Andreas Rillig

Durability of wide-area left atrial appendage isolation: Results from extensive catheter ablation for treatment of persistent atrial fibrillation

BACKGROUND Extensive ablation strategies are currently performed in addition to pulmonary vein isolation (PVI) to improve the clinical outcome of patients with drug-refractory persistent atrial fibrillation (AF). Ablation of complex fractionated atrial electrograms (CFAEs), linear lesions, and/or isolation of the left atrial appendage (LAA) are thought to improve arrhythmia-free survival. OBJECTIVE The purpose of this study was to assess the durability of wide-area left atrial appendage isolation (LAAI) achieved by PVI, an anterior line, and a mitral isthmus line. METHODS Seventy-one patients with intentional or incidental LAAI during repeat catheter ablation for treatment of persistent AF were included. The initial ablation strategy was PVI. Additional ablation strategies were performed only if PVI failed to maintain stable sinus rhythm. Durability of LAAI was assessed during a subsequent ablation procedure for arrhythmia recurrences (n = 23) or a subsequent percutaneous LAA closure (n = 48). RESULTS LAAI was performed after a mean of 3 ± 1 procedures. Ablation strategies included circumferential PVI in 71 patients (100%), mitral isthmus line in 64 (90%), anterior line in 60 (85%), CFAE in 27 (38%), and roof line in 13 (18%). LAAI occurred after ablation and bidirectional block of LA linear lesions in 63 patients (89%) and during extensive CFAE ablation in 8 patients (11%). After a median of 105 [61;426] days, the LAA remained electrically isolated in 52 of 71 patients (73%). CONCLUSION Wide-area LAAI after extensive catheter ablation for persistent AF is durable in the majority of patients. The potential clinical benefit of LAAI for maintaining stable sinus rhythm requires further investigation.

Incidence of MRI-detected brain lesions and neurocognitive function after electrical cardioversion in anticoagulated patients with persistent atrial fibrillation

BACKGROUND After electrical cardioversion (eCV) in patients with atrial fibrillation (AF), the risk for clinically apparent cerebral thromboembolism is increased in the subsequent weeks. To date, there is little evidence on the incidence of acute brain lesions (ABL) detected with cerebral magnetic resonance imaging (MRI) after eCV, in particular in patients treated with the Non-Vitamin K Antagonist oral anticoagulants (NOAC). AIMS The aim of this pilot study was to evaluate the incidence of MRI-detected ABL, as well as the neuro-cognitive function after eCV in patients with persistent AF using NOACs as compared to phenprocoumon. METHODS AND RESULTS 50 consecutive patients with persistent AF (mean age 69.6±3.5years, 26 male) were evaluated in this prospective study. Cerebral 3Tesla MRI and neuro-cognitive assessment using the National Institutes of Health Stroke Scale (NIHSS) score and the Montreal Cognitive Assessment Test (MoCA) were performed in all patients within 24h before eCV and after a median follow-up duration of 14days (Q1: 13, Q3: 19days). Patients were treated with an OAC for at least 4weeks after eCV and according to the CHA2DS2-Vasc-score thereafter. Thirty-nine patients were treated with NOACs (Dabigatran 10/50 [20%], Apixaban 21/50 [42%] and Rivaroxaban 8/50 [16]) and 11/50 patients with Phenprocoumon (22%). No patient developed ABL on cerebral MRI at the 2-week follow-up. Neurological as well as cognitive function were similar before and 2weeks after eCV (NIHSS-score: p=0.35; MoCa score: p=0.21). CONCLUSION Electrical CV in patients with persistent AF, in particular when treated with NOACs, carries a low risk for the development of MRI-detected ABL or neurocognitive decline. CLINICAL TRIALS REGISTRATION GermanClinicalTrialsRegister number: DRKS00010460.

Left atrial appendage closure in a patient with left atrial appendage thrombus using a novel fish ball technique

We report about a male patient with permanent atrial fibrillation and CHADs2-Vasc-score 3 / Hasbled-score 4. Intracranial hemorrhage occured during oral anticoagulation (OAC) with Warfarin. OAC was changed to Apixaban. Transesophageal echocardiography revealed a thrombus in the left atrial appendage (LAA) which was persistent even after changing the OAC to Dabigatran. A 28mm Amulet endocardial LAA occluder was performed using the so called fish-ball technique. No clinical significant stroke occurred during or after the procedure. LAA occlusion with the Amulet TM device may present an option in selected patients with LAA thrombus and high risk for bleeding complications under OAC.history.

