Damir Erkapic

Risk for Permanent Pacemaker After Transcatheter Aortic Valve Implantation: A Comprehensive Analysis of the Literature

Risk for Permanent Pacemaker After Transcatheter Aortic Valve Implantation.

MEDAFI-Trial (Micro-embolization during ablation of atrial fibrillation): comparison of pulmonary vein isolation using cryoballoon technique vs. radiofrequency energy

AIMS Cerebral embolism is a possible serious complication during catheter ablation of atrial fibrillation (AF). The purpose of this prospective pilot study was to analyse the incidence and possible impact of cryo ablation on cerebral lesions and possible differences to radiofrequency (RF) ablation during pulmonary vein isolation (PVI). METHODS AND RESULTS Pulmonary vein isolation was performed in 89 patients, either with the cryoballoon technique (n = 45) or with RF ablation (n = 44). Phenprocoumon was stopped 3 days before intervention and replaced by subcutaneous low-molecular-weight heparin. During the catheter procedure, an infusion of unfractionated heparin was maintained to achieve an activated clotting time (ACT) of > 300 s. Cerebral magnetic resonance imaging scans were performed 1 day before and after PVI, and at 3-month follow-up. Chronic lesions were observed in 11 patients (12.3%) before PVI without statistically significant difference between the two groups. None of the patients had neurological symptoms during or following the procedure. Seven patients (7.9%) developed acute lesions 1 day after PVI, without statistically significant difference between the group treated by cryoenergy (8.9%) and RF ablation (6.8%). Patients with acute lesions were significantly older compared with those without acute cerebral lesions. No additional cerebral lesions during follow-up were observed. CONCLUSION A considerable portion of patients with AF but without any neurological symptoms had chronic cerebral lesions before PVI. Additional acute lesions could be added after the procedure. Both ablation techniques showed additional cerebral acute lesions with no neurological symptoms after PVI.

Cryoballoon ablation of paroxysmal atrial fibrillation: 5-year outcome after single procedure and predictors of success.

AIMS Long-term efficacy following cryoballoon (CB) ablation of atrial fibrillation (AF) remains unknown. This study describes 5 years follow-up results and predictors of success of CB ablation in patients with paroxysmal atrial fibrillation (PAF). METHODS AND RESULTS In total, 163 patients were enrolled with symptomatic, drug refractory PAF. Pulmonary vein isolation (PVI) with CB technique was performed. Primary endpoint of this consecutive single-centre study was first electrocardiogram-documented recurrence of AF, atrial tachycardia or atrial flutter (AFLAT). Five years success rate after single CB ablation was 53%. In 70% of the patients acute complete PVI was achieved with a single 28 mm balloon. The univariate predictors of AFLAT recurrence were (1) size of left atrium, with normalized left atrium (NLA) ≥10.25 [hazard ratios (HR) of 1.81, 95% confidence interval (CI): 1.28-2.56] when compared with NLA <10.25 (35% vs. 53%, P = 0.0001) and (2) renal function, with impaired glomerular filtration rate (GFR) <80 ml/min (HR of 1.26, 95% CI: 1.02-1.57) when compared with GFR ≥80 ml/min (45% vs. 53%, P = 0.041). Normalized left atrium ≥10.25 was the sole independent predictor for outcome (HR 2.11; 95% CI: 1.34-3.31; P = 0.0001). CONCLUSIONS Sinus rhythm can be maintained in a substantial proportion of patients with PAF even 5 years after circumferential PVI using CB ablation. The rate of decline in freedom from AFLAT was highest within the first 12 months after the index procedure. The patients with enlarged left atrium and/or impaired renal function have lower outcome.

