Alexander Samol

Short-term versus long-term antiarrhythmic drug treatment after cardioversion of atrial fibrillation (Flec-SL): a prospective, randomised, open-label, blinded endpoint assessment trial

BACKGROUND Antiarrhythmic drugs prolong the atrial action potential and refractory period, and thereby prevent recurrent atrial fibrillation after cardioversion. The atrial action potential normalises after 2-4 weeks of sinus rhythm, suggesting that antiarrhythmic drugs might not be needed beyond that period. Therefore, we investigated whether short-term antiarrhythmic drug treatment after cardioversion is non-inferior to long-term treatment. METHODS We enrolled patients in a prospective, randomised, open-label, blinded endpoint assessment trial between May 4, 2007, and March 12, 2010, at 44 centres in Germany. Eligible patients were adults with persistent atrial fibrillation undergoing planned cardioversion. After successful cardioversion, patients were randomly assigned in permuted blocks of six per centre to: no antiarrhythmic drug treatment (control); treatment with flecainide (200-300 mg per day) for 4 weeks (short-term treatment); or flecainide for 6 months (long-term treatment). The primary endpoint was time to persistent atrial fibrillation or death. Patients and clinicians were unmasked to group assignment and treatment. The primary outcome was assessed in a core laboratory, members of which were masked to treatment group. Patients were monitored for 6 months by daily telemetric electrocardiograph (ECG) and centrally adjudicated Holter ECG recordings whenever atrial fibrillation was noted in two consecutive ECGs. Analyses were per protocol. This trial is registered, number ISRCTN62728742. FINDINGS After assay sensitivity was established with 4-week follow-up data from 242 patients showing that flecainide was superior to no treatment (Kaplan-Meier survival 70·2%vs 52·5%; p=0·0160), the trial continued to compare short-term versus long-term treatment. The primary outcome occurred in 120 (46%) of 261 patients receiving short-term treatment and in 103 (39%) of 263 patients receiving long-term treatment (event-free survival 48·4% [95% CI 41·9-55·0] vs 56·4% [49·1-63·6]; Kaplan-Meier estimate of difference 7·9% [-1·9 to 17·7]; p=0·2081 for non-inferiority; margin prespecified at 12%). In a post-hoc landmark analysis of patients who had not reached the primary endpoint in the first month, long-term treatment was superior to short-term treatment (Kaplan-Meier estimate of difference 14·3% [5·1-23·6]; hazard ratio 0·31 [0·18-0·56]; p=0·0001). INTERPRETATION Short-term antiarrhythmic drug treatment after cardioversion is less effective than is long-term treatment, but can prevent most recurrences of atrial fibrillation. FUNDING The German Federal Ministry of Education and Research, Deutsche Forschungsgemeinschaft, 3M Medica, and MEDA Pharmaceuticals.

Electrocardiographic changes during therapeutic hypothermia

AIMS Induced mild therapeutic hypothermia (MTH) is an effective treatment to improve outcome after out-of-hospital resuscitation. Adverse events are rare, but arrhythmias and bleeding complications have been reported. So far, only few data about electrocardiographic changes and associated events have been reported. METHODS Between 6/2005 and 3/2011, 109 comatose survivors of out-of-hospital cardiac arrest admitted to our institution underwent MTH. In an observational single-center study, we analyzed preclinical course, electrocardiographic changes, arrhythmias, laboratory parameters and complication rates before, during and after MTH. RESULTS MTH led to a significant decrease of heart rate (85.0±23.3 min(-1) at admission; 59.1±20.5 min(-1) during, p<0.01 and 63.1±19.2 after hypothermia p<0.05) a significant prolongation of PR (0.17±0.04 s before, 0.18±0.05 s during, p<0.05; and 0.17±0.04 s after hypothermia, p<0.01) and QTc intervals (0.47±0.05 s before, 0.49±0.05 s during, p<0.01; and 0.46±0.05 s after hypothermia, p<0.01). Two patients developed ventricular fibrillation during hypothermia, both had an acute myocardial infarction. No significant MTH related changes in electrolytes or coagulation parameters were observed. Major bleeding complications occurred in four cases (3.7%) with a trend towards more bleedings after use of preclinical thrombolysis (21.4% with to 6.4% without thrombolysis, p=0.057). We did not find increased risk for bleeding complications in patients with double platelet inhibition after PCI (14.3% compared to 9.5% without PCI, p=0.63) compared to those without PCI. CONCLUSIONS Under strict clinical and laboratory parameter control, induced mild therapeutic hypothermia can be applied to most patients after out-of-hospital cardiac arrest with no increased risk for arrhythmias despite significant electrocardiographic changes.