Apixaban, rivaroxaban, and dabigatran use in patients undergoing catheter ablation for atrial fibrillation using the second-generation cryoballoon

Data are limited on the safety of periprocedural anticoagulation with novel oral anticoagulants (NOACs) in patients undergoing pulmonary vein isolation (PVI) using the second‐generation cryoballoon (CB) for the treatment of atrial fibrillation.

[Syncope : epidemiology, definition, classification, pathophysiology and prognosis].

Syncope is a common clinical issue. Around 40 % of the total population experience syncope during their lifetime. Serious injuries and reduced quality of life are often observed after syncope. Furthermore, in some cases syncope can be associated with an unfavorable prognosis. Due to the complex etiology and pathophysiology, syncope provides challenges for doctors both in private and in clinical practices. This review is based on the latest European guidelines for syncope which were formulated by internists, neurologists, emergency physicians and cardiologists and gives an overview of the current epidemiology, definition, classification, pathophysiology and prognosis of syncope.

What is the real recurrence rate after cryoballoon-based pulmonary vein isolation? Lessons from rhythm follow-up based on implanted cardiac devices with continuous atrial monitoring

BACKGROUND Second-generation cryoballoon (CB2)-based pulmonary vein isolation (PVI) has demonstrated encouraging clinical results for the treatment of paroxysmal atrial fibrillation (AF) and persistent AF. However, rhythm follow-up after PVI is mainly based on Holter electrocardiography of limited duration. OBJECTIVE The purpose of this study was to assess the real AF burden following CB2-based PVI in patients with implanted cardiac devices. METHODS A total of 670 consecutive patients underwent CB2-based PVI at 3 electrophysiology centers. In 66 patients (9.9%), an implantable cardiac device with continuous monitor function was independently implanted before the procedure (device group). This patient cohort was compared to propensity score-matched patients without cardiac devices (n = 66; control group). RESULTS A total of 254 of 258 PVs (98.4%0 in the device group were successfully isolated using only CB2. Postprocedural device interrogation found no device or lead malfunction related to the procedure. Periprocedural complications were registered in 7 of 66 patients (11%) in the device group and in 6 of 66 patients (9%) in the control group (P = .770). Phrenic nerve palsy occurred in 6 of 66 patients (9%) in the device group) and in 2 of 66 patients (3%) in the control group) (P = .274). Clinical success in terms of freedom from AF recurrence after a 1-year follow-up period was 63.8% (95% confidence interval 53-77) in the device group and 77.3% (95% confidence interval 68-88) in the control group (P = .038). In the device group, AF/AT burden decreased from 41.8% ± 35.0% before the procedure to 10.2% ± 22.4% after 1 year (P <.0001). CONCLUSION CB2-PVI seems safe and feasible in patients with an implanted cardiac device. A significantly higher AF/AT burden was seen in patients with an implanted cardiac device compared to a control group.

Cryoballoon ablation in the elderly: one year outcome and safety of the second-generation 28mm cryoballoon in patients over 75 years old

Aims The efficacy of the second-generation cryoballoon (CB) ablation in patients with atrial fibrillation (AF) has been demonstrated previously. Data on the efficacy of CB ablation in elderly patients is missing. The aim of this study was to evaluate the long-term success rate of pulmonary vein isolation (PVI) in patients ≥75 years vs. <75 years using the second-generation 28mm CB. Methods and results Eighty patients [n = 40 ≥75 years (Group 1); n = 40 <75 years (Group 2)] with paroxysmal [n = 37 (46%) or persistent (n = 43 (54%)] AF were included. Median follow-up was 12 [6;18] months (Group 1 vs. 13 [6;27]) months (Group 2; P = 0.8). PVI was performed in all patients using cryoablation. Follow-up was obtained using 24h-Holter monitoring or via an implanted loop recorder or pacemaker. CHA2DS2VASc-Score (Group 1: 4 [4;5] vs. Group 2: 2 [1;3], P < 0.001) and HASBLED-Score (Group 1: 2 [2;3] and Group 2: 2 [1;3], (P = 0.009)) differed significantly between the two groups. Mean fluoroscopy time was 22.9 [16.3;31.9] in Group 1 and 24.5 [19.1;30.6] in Group 2 (P = 0.75), and mean procedure time was 125 min [105;151] in Group 1 and 130.5 min [117.5;147.3] in Group 2 (P = 0.66). Arrhythmia recurrence was similar in Group 1 and Group 2 (12/40 (30%) vs. 10/40 (25%) (P = 0.62). One transient ischaemic attack occurred in Group 2. No further major complications were documented in this patients cohort. Conclusion CB ablation in patients ≥75 years has favourable success rates and similar complication rates compared with patients <75 years.

Long-term follow up of 3 T MRI-detected brain lesions after percutaneous catheter-based left atrial appendage closure

Left atrial appendage closure (LAAC) for stroke prevention is an increasingly performed intervention.

