[Show abstract][Hide abstract] ABSTRACT: The role of epicardial substrate ablation of ventricular tachycardia (VT) as a first-line approach in patients with ischemic heart disease is not clearly defined. Epicardial ablation as a first-line option is standard for patients with nonischemic dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Several nonrandomized studies, including studies on patients with ischemic heart disease, have shown that epicardial VT ablation improves outcome but this approach was often used after a failed endocardial approach. The aim of this study is to determine whether a combined endo-epicardial scar homogenization as a first-line approach will improve the outcome of VT ablation.
The EPILOGUE study is a multicenter, two-armed, nonblinded, randomized controlled trial. Patients with ischemic heart disease who are referred for VT ablation will be randomly assigned to combined endo-epicardial scar homogenization or endocardial scar homogenization only (control group). The primary outcome is recurrence of sustained VT during a 2-year follow-up. Secondary outcomes include procedural success and safety.
This study is the first randomized trial that evaluates the role of a combined endo-epicardial scar homogenization versus endocardial scar homogenization for the treatment of ischemic scar-related VT.
[Show abstract][Hide abstract] ABSTRACT: Aims
Longevity of implantable cardioverter defibrillators (ICDs) is crucial for patients and healthcare systems as replacements impact on infection rates and cost-effectiveness. Aim was to determine longevity using very large databases of two teaching hospitals with a high number of replacements and a rather homogeneous distribution among manufacturers.
Methods and results
The study population consists of all patients in whom an ICD was inserted in. All ICD manufacturers operating in Switzerland and the Netherlands and all implanted ICDs were included. Implantable cardioverter defibrillator replacements due to normal battery depletion were considered events, and other replacements were censored. Longevity was assessed depending on manufacturers, pacing mode, implant before/after 2006, and all parameters combined. We analysed data from 3436 patients in whom 4881 ICDs [44.2% VVI-ICDs, 27.4% DDD-ICDs, 26.3% cardiac resynchronization therapy (CRT)-ICDs, 2.0% subcutaneous ICDs] were implanted. The four major manufacturers had implant shares between 18.4 and 31.5%. Replacement due to battery depletion (27.4%) was performed for 1339 ICDs. Patient survival at 5 years was 80.1%. Longevity at 5 years improved in contemporary compared with elderly ICDs [63.9–80.6% across all ICDs, of 73.7–92.1% in VVIs, 58.2–76.1% in DDDs, and of 47.1–66.3% in CRT defibrillators, all P value < 0.05]. Remarkable differences were seen among manufacturers, and those with better performance in elderly ICDs were not those with better performance in contemporary ones.
Implantable cardioverter defibrillator longevity increased in contemporary models independent of manufacturer and pacing mode. Still, significant differences exist among manufacturers. These results might impact on device selection.
[Show abstract][Hide abstract] ABSTRACT: Despite the effectiveness of ICD therapy in reducing mortality, the optimal timing of ICD implantation after MI remains inconclusive. The aim of this study is to evaluate the association of elapsed time from MI to implantable defibrillator (ICD) implantation on mortality and major adverse cardiac and cerebrovascular events (MACCE) in patients with prior myocardial infarction (MI).
We studied 974 patients who underwent a first ICD implantation between October 1998 and August 2011. The median time from MI to ICD implantation was 7.2 years. Elapsed time from MI to ICD was categorized into tertiles (<2.5, 2.5-12.1, >12.1 years). Additionaly, the time from most recent MI to ICD implantation was dichotomized at 18 months.
During a median follow-up of 3.4 years, 287 patients died. Cumulative mortality rates at 3, 5, and 8 years were 19%, 29%, 47%, respectively. In univariate analysis, there was a significant difference in mortality for patients in the highest tertile compared to those in the lowest tertile (HR 1.50; 95% CI 1.12 to 2.02; P = 0.007). After adjusting for baseline characteristics, there was no association between time from MI and mortality. At 8-years follow-up, the cumulative MACCE rate excluding mortality was 22%. No association between time from MI and MACCE was found.
In this study, we found no association between the elapsed time from MI to ICD implantation and 8-year all-cause mortality or MACCE in post-MI ICD patients. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
No preview · Article · Aug 2015 · Pacing and Clinical Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Poor catheter-to-myocardial contact can lead to ineffective ablation lesions and suboptimal outcome. Contact force (CF) sensing catheters in ventricular tachyarrhythmia (VT) ablations has not been studied for their long-term efficacy.
The aim of this study was to compare CF ablation to manual ablation (MAN) and remote magnetic navigation (RMN) ablation for safety and efficacy in acute and long-term outcome.