Predictors and Outcome of Early-Onset Pneumonia After Out-of-Hospital Cardiac Arrest

BACKGROUND: Early-onset pneumonia (EOP) after out-of-hospital cardiac arrest is frequently observed. Causative factors are loss of airway protection during cardiac arrest, pulmonary contusion, and emergency airway management. We assessed the incidence, risk factors, and clinical course of EOP, and evaluated the impact of an early exchange of the prehospitally inserted endotracheal tube (ETT). METHODS: In our retrospective analysis we included 104 consecutive subjects admitted to our ICU after out-of-hospital cardiac arrest between 2007 and 2012. All subjects underwent therapeutic hypothermia. We analyzed clinical course, inflammation indicators, Clinical Pulmonary Infection Score, occurrence of EOP, duration of ventilatory support, microbiological findings, and short-term outcome. RESULTS: Of the 104 subjects, 46.2% received an exchange of ETT directly after hospital admission. Neither ETT exchange nor observed aspiration were associated with elevated CPIS or EOP, nor with proof of microorganisms in respiratory secretions. We found no differences in duration of ventilatory support, PaO2/FIO2, ICU days, or outcome. C-reactive protein was significantly higher in subjects with aspiration (P = .046). Sex, age, smoking status, aspiration, cause of cardiac arrest, first detected heart rhythm, and use of supraglottic airways devices were not associated with EOP. Subjects with EOP had a longer need for ventilatory support (P = .005), higher tracheotomy rate (P = .03), longer ICU stay (P = .005), higher C-reactive protein (P < .001), higher body temperature (P = .003), higher Clinical Pulmonary Infection Score (P < .001), and lower PaO2/FIO2 (P = .008). CONCLUSIONS: The rate of EOP was not significantly influenced by the exchange of the preclinically inserted ETT, but was associated with longer need for mechanical ventilation and ICU stay.

Low stroke risk after elective cardioversion of atrial fibrillation: An analysis of the Flec-SL trial

BACKGROUND Current recommendations for anticoagulation management during cardioversion are largely based on historical data and expert consensus. METHODS AND RESULTS To characterize current practice of anticoagulation during and after elective cardioversion for AF and the risk of stroke and bleeding events, all patients enrolled into the Flec-SL trial were analyzed for stroke/transient ischemic attack and major bleeds after cardioversion. Flec-SL (ISRCTN62728743, NCT00215774) enrolled 635 patients (mean age 63.7 ± 10.9, 66% male). 629 (99.1%) patients received periprocedural anticoagulation, 556 (87.6%) were adequately anticoagulated following current recommendations. 202 (31.8%) patients underwent transesophageal echocardiography-guided cardioversion. Electrical cardioversion was used in 508 patients (80.0%), pharmacological cardioversion in 127 (20%). Six patients suffered from stroke (n = 5) or transient ischemic attack (3 TIAs in 1 patient, event rate 0.9%, 95% CI 0.4-2.1), five others from major bleeds (event rate 0.8%, 95% CI 0.3-1.9), consistent with the low reported event rates in prior studies. Three strokes occurred in the first 5 days after cardioversion. Events were independent of type of cardioversion or the use of TEE to exclude thrombi. CONCLUSION Strokes are rare in this large, prospectively followed cohort of patients undergoing cardioversion for AF and receiving antithrombotic therapy following local routine. These results support adherence to current recommendations for anticoagulation during cardioversion of AF.

