[Show abstract][Hide abstract] ABSTRACT: Left atrial (LA) size has been associated with cardiovascular outcomes and the success of different therapy strategies in patients with atrial fibrillation (AF) [1,2]. The assessment of LA is therefore recommended in the clinical routine in all AF patients . There are several imaging modalities to assess the LA, though echocardiography is widely available and thus the most frequently used. However, the echocardio-graphic LA diameter (LAD) does not reliably reflect the true size of LA anatomy, as pathological LA is often enlarged asymmetrically during AF progression [4–6]. Computer tomography (CT) is a modality that has been increasingly used to obtain three-dimensional (3D) images prior to AF catheter abla-tion. This provided new insights on the LA shape and volume, which have been proven to be better predictors of AF recurrences after LA ab-lation in comparison to the commonly used anterior–posterior LA diameter [4–6]. Recently we demonstrated that LA dilatation is more pronounced on the coronal plane, as represented by the transversal LA diameter (LA-TV) . Furthermore, LA-TV was associated with AF recurrences and remained stronger predictor for rhythm outcomes compared with the echocardiographic LA diameter. We also demonstrated strong association between pro-inflammatory plasma markers and AF recurrences [8,9]. However, whether LA size parameters are associated with peripheral plasma markers of inflammation is unknown. Consequently, the present study (approved by the ethics committee) recruited 51 consecutive patients presenting for their first AF cath-eter ablation at Heart Center Leipzig. All patients gave informed consent according to institutional guidelines and the Declaration of Helsinki. Echocardiography and cardiac-CT with a multidetector 64-row helical system (Brilliance 64, Philips, Best, Netherlands) were performed (2 ± 1 days) before the procedure. CT data were reviewed using 3D reconstruction (EnSite Verismo, SJM, MN) and LA volume (LAV) was determined after exclusion of the atrial appendage (LAA) and the pulmonary veins (PV). LA was then centered on all three cutting planes and the superior–inferior (SI), transversal (TV) and anterior–posterior (AP) diameters were measured. Measurements were performed offline by an experienced observer and were repeated 4 weeks later by the same investigator and a second blinded reviewer. High sensitive inter-leukin 6 (hsIL-6) was analyzed from pre-procedural blood samples using a commercially available assay. Catheter ablation was performed as previously described , with circumferential ablation of the ipsilateral pulmonary veins, verified with a multipolar circular catheter. In patients with persistent AF, additional linear lesions were added at the mitral isthmus and the posterior LA wall to create a " box " lesion. Follow-up was performed with repeated 7-day-Holter ECG recordings at 6, 12, 24 and 36 months. Recurrence was defined as any documented atrial tachycardia or fibrillation episodes of ≥30 s (after a 3 month blanking period). Statistical analyses were performed with SPSS 17 (SPSS Inc., Chicago, USA). Parameters with a p-value b 0.1 in the univariable analysis (UV), were introduced in multivariable analyses (MV) in order to identify with hsIL-6 levels independently associated parameters. A two-tailed p value b 0.05 was considered significant. The clinical characteristics of the study population are presented in Table 1. The intra-and inter-observer correlation coefficients were ≥ 0.88. We found a significant correlation between peripheral hsIL-6 and LA-TV (r 2 = 0.34, p = 0.017) but not with LAV (p = N.S., Fig. 1). On univariable analysis, advanced age, higher BMI and lower eGFR aswell as with left atrial dimensions – e.g. LA-AP, LA-TV and LAD (but not LAV) – were significantly associated with hsIL-6 levels. On mul-tivariable analysis, the levels of hsIL-6 remained associated with age (r 2 = 0.28, p = 0.029), BMI (r 2 = 0.33, p = 0.011), renal dysfunction left atrial; hsIL-6, high sensitive interleukin 6 (hsIL-6).
Full-text · Article · Jan 2016 · International journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: Introduction:
The porcine model is generally accepted for the development and testing of new forms oftherapy including ablation of atrial fibrillation (AF). However, the challenging left atrial (LA) and pulmonary vein (PV) anatomy enables only limited percutaneous catheter-based PV access.
Here we present I) an alternative percutaneous transapical access, which enables easy and safe retrograde transmitral LA and PV mapping and ablation; II) early experience of LA mapping and successful circumferential PV isolation with novel mapping system (Rhythmia(TM)) and new generation of ablation catheter equipped with micro electrodes (IntellaTip MiFi).
Although the experience with the transapical approach is limited, the initial results are promising as this may offer an alternative approach for tasting new technologies and translational research.
Full-text · Article · Nov 2015 · International Journal of Clinical and Experimental Medicine
[Show abstract][Hide abstract] ABSTRACT: Background:
There remains a lack of consensus regarding the ideal ablation strategy for atrial fibrillation (AF), particularly in patients with persistent or longstanding persistent AF. Given increasing evidence from clinical imaging studies that rotors sustain AF, rotor elimination may be a desirable procedural endpoint. However, there is no description to date of the clinical outcomes using rotor elimination during ablation as the procedural endpoint. Moreover, a series of studies question whether procedural AF termination is a desirable endpoint for ablation after many forms of AF ablation.
Methods and results:
We report a single-center experience of rotor elimination during AF ablation using Focal Impulse and Rotor Mapping (FIRM), describing 20 consecutive patients with case descriptions of 3 patients with recurrent longstanding persistent AF after prior ablation. In all cases, endocardial mapping using a 64-electrode basket catheter was performed to identify rotors, which were eliminated using radiofrequency catheter ablation. After it was verified that all identified rotors were eliminated, standard ablation consisting of PV isolation was performed. Notably, persistent AF terminated in only 1/20 (5%) patients. However, after a follow-up of 6 months, single-procedure freedom from AF was 80% (16/20 patients) with only 1 patient on antiarrhythmic drugs. All 3 patients in the highlighted series are AF free despite the lack of acute procedural AF termination.
Patients with persistent AF including those with unsuccessful prior ablation can be treated successfully by rotor targeted ablation, using the elimination of all rotors rather than acute AF termination as the procedural endpoint. This article is protected by copyright. All rights reserved.
No preview · Article · Nov 2015 · Journal of Cardiovascular Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Catheter ablation has become an established treatment for patients with atrial fibrillation (AF). Trigger elimination by pulmonary vein (PV) isolation represents the cornerstone of ablation strategies. Success rates after PV isolation (PVI) differ depending on the form of the arrhythmia, generally being higher in paroxysmal than in persistent AF. This difference may be explained by the presence and extent of structural atrio-myocardial disease, which is often associated with more chronic forms of the arrhythmia. However, the association between the substrate (i.e., atrio-myocardial disease) and the clinical and electrocardiographic AF phenotype, particularly the potential causal relation between substrate and arrhythmia presentation, is complex and currently under intense debate.(1) The introduction of the concept of a fibrotic atrial cardiomyopathy as a primary disease driving AF has great impact both on pathophysiological understanding of AF and subsequent treatment strategies.
No preview · Article · Nov 2015 · Journal of Cardiovascular Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Drs. Bollmann, Kosiuk and Hindricks have received moderate consulting and lecture fees from Boston Scientific Isolation of the pulmonary veins (PVI) is the cornerstone of atrial fibrillation (AF) ablation with a high acute success rate. Nevertheless, in some cases identification and elimination of residual PV antral gaps remains challenging. This article is protected by copyright. All rights reserved
No preview · Article · Oct 2015 · Journal of Cardiovascular Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: New devices that modulate the autonomic nervous system are being developed to improve outcomes in patients with chronic heart failure for whom optimal medical therapy is insufficient. Devices for baroreceptor activation therapy, vagal nerve stimulation, cardiac contractility modulation, and sleep apnea are now being evaluated in trials and showing promise.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Cardiac resynchronization therapy (CRT) is an effective treatment option for heart failure in elderly patients, but the additional benefit of an implantable defibrillator (ICD) in these patients is not evidenced.
Purpose: To evaluate the impact of an ICD on allcause mortality in elderly patients undergoing a CRT device implantation.
Methods: Patients at the age of ≥75 years who underwent implantation of either a CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) were identified out of hospital records. Only patients with a Class I or IIa indication for CRT and the primary prophylactic implantation of an ICD due to a severe impairment of the left ventricular ejection fraction (LVEF) were included in the analysis. Patient characteristics, procedural data and allcause mortality were compared between the two groups.
Results: Between January 2008 and August 2014 two-hundred forty-five seniors were implanted with a CRT device in our centre, whereof 80 patients with CRT-P and 97 patients with CRT-D represent the two study groups. Patients in the CRT-P group were more often females (44 vs. 25%; p<0.001), older (82.6±4.5 vs. 77.8±1.9 years, p<0.001), had a better LV-EF (29,6±5,9 vs. 27,4±6,0%; p=0.015) and narrower QRS-complexes (150±19 vs. 158±18ms; p=0.025). During a mean follow-up of 25.0±19.3 months 62 (35%) of the 177 study patients died, 28 (35%) in the CRT-P and 34 (35.1%) in the CRT-D group, respectively. The KaplanMeier analysis of survival probability showed no significant difference (p=0.502) between the groups (Figure). Inadequate ICD interventions were recorded in 4 patients (4.1%) and 5 patients (5.2%) received adequate therapies in the CRT-D group.
Conclusion: An additional ICD has no impact on survival in elderly patients implanted with a CRT device.
Full-text · Article · Aug 2015 · European Heart Journal