A total of 239 consecutive patients who underwent VT ablation with the use of MAN, CF or RMN catheters were included in this single-center cohort study from January 2007 until March 2014. The primary endpoints were procedural success, acute major complications and VT recurrences at follow-up. The median follow-up period was 25 months.
Acute success was achieved in 182 out of 239 procedures (76%). Acute success in manual ablation, CF ablation and RMN ablation was 71%, 71% and 86%, respectively (P = 0.03). Major complications occurred in 3.3% and there were less major complications (P = 0.04) in the RMN group. After an initial successful procedure, 66 of 182 patients (36%) patients had a recurrence during follow-up. This was not significantly different between groups. Using an intention-to-treat analysis, 124 patients (52%) had a recurrence. The recurrence rate was lowest in the RMN group.
The use of CF sensing catheters did not improve procedural outcome or safety profile in comparison to non-CF sensing ablation in this observational study of ventricular arrhythmia ablations. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
No preview · Article · Jul 2015 · Journal of Cardiovascular Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Remote magnetic navigation (RMN) has been used in various electrophysiological procedures, including atrial fibrillation (AF) ablation. Atrial-esophageal fistula (AEF) is one of most disastrous complications of AF ablation. We aimed to evaluate the incidence of AEF during AF ablation using RMN in comparison to manual ablation.
We conducted the first international survey among RMN operators for assessment of the prevalence of AEF and procedural parameters affecting the risk. Data from parallel survey of AEF among Canadian interventional electrophysiologists (CIE) using only manual catheters served as control.
Fifteen RMN operators (who performed 3637 procedures) and 25 manual CIE operators (7016 procedures) responded to the survey. RMN operators were more experienced than CIE operators (16.3 ± 8.3 vs. 9.2 ± 5.4 practice years in electrophysiology, p = 0.007). The maximal energy output in the posterior wall was higher in the operator using RMN (33 ± 5 vs. 28.6 ± 4.9 W; p = 0.02). Other parameters including use of preprocedural images, irrigated catheter, pump flow rate, esophageal temperature monitoring, intracardiac echocardiography (ICE), and general anesthesia were similar. CIE operators administered proton-pump inhibitors postoperatively significantly more than RMN operators (76 vs. 35 %, p = 0.01). AEF was reported in 5 of the 7016 patients in the control group (0.07 %) but in none of the RMN group (p = 0.11).
AEF is a rare complication and its evaluation necessitates large-scale studies. Although no AEF case with RMN was reported in this large study or previously on the literature, the rarity of this complication prevents firm conclusion about the risk.
No preview · Article · May 2015 · Journal of Interventional Cardiac Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Background: Mitral annulus (MA) remodeling was suggested to have a role in the occurrence of mitral valve (MV) leaflet flail in pts with organic mitral regurgitation (OMR).
Aim: To assess the extent of MA remodeling and dysfunction in relation to the severity of MV disease in pts with OMR.
Methods: We acquired 3D full-volumes of the MA and left ventricle (LV) in 52 pts (57 ± 15 yrs, 34 men) with OMR (40 pts with posterior mitral prolapse, 12 pts with Barlow disease), and in sinus rhythm. MV morphology was assessed using both en-face view of volume rendered images and longitudinal slices of the datasets. MA size and function were automatically assessed during cardiac systole (MV assessment 2.3, TomTec). LV volumes and ejection fraction (LVEF) were measured with AutoLVQ (Echopac BT 12, GE).
Results: 14 pts showed a flail of the MV, and 38 pts MV prolapse without flail. LVEF, MA displacement and MA size and geometry were similar in pts with and without MV flail (Table). Conversely, MA fractional area change was significantly decreased in pts with leaflet flail. Binary logistic regression showed that decreased MA fractional area change was associated with the presence of leaflet flail (β=0.20, p=0.02).
Conclusions: In pts with OMR and normal LV function, the contractile dysfunction of the MA, and not the size of the MA, is associated with the presence of leaflet flail. Further studies are needed to assess if the MA contractile dysfunction precedes or is a consequence of the occurrence of MV flail.
