atrial fibrillation. Preventive pacing is so far with a significant and not-predictable amount of non-responders no "early" stage of therapy in patients with recurrent symptomatic atrial fibrillation and no additional conventional pacing indication.
Herz 07/2002; 27(4):345-56. · 0.92 Impact Factor
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ABSTRACT: Etablierte Therapieempfehlungen: Die Schrittmachertherapie in Form der frequenzadaptiven ventrikulren Demand-Stimulation stellt bei allen Formen der symptomatischen Bradyarrhythmia absoluta eine etablierte und bewhrte Behandlung dar. Bei paroxysmalem oder persistierendem Vorhofflimmern sollte im Falle einer Zwei-Kammer-Stimulation das implantierte Aggregat ber einen automatischen Betriebsartwechsel ("Mode Switch") verfgen, zum einen, um eine schrittmachervermittelte rasche berleitung von Vorhofflimmern zu verhindern, vor allem aber, um diesen Patienten auerhalb ihrer Paroxysmen alle Vorteile der Zwei-Kammer-Stimulation zukommen zu lassen, wie verbesserte Hmodynamik und Frequenzadaptation, niedrigerer Vorhofflimmerprogress und geringere Thromboembolierate gegenber der Ein-Kammer-Stimulation im Sinusrhythmus. Zukunftsperspektive: Als neues Einsatzgebiet der Schrittmachertherapie wird die prventive Stimulation erprobt, d. h. die Anwendung von Stimulationsmanvern mit dem Ziel das Auftreten von Vorhofflimmern zu verhindern. Zahlreiche methodische Anstze, wie Varianten des atrialen Stimulationsortes (septale oder Bachmann-Bndel-nahe Stimulation), das "Multisite Pacing", prventive Algorithmen mit konventioneller oder varianter Vorhofelektrodenlage sowie Hybrid- und Triplekonzepte sind hier bereits technisch realisiert worden. Da alle diese Interventionen unter Bercksichtigung der groen intra- und interindividuellen Variabilitt der Vorhofflimmerinduktion antiarrhythmisch, aber prinzipiell auch proarrhythmisch wirken knnen, ist die Studienlage zur Beurteilung der Therapieeffizienz von besonderer Bedeutung. Hier erscheint die septale oder Bachmann-Bndel-nahe Stimulation sowie die Anwendung prventiver Stimulationsalgorithmen als aussichtsreichste Interventionsform, zumal erste prospektive Untersuchungen einen signifikant gnstigen Einfluss auf die Entwicklung von permanentem Vorhofflimmern wie auch die Vorhofflimmerrezidivneigung ergeben haben. Schlussfolgerungen: Dies sollte Motivation sein, bei Patienten mit konventioneller Schrittmacherindikation und symptomatischem Vorhofflimmern den Einsatz einer z. B. spetalen Eletrodenlage oder prventiver Stimulationsalgorithmen in Erwgung zu ziehen.Die prventive Stimulation stellt aber aufgrund ihrer nur inkompletten Therapieerfolge und des relevanten Anteils an "Nonrespondern" zum jetzigen Zeitpunkt sicher noch keine "frhe" Eskalationsstufe in der Behandlung von Vorhofflimmern bei Patienten ohne stimulationsbedrftige Bradykardie dar. Abstract Pacing therapy is well established in all cases of symptomatic bradyarrhythmic atrial fibrillation. In paroxysmal or persistent atrial fibrillation, the implanted dual chamber pacemaker device should incorporate an automatic mode switching algorithm. Mode switch in case of atrial fibrillation detection avoids pacemaker mediated rapid ventricular pacing during an atrial tachyarrhythmia and allows to perform dual chamber pacing during phases of sinus rhythm which is the preferable mode due to improved hemodynamics, rate adaptation, lower progress in atrial fibrillation burden and a lower rate of thromboembolic events as compared to ventricular pacing. Perspektive: The possibility to prevent from atrial fibrillation recurrencies by pacing is currently under investigation. Various methodological approaches, for example multisite or alternate single site pacing, preventive pacing algorithms or hybrid- and even triple-therapy concepts are used for that purpose. Due to the theoretical point of view, that all these pacing interventions may reduce atrial fibrillation but also have the potential to act in a proarrhythmic manner, the data from adequately designed trials is of major importance: Septal pacing and preventive pacing algorithms seem to have a beneficial effect in a limited number of so far available studies, Conclusion: In clinical practice, preventive pacing and/or placement of the atrial lead in a septal position should therefore be available in those patients with a conventional pacing indication in addition to symptomatic recurrent atrial fibrillation. Preventive pacing is so far with a significant and not-predictable amount of non-responders no "early" stage of therapy in patients with recurrent symptomatic atrial fibrillation and no additional conventional pacing indication.
Herz 05/2002; 27(4):345-356. · 0.92 Impact Factor