Pulmonary Vein Stenting for the Treatment of Acquired Severe Pulmonary Vein Stenosis after Pulmonary Vein Isolation: Clinical Implications after Long-Term Follow-Up of 4 Years

Pulmonary Vein Stenting. Introduction: Severe pulmonary vein stenosis (PVS) after catheter ablation of atrial fibrillation (AF) is a well‐recognized complication with a further reported incidence of 1.3%. The preferred therapy for symptomatic PVS is pulmonary vein (PV) angioplasty, but this treatment modality is followed by restenosis in 44–70%. Whether there is additional long‐term benefit from PVS stenting is uncertain. The aim of this study was the evaluation of the long‐term success after PV stenting of severe stenosis.

Radiation Dose Exposure of Computed Tomography Coronary Angiography - Comparison of Dual Source -, 16 – slice and 64 – slice - CT

Background: Dual-source CT (DSCT) promises a significant reduction of radiation dose exposure for coronary CT angiography (CTA). Large studies on radiation dose estimates are rare. Objective: To compare radiation dose estimates of DSCT with 16- and 64-slice multidetector CT (MDCT) for non-invasive coronary angiography. Patients and design: Retrospective data analysis was performed on 292 patients: 56 patients were examined with 16-slice MDCT, 38 patients with 64-slice MDCT and 202 patients using DSCT. The effective dose (ED) estimates were calculated for all patients from the dose–length product and the conversion factor k (0.017 mSv/mGy/cm), as recommended by current guidelines. Results: The mean (SD) ED for patients examined by 16-slice MDCT was 9.8 (1.8) mSv, for 64-slice MDCT 8.6 (2.8) mSv and for DSCT 11.4 (7.2) mSv. With a protocol of 100 kV tube voltage and 110 ms ECG pulsing window the mean (SD) ED was 3.8 (1.7) mSv for DSCT scanning. When DSCT with a tube voltage of 100 kV was used, a significant inverse correlation between heart rate and radiation dose exposure was found. Conclusions: When standard protocols for coronary CTA with 16-, 64-slice MDCT and DSCT scanners are used, the radiation dose is still high. However, using optimised and individually adjusted protocols low estimated radiation doses can be achieved.

Long-term benefit of implantable cardioverter/defibrillator therapy after elective device replacement: results of the INcidence free SUrvival after ICD REplacement (INSURE) trial—a prospective multicentre study

AIMS Prevention of sudden cardiac death by means of the implantable cardioverter/defibrillator (ICD) is considered to be a lifelong therapy. However, it is still unresolved if patients who never experienced an appropriate ICD intervention during generator longevity really need to undergo device replacement. METHODS AND RESULTS The INSURE trial was a multicentre prospective observational cohort study that enrolled patients at the time of their first ICD replacement. Patients with and without previous appropriate ICD therapy were enrolled prospectively and were evaluated every 3-6 months after ICD replacement. Primary endpoint of the study was the first occurrence of appropriate ICD therapy after device replacement. Five hundred and ten patients (83% males, mean age 65 ± 10 years, mean ejection fraction 39 ± 16%) were enrolled between 2002 and 2007 in the study after an average lifespan of their first ICD generator of 62 ± 18 months. Three years after elective ICD replacement, the rates of appropriate ICD therapies in patients with (n = 245) and without (n = 265) former appropriate ICD intervention were 48.1 and 21.4% (adjusted hazard ratio 3.08, CI: 2.15-4.39, P < 0.001). Notably, no predictive factors for lower need of ICD therapy could be identified in patients without prior appropriate ICD intervention. CONCLUSIONS In this study, a significant number of ICD-indicated patients without the need for therapy by their first device received appropriate ICD intervention after generator replacement. There were no predictors for lower need of ICD therapy. Hence, ICD replacement appears still necessary in patients without prior ICD interventions.