[Interventional stroke prophylaxis : endocardial and epicardial left atrial appendage closure].

ZusammenfassungVorhofflimmern (VHF) stellt derzeit mit einem geschätzten Risiko von etwa 5% pro Jahr eine der häufigsten Ursachen für einen ischämischen Schlaganfall dar. Die orale Antikoagulation ist als effektive Therapieform zur Reduktion des Schlaganfallrisikos bei Patienten mit VHF etabliert; sie ist allerdings auch mit einem erhöhten Blutungsrisiko assoziiert. Es konnte gezeigt werden, dass bei Patienten mit VHF im Falle des Nachweises eines Thrombus im Herzen dieser zu über 90% im linken Vorhofohr (LAA) lokalisiert ist. Auf Basis dieser Erkenntnisse stehen seit einiger Zeit neben der oralen Antikoagulation verschiedene Systeme für einen interventionellen Verschluss des LAA zur Reduktion des Schlaganfallrisikos zur Verfügung. Neben den endokardialen LAA-Verschluss-Systemen wie beispielsweise dem WATCHMAN™- oder dem AMPLATZER™-System ist vor Kurzem ein epikardiales LAA-Verschluss-System (LARIAT™) vorgestellt worden. In diesem Artikel werden sowohl die endokardialen als auch die epikardialen Verschlusssysteme erläutert und neben Indikation und Handhabung auch die Vor- und Nachteile der jeweiligen Systeme, basierend auf der aktuellen Datenlage, herausgearbeitet.AbstractAtrial fibrillation (AF) is currently one of the major causes of ischemic stroke with an estimated stroke risk of 5% per year. Oral anticoagulation is an effective treatment for the reduction of stroke risk in patients with AF but is also associated with an increased risk of bleeding. In patients with AF it has been shown that left atrial thrombi can be identified within the left atrial appendage (LAA) in more than 90% of cases. On the basis of these findings LAA closure devices have been developed as an alternative to oral anticoagulation. Besides endocardial LAA occluders, such as the WATCHMAN™ and AMPLATZER™ devices, an epicardial LAA occluder (LARIAT™) has recently been introduced. The following review introduces the various endocardial and epicardial LAA closure devices and assesses the indications, management, advantages and disadvantages of the two approaches according to the current literature.Atrial fibrillation (AF) is currently one of the major causes of ischemic stroke with an estimated stroke risk of 5% per year. Oral anticoagulation is an effective treatment for the reduction of stroke risk in patients with AF but is also associated with an increased risk of bleeding. In patients with AF it has been shown that left atrial thrombi can be identified within the left atrial appendage (LAA) in more than 90% of cases. On the basis of these findings LAA closure devices have been developed as an alternative to oral anticoagulation. Besides endocardial LAA occluders, such as the WATCHMAN™ and AMPLATZER™ devices, an epicardial LAA occluder (LARIAT™) has recently been introduced. The following review introduces the various endocardial and epicardial LAA closure devices and assesses the indications, management, advantages and disadvantages of the two approaches according to the current literature.

Efficacy and safety of cryoballoon ablation in the elderly: A multicenter study

BACKGROUND The prevalence of atrial fibrillation (AF) increases with age. Second-generation cryoballoon (CB2)-based PVI has demonstrated encouraging clinical results in the treatment of paroxysmal (PAF) and persistent atrial fibrillation (PersAF). The objective of this study was to assess data on safety, efficacy and long-term clinical success of CB2-based pulmonary vein isolation (PVI) in patients ≥75 years of age. METHODS CB2-based PVI was performed in 104 patients ≥75 years of age (elderly group) and symptomatic AF (PersAF: n = 44, 42.3%) in three highly experienced German EP centers. The data was compared to propensity score matched patients with age <75 years (n = 104, control group; PersAF: n = 45, 43.3%, p = 0.956). RESULTS The median age of the elderly group was 77.5 [75, 80] years while it was 63 [52, 70] years of control group patients (p = 0.0001). The median procedure time was 92.5 [75, 120] minutes (elderly group) and 100 [75, 120] (control group), p = 0.124. Major complications were registered in 7/104 (6.7%) elderly patients and 7/104 (6.7%) control group patients (p = 0.999). Clinical success in terms of freedom from AF recurrence after one-year follow-up was 80% (95% CI: 72-88) and 82% (95% CI: 75-90) and after three-year follow-up 59% (95% CI: 47-74) and 49% (95% CI: 37 64) for the elderly group and the control group, respectively (p = 0.7). CONCLUSIONS CB2-based PVI in patients ≥75 years of age appears safe, is associated with low procedure times and shows promising clinical success rates equal to patients of the younger population.