Thomas Kleemann

Klinikum Ludwigshafen, Ludwigshafen, Rheinland-Pfalz, Germany

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Publications (33)160.49 Total impact

  • T. Kleemann · M. Strauß · K. Kouraki
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    ABSTRACT: With the increase in the age of the total population it is to be expected that the number of acute emergencies involving patients with pacemakers will also increase. Specific pacemaker problems, such as pacemaker tachycardia or pacemaker dysfunction can trigger off emergency situations in pacemaker patients, which can be recognized and acutely resolved by the emergency physician. The placement of a magnet on the pacemaker may be useful in order to terminate pacemaker tachycardia in an emergency or to temporarily bridge the loss of pacemaker stimulation. However, for patients with acute coronary syndrome a pacemaker can complicate the diagnosis of acute myocardial infarction if the electrocardiogram (ECG) is altered by pacemaker stimulation. Thus, basic knowledge about pacemaker ECG and pacemaker therapy is essential for an emergency physician. This article gives a brief summary of the basic principles of pacemaker function and deals with possible emergency situations in patients with pacemakers. © 2015 Deutsche Gesellschaft für Kardiologie - Herz- und Kreislaufforschung e.V. Published by Springer-Verlag Berlin Heidelberg - all rights reserved
    No preview · Article · Oct 2015 · Notfall
  • T Kleemann
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    ABSTRACT: Cardiac contractility modulation (CCM) is a stimulation therapy by an implantable impulse generator, which enhances ventricular contractile performance by delivering CCM impulses to the right ventricle during the absolute refractory period. The CCM signals mediate increased inotropy by prolonging the duration of the action potential, which leads to an enhanced influx of calcium into cardiomyocytes and a greater release of calcium by the sarcoplasmic reticulum. The increase of cardiac contractility is not associated with increased oxygen consumption. Several small studies have shown that CCM therapy can safely improve symptoms of heart failure and peak oxygen consumption in patients with moderate to severe heart failure who are not eligible for resynchronization therapy. Therefore, CCM is a novel potential therapy for patients with heart failure, an ejection fraction ≤ 35 % and a normal QRS duration < 130 ms. However, apart from selecting appropriate patients for CCM therapy there are still unanswered questions, such as the impact of CCM therapy on established clinical endpoints. At present no data are available which have shown that CCM therapy leads to reduction of hospitalization for heart failure or mortality.
    No preview · Article · Oct 2015 · Herz
  • T. Kleemann · M. Strauß · K. Kouraki
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    ABSTRACT: With the increase in the age of the total population it is to be expected that the number of acute emergencies involving patients with pacemakers will also increase. Specific pacemaker problems, such as pacemaker tachycardia or pacemaker dysfunction can trigger off emergency situations in pacemaker patients, which can be recognized and acutely resolved by the emergency physician. The placement of a magnet on the pacemaker may be useful in order to terminate pacemaker tachycardia in an emergency or to temporarily bridge the loss of pacemaker stimulation. However, for patients with acute coronary syndrome a pacemaker can complicate the diagnosis of acute myocardial infarction if the electrocardiogram (ECG) is altered by pacemaker stimulation. Thus, basic knowledge about pacemaker ECG and pacemaker therapy is essential for an emergency physician. This article gives a brief summary of the basic principles of pacemaker function and deals with possible emergency situations in patients with pacemakers.
    No preview · Article · Jun 2015 · Notfall
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    ABSTRACT: A significant number of patients with an implantable cardioverter/defibrillator (ICD) for primary prevention receive inappropriate shocks. Previous studies have reported a reduction of inappropriate therapies with simple modifications of ICD detection settings, however, inclusion criteria and settings varied markedly between studies. Our aim was to investigate the effect of raising the ICD detection zone in the entire primary prevention ICD population. 543 patients receiving an ICD for primary prevention were randomized to either conventional or progressive ICD programming. The detection rate was programmed at 171 bpm for ventricular tachycardia (VT) and 214 bpm for ventricular fibrillation (VF) in the Conventional group and 187 bpm for VT and 240 bpm for VF in the Progressive group. 43 % of patients received single-chamber and 57 % dual-chamber detection devices (DDD-ICD 19 %; CRT-D 38 %). The primary endpoint consisted of inappropriate therapies and untreated VT/VF. The primary endpoint was reached in 35 patients (13 %) in the Conventional group and 17 patients (6 %) in the Progressive group (p = 0.004). Progressive ICD programming led to significantly fewer amount of patients with ICD therapies (26 vs. 14 %; p < 0.001) and shocks (11 vs. 5 %; p = 0.023) compared to conventional ICD programming. Sub-analyses showed the greatest reduction of inappropriate therapies and shocks in dual-chamber detection devices with progressive compared to single-chamber detection devices with conventional ICD programming (p < 0.001). Progressive ICD programming reduces the number of inappropriate therapies and shocks in a broad primary prevention ICD population particularly in combination with dual-chamber detection algorithms. http://clinicaltrials.gov ; ClinicalTrials.gov identifier NCT01217528.
    No preview · Article · May 2015 · Clinical Research in Cardiology
  • Thomas Kleemann · Margit Strauss · Kleopatra Kouraki · Ralf Zahn
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    ABSTRACT: In patients with an implantable cardioverter-defibrillator (ICD), ICD shocks due to ventricular tachycardia (VT) or ventricular fibrillation (VF) have been associated with an increased mortality. It is not known whether patients with antitachycardia pacing (ATP)-terminated VT/VF episodes have a similar worse outcome. The aim of this study was to evaluate the clinical course and prognostic impact of ATP-terminated episodes on mortality in ICD patients. A total of 1398 consecutive patients of the prospective single-centre ICD-registry Ludwigshafen who underwent an ICD implantation between 1992 and 2008 for primary or secondary prevention of sudden cardiac death were analysed. Patients treated with ATP were compared with patients with appropriate ICD shocks or patients without any appropriate ATP or ICD shock. During the median follow-up time of 6 years, 749 (54%) patients experienced 17 827 episodes of VT or VF which were terminated by ATP in 74% and by shock in 26% of patients. In approximately half (n = 321/749) of those patients with VT/VF, the first episode was terminated by ATP. In a multivariate analysis adjusted for different baseline confounding parameters, the occurrence of first ATP therapy was associated with a higher mortality rate [hazard ratio (HR) 2.60, 95% confidence interval (CI) 2.02-3.35]. When excluding all patients with appropriate ICD shocks first ATP therapy remained associated with a worse prognosis (HR 1.92, 95% CI 1.38-2.67). In ICD patients, about three-fourths of ventricular arrhythmias are terminated by ATP. The occurrence of ATP-terminated episode is associated with an increased mortality rate. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.
    No preview · Article · Feb 2015 · Europace
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    ABSTRACT: Outcome data of patients with implantable cardioverter defibrillators (ICD) and atrial fibrillation (AF) are conflicting. The German DEVICE registry aims to add further information on this particular cohort. The German DEVICE registry is a nationwide prospective multicenter database of ICD implantations. 3261 patients are included (81% males, 2701 (82.8%) first ICD implantations, 560 (17.2%) ICD replacements). Cardiac resynchronization therapy (CRT-D) was performed in 882 patients (27.0%). Sinus rhythm (SR) was present in 2654 (81.4%) and atrial fibrillation (AF) in 607 (18.6%). Left ventricular ejection fraction (LVEF) did not differ between groups (SR 32.3%, AF 30.4%; p=0.09). AF patients were older (AF 70.9 versus SR 63.9years; p<0.0001), presented with more co-morbidities (diabetes, hypertension, chronic kidney disease; all p<0.001). In-hospital complications were not significantly different between groups (p=0.58). Follow-up information after one year was available in 2967 patients (91%). One-year overall mortality after first ICD implantation was 4.9% for SR and 11.2% for AF patients (p<0.0001); mortality one year after ICD replacement was 8.4% for SR and 12.0% for AF (p=0.34). No statistically significant difference between SR and AF patients receiving a CRT device was observed (SR 6.9%, AF 10.7%, p=0.16) in terms of one-year mortality. The German DEVICE registry demonstrates that patients with AF who receive ICD devices are older, have more co-morbidity and more severe heart failure. AF carries an independent 1.39 fold risk (95% CI 1.02-1.89) of death after one year in patients only with first ICD implantation.