Genetic analysis of sudden unexplained death: A multidisciplinary approach

Each year infants, children and young adults die suddenly and unexpectedly. In many cases the cause of death can be elucidated by medico-legal autopsy, however, a significant number of these cases remain unexplained despite a detailed postmortem investigation and are labeled as sudden unexplained death (SUD). Post-mortem genetic testing, so called molecular autopsy, revealed that primary arrhythmogenic disorders including long QT syndrome and catecholaminergic polymorphic ventricular tachycardia (CPVT) may account for a certain number of these cases. Because of the inheritance of these diseases, close relatives of the deceased may also at potential risk of carrying fatal cardiac disorders. Therefore, advanced diagnostic analyses, genetic counseling and interdisciplinary collaboration should be integral parts of clinical and forensic practice. In the present study, we performed mutation analyses of the major genes causing cardiac channelopathies in 15 SUD cases. In four cases we found putative pathogenic mutations in cardiac ion channel genes. Clinical and genetic examination of family members of SUD victims was also performed and affected family members were identified. This study demonstrates that molecular genetic screening needs to become an inherent part of the postmortem examination. This will enhance the ability of screening family members of SUD victims who may be at risk. The present data also illustrate that detection and follow up of familial cases of sudden death is challenging and requires a close multidisciplinary collaboration between different medical disciplines, with great responsibility for the forensic pathologist.

Clinical impact of a novel three-dimensional electrocardiographic imaging for non-invasive mapping of ventricular arrhythmias-a prospective randomized trial.

AIMS ECVUE™ technology, a novel, three-dimensional, non-invasive mapping system, offers a unique arrhythmia characterization and localization. We sought to evaluate the clinical impact of this system in routine clinical mapping and ablation of ventricular arrhythmias (VAs). METHODS AND RESULTS Patients with monomorphic premature ventricular contractions with or without monomorphic ventricular tachycardia were enrolled prospectively and randomized into two groups: ventricular ectopy localization using either 12-lead electrocardiogram (ECG) algorithms or with ECVUE™, followed by conventional guided ablation. Forty-two patients were enrolled in the study. The ECVUE™ system accurately identified both the chamber and sub-localized the VA origin in 20 of 21 (95.2%) patients. In contrast, using 12-lead ECG algorithms, the chamber was accurately diagnosed in 16 of 21 (76.2%) patients, while the arrhythmia origin in only 8 of 21 (38.1%), (P = 0.001 vs. ECVUE™). Acute success in ablation was achieved in all patients. Regarding the number of radiofrequency-energy applications (in total 2 vs. 4, P = 0.005) in the ECVUE™ arm, ablation was more precise than the ECG group which used standard of care activation and pace mapping-guided ablation. Three months success in ablation was 95.2% for the ECVUE™ and 100% for the ECG group (P = ns). Time to ablation was 35.3 min in the conventional arm and 24.4 min in ECVUE Group, (P = 0.035). The X-ray radiation exposure was 3.21 vs. 0.39 mSv, P = 0.001 for the ECVUE™ group and ECG group. CONCLUSION ECVUE™ technology offers a clinically useful tool to map VAs with high accuracy and more targeted ablations superior to the body surface ECG but had significantly higher radiation exposure due to computed tomography scan.

Pulmonary Vein Antrum Isolation and Terminal Part of the P Wave

Background:  Delayed interatrial conduction, manifested on the electrocardiogram as a P wave ≥110 ms (interatrial block, IAB), is highly prevalent and associated with atrial fibrillation (AF). It is correlated with P‐terminal force (Ptf; product of the duration and amplitude of the negative terminal phase of the P wave in lead V1). Our purpose was to describe the modifications of the P‐wave duration and Ptf after pulmonary vein antrum isolation (PVAI) in patients with paroxysmal AF.

Electrical storm in a patient with arrhythmogenic right ventricular cardiomyopathy and SCN5A mutation

We described a case of a 58-year-old man with organic changes consistent with right ventricular cardiomyopathy. He also had a loss-of-function mutation in the cardiac sodium channel gene SCN5A, described in Brugada syndrome. He first presented with non-sustained ventricular tachycardia and was implanted with an implantable cardioverter defibrillator. He remained asymptomatic for 8 years until he developed recurrent episodes of ventricular tachyarrhythmias, which required multiple shocks. The patient was treated with a combination of quinidine and verapamil and since then remained free of arrhythmias.