MA parametersMVP with flail N=14MVP without flail N=38pAntero-posterior diameter (cm)3.6 ± 0.63.4 ± 0.60.274Anterolateral-posteromedial diameter (cm)4.6 ± 0.74.6 ± 0.70.946MA area (cm2)13.8 ± 3.812.9 ± 4.10.458MA circumference (cm)13.5 ± 2.013.0 ± 2.00.464Anterior leaflet area (cm2)6.3 ± 2.26.5 ± 2.30.485Posterior leaflet area (cm2)9.1 ± 2.47.5 ± 2.90.063Sphericity Index0.8 ± 0.080.75 ± 0.070.051Non-planarity angle (0)150 ± 12155 ± 110.190MA height (mm)6.0 ± 0.25.4 ± 0.20.297MA fractional area change (%)19 ± 323 ± 60.015*MA displacement (mm)10.6 ± 2.69.5 ± 3.30.237
Full-text · Article · Dec 2014 · European Heart Journal – Cardiovascular Imaging
[Show abstract][Hide abstract] ABSTRACT: Background:
The data supporting the practice of empiric slow pathway ablation (ESPA) in patients with documented supraventricular tachycardia (SVT) who are non-inducible at electrophysiology study (EPS) is limited. The aim of this study is to assess the efficacy of ESPA in adults.
A multi-center cohort study of patients who had ESPA between January 2008 and October 2013 was performed. Patients were identified by screening sequential SVT ablation procedures.
Forty-three (5%) out of 859 SVT ablation procedures were identified as ESPA. The median age was 53 (IQR: 24) years; 63% were female. All patients had pre-EPS documentation of SVT (either strip or ECG). In 23 (53.5%) cases, pre-EPS ECG showed short RP tachycardia. Thirty-two (74.4%) patients had dual atrioventricular nodal physiology (DAVNP) plus echo beats. Junctional rhythm (JR) as procedural endpoint was noted in 39 (90.7%) patients. In 18 (41.9%) patients, the abolishment of DAVNP was achieved. No complications were encountered. A median follow-up of 17 months (range: 6 to 31 months) revealed 83.7% (36 of 43) success rate, defined as the absence of pre-procedural symptoms and any documented sustained arrhythmia. As compared to patients with recurrence (n=7), patients with no recurrence (n=36) had significantly higher prevalence of clinical short RP tachycardia (61.1% vs. 14.3%, p=0.038), and EPS finding of DAVNP plus echo beats (80.6% vs. 42.9%, p=0.034).
ESPA is a reasonable approach in patients with documented SVT, in particular in short RP tachycardia, who are not inducible at EPS. Larger studies are required to assess this practice.
No preview · Article · Oct 2014 · International Journal of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Introduction:
A left atrial (LA) anterior ablation line (AnL), connecting the mitral annulus and right pulmonary veins or a roof line, has been suggested as an alternative to mitral isthmus (MI) ablation for perimitral flutter (PMF). Theoretically, the AnL can exclude the LA septal wall from the reentrant circle, and lead to involvement of the right atrium (RA) in a tachycardia (AT) mechanism.
Methods and results:
Among 807 patients undergoing atrial fibrillation ablation, PMF was diagnosed in 28 subjects, and AnL was performed in 13, and MI ablation in 15 cases. In 4 (31%) patients, AnL resulted in abrupt AT cycle length prolongation, which was associated with the development of a clockwise biatrial tachycardia (bi-AT). The bi-AT propagated along the lateral and posterior mitral annulus, entered the RA via the coronary sinus, and after activating the RA septum reentered the LA over the Bachmann's bundle. The bi-AT was terminated by ablation in Bachmann's bundle insertion areas in the RA or LA. No bi-AT was documented in the MI group. One patient in the AnL group died of stroke in 10 days following the procedure. Anatomic evaluation showed that at the level of the AnL the RA anteroseptal area was separated from the LA by the aortic root, and was free from ablation damage.
A bi-AT can develop when an AnL is created for PMF termination. Biatrial entrainment mapping facilitates diagnosis. Termination of the bi-AT is feasible when ablated from either RA or LA.
[Show abstract][Hide abstract] ABSTRACT: Background
Hypertrophic cardiomyopathy (HCM) patients may develop interatrial activation delay, indicated by complete separation of right and left atrial activation on the ECG. This study aimed to determine the prevalence of interatrial activation delay and the relation to atrial tachycardia (AT) cycle length (CL) in HCM patients.