T-wave integral: an electrocardiographic marker discriminating patients with arrhythmogenic right ventricular cardiomyopathy from patients with right ventricular outflow tract tachycardia

AIMS Clinical and electrocardiographic (ECG) presentation of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and idiopathic right ventricular outflow-tract tachycardia (RVOT) may be similar. The aim of the study was to assess the validity and utility of T-wave integral measurement as an ECG discriminator of patients with ARVC and RVOT using a body surface mapping (BSM). METHODS AND RESULTS A 120-channel BSM with quantitative signal analysis of the T-wave integral was performed in 10 patients with ARVC. Results were compared with those obtained from 13 patients with RVOT and a control group of 12 healthy subjects (controls). Age, body mass index, and QRS-axis on surface ECG were not significantly different between the groups. Arrhythmogenic right ventricular cardiomyopathy patients showed a significantly negative T-wave integral in the right lower anterior region of the torso when compared with RVOT (P < 0.001). There was no statistically significant difference between RVOT patients and controls. At a cut-off level of -0.3 mV ms, sensitivity and specificity were 83% [area under curve (AUC) 0.85 ± 0.04 for the comparison of ARVC and RVOT]. These differences were pronounced in ARVC patients with a plakophlin-2 mutation (P < 0.001). CONCLUSION Quantitative analysis of the BSM T-wave integral in distinct anatomical regions discriminates ARVC patients from RVOT patients and controls and may serve as an additional diagnostic tool.

QRS integral: an electrocardiographic indicator of mechanical interventricular asynchrony

AIM The aim of this study was to investigate whether interventricular asynchrony (IVA) can be measured by electrocardiography. METHODS Sixty-two patients (New York Heart Association heart failure functional class III: age, mean +/- SD: 64 +/- 9 years; ejection fraction, mean +/- SD: 24% +/- 8%; dilative cardiomyopathy/ischemic cardiomyopathy, n = 39/23) with left bundle branch block (QRS duration, mean +/- SD: 165 +/- 21 milliseconds) underwent a 120-channel body surface mapping. QRS integral was analyzed and compared with IVA (echo). RESULTS Interventricular asynchrony was associated with significantly decreased QRS integrals 15 cm cranial and 6 cm lateral from V1 in patients with normal axis (n = 36): At a cutoff value of -26 milliseconds mV, receiver operating characteristic analysis to predict IVA revealed a sensitivity of 89% and a specificity of 83% (area under curve, mean +/- SEM: 0.9 +/- 0.07; P < .001). In patients with left axis deviation (n = 26), IVA showed significantly decreased QRS integrals 10 cm caudal from V1: at a cutoff value of -89 milliseconds mV, receiver operating characteristic analysis to predict IVA revealed a sensitivity of 83% and a specificity of 100% (area under curve, mean +/- SEM: 0.9 +/- 0.07; P < .002). CONCLUSIONS Interventricular asynchrony strongly correlates with QRS integral. Key lead positions, however, are axis dependent and outside standard leads.

Improved Clinical Risk Stratification in Patients with Long QT Syndrome? Novel Insights from Multi-Channel ECGs

Background We investigated whether multichannel ECG-recordings are useful to risk-stratify patients with congenital long-QT syndrome (LQTS) for risk of sudden cardiac death under optimized medical treatment. Methods In 34 LQTS-patients (11 male; age 31±13 years, QTc 478±51ms; LQT1 n = 8, LQT2 n = 15) we performed a standard 12-channel ECG and a 120-channel body surface potential mapping. The occurrence of clinical events (CE; syncope, torsade de pointes (TdP), sudden cardiac arrest (SCA)) was documented and correlated with different ECG-parameters in all lead positions. Results Seven patients developed TdP, four survived SCA and 12 experienced syncope. 12/34 had at least one CE. CE was associated with a longer QTc-interval (519±43ms vs. 458±42ms; p = 0.001), a lower T-wave integral (TWI) on the left upper chest (-1.2±74.4mV*ms vs. 63.0±29.7mV*ms; p = 0.001), a lower range of T-wave amplitude (TWA) in the region of chest lead V8 (0.10±0.08mV vs. 0.18±0.07mV; p = 0.008) and a longer T-peak-T-end time (TpTe) in lead V1 (98±23ms vs. 78±26ms; p = 0.04). Receiver-operating-characteristic (ROC) analyses revealed a sensitivity of 96% and a specificity of 75% (area under curve (AUC) 0.89±0.06, p = 0.001) at a cut-off value of 26.8mV*ms for prediction of CE by TWI, a sensitivity of 86% and a specificity of 83% at a cut-off value of 0.11mV (AUC 0.83±0.09, p = 0.002) for prediction of CE by TWA and a sensitivity of 83% and a specificity of 73% at a cut-off value of 87ms (AUC 0.80±0.07, p = 0.005) for prediction of CE by TpTe. Conclusions Occurrence of CE in LQTS-patients seems to be associated with a prolonged, low-amplitude T-wave.

Efficacy of a one-catheter concept for transradial coronary angiography

Introduction Transradial coronary angiography (TRC) can be performed with a one-catheter approach for the right and left coronary ostium (R/LCO). We investigated the performance of a special diagnostic catheter widely used for the one-catheter-approach, the Tiger (Tiger II, TerumoTM). Methods In a dual center registry we analyzed 1412 TRC-procedures exclusively performed by experienced TRC-operators. We compared the performance of the Tiger with Judkins catheters by retrospectively judging ostial catheter stability during contrast injection, and by measuring contrast use, fluoroscopy time (FT) and complication rate. Results Poor or failed ostial engagement was found in 40.5% in the Tiger group, compared to 46.6% with the use of Judkins catheters (p<0.183). Ostial instability of the Tiger was found more often during engagement of the LCO than the RCO (34.4% vs. 10.8%, p<0.001), whereas it was similar in the LCO and RCO for Judkins catheters (27.4% vs. 26.7%, p = 0.840). TRC-procedures performed with Tiger catheters were associated with less contrast volume (63.48 ± 29.83mL vs. 82.51 ± 56.58mL, p<0.004) and shorter FT than with Judkins catheters. (198.27 ± 194.8sec vs. 326.85 ± 329.70sec). Forearm hematomas occurred less often with the Tiger (1.2% vs. 6.6%, p< 0.02). Conclusion The Tiger employed as a single catheter in TRC is an effective tool to achieve lower contrast volume and fluoroscopy time at a low complication rate. Unstable engagement affects predominantly the left coronary artery, but its overall frequency is similar for both, the Tiger and Judkins catheters.

A rare cause of fatal right ventricular cardiac decompensation.

Hereditary hemorrhagic telangiectasia is an autosomal dominant vascular disease often manifesting with epistaxis, telangiectasia, and intraparenchymatous arteriovenous malformations. We report on the case of a 71-year-old man who was admitted to hospital due to a tricuspid valve insufficiency. During the following days, the patient developed liver and renal failure; the clinical condition worsened rapidly. Computed tomographic diagnostics revealed arteriovenous malformations in the lung and in the liver portal. Additionally, mucocutaneous telangiectasia in the mouth was found. Hereditary hemorrhagic telangiectasia was assumed; nevertheless, an effective treatment was impossible because of the patients worse clinical state; he died a few days later. Autopsy affirmed the diagnosis of hereditary hemorrhagic telangiectasia; molecular genetic analysis revealed a heterozygous mutation in the ALK-1 gene. Despite its relatively high prevalence, hereditary hemorrhagic telangiectasia is not considered as a diagnosis as frequently as it should be, and clinicians need to be aware of the signs of hereditary hemorrhagic telangiectasia as well as the appropriate diagnostic workup.

TCT-208 Safety and efficacy of short triple-therapy after DES-implantation.

Due to growing incidence of both, atrial fibrillation and coronary artery disease, more patients need a triple-therapy (TT)consisting of dual antiplatelet therapy and anticoagulation after PCI. Existing data on duration and intensity of TT is scarce and conflicting. The ESC-guidelines recommend