    No preview · Article · Aug 2013 · International journal of cardiology
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    K. Kouraki · M. Strauss · A. Skarlos · R. Zahn · T. Kleemann
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    ABSTRACT: Purpose: The problem of premature insulation failure of Riata ICD leads manufactured by St. Jude Medical Inc. is well documented. According to the manufacturer, there is a lead-specific relative risk among the Riata leads: Riata 8F single coil leads are regarded to have the highest risk, Riata 8F dual coil and Riata ST 7 F single coil leads are of intermediate risk and Riata ST 7F dual coils carry the lowest risk of lead failure. Aim of this analysis was to evaluate the rate of lead failure between the different Riata lead types at our hospital. Methods: We performed a single-center retrospective analysis of 680 Riata leads implanted between 03/2002 and 01/2009. These included 39 high risk leads (1572, 1582), 574 intermediate risk leads (1572, 1582, 1570, 1571, 1580, 1581) and 67 low risk leads (7000, 7001, 7040). Patients with lead revision due to dislodgement or infection were excluded from the study. Lead failure was defined as an insulation failure or fracture requiring surgical revision. Results: During a follow-up time of three years, 111 (16.3%) of the leads had to be replaced, 37 (5.4%) because of pacing/sensing problems and 74 (10.9%) because of lead failure. The distribution of replaced leads among the three risk groups is demonstrated in the table. The median time of lead replacement was 1056 days (IQR 628-1669) after implantation and did not statistically differ between the three groups. Two thirds of the patients presented for routine control, whereas 26% presented with ICD shock, 4% with ICD alarm and 5% with other symptoms such as syncope, bradycardia and muscle twitching. The median time of presentation for these patients was 52 days after the last normal control and did not statistically differ between the three groups. View this table:Enlarge table
    Preview · Article · Aug 2013 · European Heart Journal
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    M. Strauss · K. Kouraki · U. Weisse · R. Zahn · T. Kleemann
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    ABSTRACT: Background: Placement of the Coronary Sinus (CS) lead in Cardiac Resynchronisation Therapy (CRT) devices is a challenging procedure with the need of surgical revision for lead dislodgement or Phrenic Nerve Stimulation (PNS) in about 8% of the patients (pts). With the Quartet electrode, 10 different stimulation vectors can be programmed (see picture 1) in order to perform "electric" instead of surgical CS lead revision, if necessary. Objective: To verify the effectiveness of the quadripolar lead concerning CS lead failure compared to bipolar CS leads. Methods: 38 ICDs were newly implanted with the quadripolar lead from 11/2009 until 12/2010 and 23 ICD with a bipolar CS lead. Operative and follow-up data were prospectively noted. Results: Results of implantation procedure and FU data after a mean follow up of 460 days are listed in table 1. View this table:Enlarge table
    Preview · Article · Aug 2013 · European Heart Journal
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    Full-text · Conference Paper · Jun 2013
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    ABSTRACT: The wearable cardioverter-defibrillator (WCD) is indicated in patients who are considered to be at temporarily high risk for sudden cardiac death (SCD), when an implantable defibrillator is not yet clearly indicated. We report the case of a 41-year-old patient with a newly diagnosed severely reduced left ventricular (LV) function for suspected myocarditis and repeated nonsustained ventricular tachycardia (VT). This patient was supplied with a WCD who came back to the hospital 4 weeks after discharge with an electrical storm and adequate discharge of the WCD. After application of amiodarone, no further arrhythmias were detected during intrahospital course. For further risk stratification, we performed a magnetic field imaging (MFI), that was reported to be useful in risk assessment of SCD in patients with ischemic cardiomyopathy. This measurement showed a normal result, but we decided to give an implantable cardioverter-defibrillator (ICD) to the patient. During a follow-up of 1 year, no further arrhythmias occurred. With this case, we report the efficacy of a WCD, which is a novel tool in patients at temporarily high risk of SCD and we report a novel method of risk stratification in patients with a high risk of SCD.
    No preview · Article · May 2013 · Herzschrittmachertherapie & Elektrophysiologie
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    ABSTRACT: Background Magnet field imaging (MFI) is a noninvasive method to determine cardiac electromagnetic activity. Aim of the study This study aims to compare the electromagnetic QRS fragmentation index (eQFI) in survivors of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) to healthy individuals. Methods Twenty-five consecutive patients with documented sustained VT or VF who underwent a MFI investigation between December 2009 and October 2011 were compared with 25 age- and sex-matched healthy individuals. Results Patients with documented VT or VF showed a trend to higher eQFI values compared with the control group (p = 0.06). This increase was mainly driven by VT/VF patients with ischemic cardiomyopathy (CMP) which was markedly elevated compared with the healthy controls (1.48 vs. 1.07; p = 0.01). In patients with nonischemic CMP or acute coronary syndrome, eQFI was not different from the healthy group. Conclusions Electromagnetic QRS fragmentation is increased in VT/VF patients with ischemic CMP but not in patients with ventricular arrhythmias of other origin. Further investigations in prospective cohorts should evaluate the prognostic value of electromagnetic QRS fragmentation in patients with ischemic heart disease to predict the occurrence of VT/VF and to guide therapy.
    No preview · Article · Nov 2012 · Journal of Interventional Cardiac Electrophysiology
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    ABSTRACT: Atrial fibrillation (AF) is amongst the most important etiologies of ischaemic stroke. In a population-based stroke registry, we tested the hypothesis of low adherence to current guidelines as a main cause of high rates of AF-associated stroke. Within the Ludwigshafen Stroke Study (LuSSt), a prospective ongoing population-based stroke register, we analyzed all patients with a first-ever ischaemic stroke (FEIS) owing to AF in 2006 and 2007. We determined whether AF was diagnosed before stroke and assessed pre-stroke CHADS2 and CHA2DS2-VASc scores. In total, 187 of 626 patients with FEIS suffered from cardioembolic stroke owing to AF, which was newly diagnosed in 57 (31%) patients. Retrospective pre-stroke risk stratification according to CHADS2 score indicated low/intermediate risk in 34 patients (18%) and high risk (CHADS2 ≥ 2) in 153 patients (82%). Application of CHA2DS2-VASc score reduced number of patients at low/intermediate risk (CHA2DS2-VASc score 0–1) to five patients (2.7%). In patients with a CHADS2 score ≥ 2 and known AF (n = 106) before stroke, 38 (36%) were on treatment with vitamin K antagonists on admission whilst only in 16 patients (15%) treatment was in therapeutic range. Our study strongly supports the hypothesis that underuse of oral anticoagulants in high-risk patients importantly contributes to AF-associated stroke. CHA2DS2-VASc score appears to be a more valuable risk stratification tool than CHADS2 score. Preventive measures should focus on optimizing pre-stroke detection of AF and better implementation of present AF-guidelines with respect to anticoagulation therapy.
    No preview · Article · Jul 2012 · European Journal of Neurology
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    ABSTRACT: Recent studies suggest a worse impact of inappropriate shock therapies on the outcome of patients with an implantable cardioverter-defibrillator (ICD). However, it is not known whether the worse impact is attributed to the ICD shock itself or due to the underlying heart disease. The aim of the study was to evaluate the impact of inappropriate ICD shocks on clinical outcome by comparing ICD shocks triggered by atrial fibrillation (AF) with shocks caused by lead failure. A total of 1,411 consecutive patients of the prospective single-center ICD-registry Ludwigshafen who underwent an ICD implantation between 1992 and 2008 for primary or secondary prevention of sudden cardiac death were analyzed. During the median follow-up of 3 years, 297 (21%) patients experienced inappropriate ICD shocks. Sixty percent of patients had inappropriate shocks due to AF and 24% due to lead defect or T-wave oversensing. Multiple ICD shocks (≥2) triggered by AF were associated with a worse prognosis, whereas a single shock due to AF or 1 or multiple shocks resulting from lead failure were not. ICD shocks caused by AF occurred more often in tandem with a serious adverse event than in patients with a lead failure (15% vs 6%, P < 0.05). Multiple ICD shocks triggered by AF are associated with a worse prognosis in ICD patients, whereas a single shock due to AF or shocks resulting from lead failure are not. These data support that the ICD shock itself has no worse impact on the outcome of ICD patients.
    No preview · Article · Feb 2012 · Journal of Cardiovascular Electrophysiology
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    ABSTRACT: Stroke etiology in ischemic stroke guides preventive measures and etiological stroke subgroups may show considerable differences between both sexes. In a population-based stroke registry we analyzed etiological subgroups of ischemic stroke and calculated sex-specific incidence and mortality rates. The Ludwigshafen Stroke Study is a prospective ongoing population-based stroke registry. Multiple overlapping methods of case ascertainment were used to identify all patients with incident stroke or transient ischemic attack. Modified TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria were applied for subgroup analysis in ischemic stroke. Out of 626 patients with first-ever ischemic stroke in 2006 and 2007, women (n = 327) were older (73.5 ± 12.6 years) than men (n = 299; 69.7 ± 11.5 years; p < 0.001). The age-adjusted incidence rate of ischemic stroke was significantly higher in men (1.37; 95% CI 1.20-1.56) than in women (1.12; 95% CI 0.97-1.29; p = 0.04). Cardioembolism (n = 219; 35.0%), small-artery occlusion (n = 164; 26.2%), large-artery atherosclerosis (n = 98; 15.7%) and 'probable atherothrombotic stroke' (n = 84; 13.4%) were common subgroups of ischemic stroke. Stroke due to large-artery atherosclerosis (p = 0.025), current smoking (p = 0.008), history of smoking (p < 0.001), coronary artery disease (p = 0.0015) and peripheral artery disease (p = 0.024) was significantly more common in men than in women. Overall, 1-year survival was not different between both sexes; however, a significant age-sex interaction with higher mortality in elderly women (>85 years) was detected. Cardioembolism is the main source for ischemic stroke in our population. Etiology of ischemic stroke differs between sexes, with large-artery atherosclerotic stroke and associated diseases (coronary artery disease and peripheral artery disease) being more common in men.
    Full-text · Article · Dec 2011 · Cerebrovascular Diseases
  • M Strauss · T Kleemann · U Weisse · F-U Sack · R Zahn
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    ABSTRACT: We report the case of a 63-year-old man with ischemic cardiomyopathy having an implantable cardioverter defibrillator (ICD) implanted for repeated ventricular tachycardia (VT). After several revisions of the ICD lead, a thrombosis of the left venous system was diagnosed. A right pectoral ICD device was implanted, and a sufficient defibrillation threshold (DFT) could not be achieved during the operation. Thus, a further defibrillation lead was implanted into the coronary sinus, which successfully terminated ventricular fibrillation.
    No preview · Article · Jun 2011 · Herzschrittmachertherapie & Elektrophysiologie
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    ABSTRACT: Aim of this study is to evaluate reproducibility, consistency and the impact of moderate exercise workload on optimized PV and VV delays as determined by the IEGM-based QuickOpt™ method (St. Jude Medical), that was shown to produce hemodynamic performance similar to that obtained by echo-guided aortic VTI maximization. Sixty patients with CRT-ICD (65 ± 9 years, 12% female, LVEF 28 ± 9%, 48% CAD and 52% DCM) were enrolled. IEGM-based PV/VV optimization was conducted six times: twice at rest, twice immediately after a 6-min walk test and twice following a 3-min recovery period. Timing cycle delays were programmed in accordance with the optimization results. Follow-up was performed after 1 year. Although significant difference in heart rate was reached [68 ± 9 bpm (REST) vs. 79 ± 12 (6MWT), p < 0.001], differences were not observed between IEGM-based optimized PV/VV delays: PV(opt) = 128 ± 14 ms (REST) versus 130 ± 17 ms (6MWT) versus 129 ± 16 ms (RECOV); VV(opt) = 15 ± 24 ms (REST) versus 15 ± 22 ms (6MWT) versus 16 ± 24 ms (RECOV). During 1-year follow-up PV(opt) and VV(opt) remained stable (ΔPV(opt) = 10 ± 10 ms, ΔVV(opt) = 9 ± 11 ms). Optimized IEGM-based timing cycle delays are independent of moderate exercise status within a particular patient but varied between patients. This supports the use of PV/VV optimization in each CRT patient.
    No preview · Article · Nov 2010 · Clinical Research in Cardiology
  • K. Seidl · M. Strauss · T. Kleemann
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    ABSTRACT: Patients who survive out-of-hospital cardiac arrest or symptomatic ventricular tachyarrhythmias are at considerable risk of recurrence of these events and ultimately death. The implantation of an implantable cardioverter defibrillator (ICD) in patients with previous sustained ventricular tachyarrhythmias (VT) is considered secondary prevention of sudden cardiac death. The purpose of this review is to summarize the most important trials on secondary prevention with an ICD. The results from a meta-analysis showed a relative-risk reduction of 28% in overall mortality. Compared with amiodarone, an ICD provided maximal benefit for those patients with an ejection fraction between 20% and 35%. The results of the ICD trial demonstrate that there is clear evidence for the effectiveness of an ICD in patients with unstable VT; however, for patients with stable VT the results are less clear. Data on older patients are scant, and whether the survival benefit observed in the middle aged and younger-old also extend to older elderly patients with a more limited life span is less clear. Therefore, as the population becomes older, it is important to evaluate the safety, effectiveness, and the cost effectiveness of ICD implantation in this population. Guidelines are important and helpful to guide clinical decisions, but the indication for an ICD still remains an individual decision after evaluation of the risks and benefits for the individual patient. However, the patient needs to be involved, which emphasizes the importance of dialogue between the patient and physician.
    No preview · Article · Jun 2010 · Herzschrittmachertherapie & Elektrophysiologie
  • K Seidl · M Strauss · T Kleemann
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    ABSTRACT: Patients who survive out-of-hospital cardiac arrest or symptomatic ventricular tachyarrhythmias are at considerable risk of recurrence of these events and ultimately death. The implantation of an implantable cardioverter defibrillator (ICD) in patients with previous sustained ventricular tachyarrhythmias (VT) is considered secondary prevention of sudden cardiac death. The purpose of this review is to summarize the most important trials on secondary prevention with an ICD. The results from a meta-analysis showed a relative-risk reduction of 28% in overall mortality. Compared with amiodarone, an ICD provided maximal benefit for those patients with an ejection fraction between 20% and 35%. The results of the ICD trial demonstrate that there is clear evidence for the effectiveness of an ICD in patients with unstable VT; however, for patients with stable VT the results are less clear. Data on older patients are scant, and whether the survival benefit observed in the middle aged and younger-old also extend to older elderly patients with a more limited life span is less clear. Therefore, as the population becomes older, it is important to evaluate the safety, effectiveness, and the cost effectiveness of ICD implantation in this population. Guidelines are important and helpful to guide clinical decisions, but the indication for an ICD still remains an individual decision after evaluation of the risks and benefits for the individual patient. However, the patient needs to be involved, which emphasizes the importance of dialogue between the patient and physician.
    No preview · Article · Jun 2010 · Herzschrittmachertherapie & Elektrophysiologie
  • Karlheinz Seidl · Thomas Kleemann

    No preview · Article · Jun 2010 · Kardiologie up2date
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    ABSTRACT: The aim of the study was to evaluate the incidence of ventricular arrhythmia and clinical outcome in patients receiving a cardiac resynchronization therapy (CRT) depending on the left ventricular (LV) lead position. A total of 187 consecutive patients with advanced heart failure who received a CRT-implantable cardioverter defibrillator were analyzed. Forty patients (21%) had a LV lead in the anterior/apical (anterior) and 147 patients (79%) in the posterior/posterolateral (posterior) region. The total median follow-up time was 644 days. The incidence of ventricular arrhythmia was 35% in patients with an anterior LV lead versus 30% in patients with a posterior LV lead (p = 0.53). The 1- and 2-year mortality in the anterior LV lead group was 19% and 22%, as compared with 0.7% and 3.2%, respectively, in the posterior LV lead group (p < 0.001). In a multivariable analysis, an anterior LV lead was independently associated with an increased mortality (hazard ratio 5.88, 95% confidence interval 2.22-16.67). The major cause of death was end-stage heart failure whereas the incidence of sudden cardiac death was not different between both groups. Thus, biventricular pacing with an anterior LV lead seems to have no impact on the incidence of ventricular arrhythmia but may be associated with an increased mortality rate due to worsening heart failure.
    No preview · Article · Mar 2010 · Journal of Interventional Cardiac Electrophysiology

Publication Stats

507 Citations
160.49 Total Impact Points

Institutions

  • 2007-2015
    • Klinikum Ludwigshafen
      Ludwigshafen, Rheinland-Pfalz, Germany
  • 2009
    • BG Trauma Center Ludwigshafen
      Ludwigshafen, Rheinland-Pfalz, Germany
  • 2008
    • Universität Heidelberg
      Heidelburg, Baden-Württemberg, Germany
    • Institut für Herzinfarktforschung
      Mayence, Rheinland-Pfalz, Germany