159 HCM patients were included (mean age 52 ± 14 yrs). In group I (n = 15,9%) patients had atrial arrhythmias and progressive ATCL. In group II (n = 22, 14%) patients had a stable ATCL. In group III (n = 122, 77%) HCM patients without AT were included. P wave morphology and change in P wave duration (ΔP and Pmax) and changes in ATCL (ΔATCL) were analysed. Mean follow up was 8.7 ± 4.7 years. Results
In group I 33% (n = 5) had separated P waves. In group II no P wave separation was identified (OR 1.50 [1.05-2.15], p = 0.007). In group I patients were older compared to group III (62.6 ± 15.1vs. 50.2 ± 14.0 y, p = 0.002) and had longer follow up (13.4 ± 2.2 vs. 7.8 ± 4.6 y, p < 0.001). In group III Pmax and ΔP was significantly lower (105.1 ± 22.0 ms and 8.9 ± 13.2 ms, both p < 0.0001). Group I patients had an increased LA size compared to group II (61.1 ± 11.6 vs. 53.7 ± 7.5 mm, p = 0.028) and higher E/A and E/E prime ratios (p = 0.007; p = 0.037, respectively). In group I 93.3% of the identified mutations were typical Dutch founder mutations of the MYBPC3 gene.
In HCM patients a unique combination of separated P waves and regularization of ATs is associated with larger atria, higher LA pressures and myosin binding protein mutations.
Full-text · Article · Aug 2014 · IJC Heart and Vessels
[Show abstract][Hide abstract] ABSTRACT: Objective:
It is not clear whether patients who received an implantable cardioverter-defibrillator (ICD) for primary prevention should undergo device replacement if they never experienced an appropriate ICD therapy during the first generator longevity. This study evaluated the incidence and predictors of appropriate ICD therapy after device replacement in this specific population.
From two large prospective ICD registries, we identified all primary prevention patients who had a first ICD replacement without previous appropriate ICD therapy. Cox regression analysis was used to identify predictors of appropriate ICD therapy.
Of 403 primary prevention patients needing first ICD replacement, 275 patients (68%) had not received previous appropriate ICD therapy. Patients without previous appropriate ICD therapy before first ICD replacement (mean age at replacement 62 ± 12 years, 75% male) had a mean follow-up of 86 ± 24 months after the initial implantation and 30 ± 24 months after device replacement. Following replacement, 3-year cumulative incidence of appropriate ICD therapy was 13.7% (95% CI 8.6 to 18.8%). No predictive factors associated with appropriate ICD therapy after replacement could be identified in spite of including seven clinically relevant factors.
A considerable number of primary prevention patients without previous appropriate ICD therapy before first ICD replacement received appropriate ICD therapy after replacement. As there were no predictors of appropriate ICD therapy after replacement, replacing an ICD is still recommended in all primary prevention patients despite the lack of appropriate ICD therapy during first battery service life.
No preview · Article · Aug 2014 · Heart (British Cardiac Society)
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: A 72-year-old man with an infected permanent dual chamber pacemaker. INVESTIGATION: The patient underwent successful generator removal, although the pacemaker leads were left due to severe entrapment despite energetic external traction, Percutaneous lead extraction was performed and was complicated by tricuspid valve avulsion leading to severe tricuspid regurgitation. DIAGNOSIS: Entrapment of infected pacemaker lead. MANAGEMENT: First, a loop around the leads was created using the combination of a gooseneck snare and a wire. Second, a single goose snare was used to remove the remaining severel gentrapped piece of lead.
No preview · Article · Jul 2014 · EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology
[Show abstract][Hide abstract] ABSTRACT: The implantable cardioverter defibrillator (ICD) is effective in preventing sudden cardiac death. However, in elderly patients (aged 75 years or older) the role of ICDs is still not well-defined and controversial.
We retrospectively analysed all clinical and survival data of all ICD patients who were ≥75 years at the date of implantation in the Erasmus MC, Rotterdam, the Netherlands and the University Hospital, Basel, Switzerland. Kaplan-Meier survival analysis was performed, and mortality predictors were identified. Mortality of the cohort was compared with a random sample of patients aged 60-70 years originating from the same database and to an age- and sex-matched cohort of Dutch persons.
The study cohort consisted of 179 patients aged 75 years or older who were implanted between February 1999 and July 2008. The median follow-up time was 2.0 (IQR 2.8) years. Survival rates after 1, 2 and 3 years were 87, 82, 75 %, respectively. Survival was similar for primary and secondary prevention. Mortality in this study population could be predicted by combining four clinical risk factors: QRS duration >120 ms, NYHA class > II, renal failure and atrial fibrillation (AF). Survival was worse compared with the group of ICD patients aged 60-70 years and to the age- and sex-matched group of elderly persons. However, survival was not significantly worse when comparing elderly ICD patients without additional risk factors to the general population.
Elderly patients still have an acceptable survival probability independent of prevention indication, certainly if there are no additional clinical risk factors. The presence or absence of additional clinical risk factors should be taken into account when making the decision for implantation, since they strongly correlate with survival.
Full-text · Article · May 2014 · Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation