Hildegard Tanner

Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence.

Background—The objective of this study was to assess the incidence and impact of asymptomatic arrhythmia in patients with highly symptomatic atrial fibrillation (AF) who qualified for radiofrequency (RF) catheter ablation. Methods and Results—In this prospective study, 114 patients with at least 3 documented AF episodes together with corresponding symptoms and an ineffective trial of at least 1 antiarrhythmic drug were selected for RF ablation. With the use of CARTO, circumferential lesions around the pulmonary veins and linear lesions at the roof of the left atrium and along the left atrial isthmus were placed. A continuous, 7-day, Holter session was recorded before ablation, right after ablation, and after 3, 6, and 12 months of follow-up. During each 7-day Holter monitoring, the patients recorded quality and duration of any complaints by using a detailed symptom log. More than 70 000 hours of ECG recording were analyzed. In the 7-day Holter records before ablation, 92 of 114 patients (81%) had documented AF episodes. All episodes were symptomatic in 35 patients (38%). In 52 patients (57%), both symptomatic and asymptomatic episodes were recorded, whereas in 5 patients (5%), all documented AF episodes were asymptomatic. After ablation, the percentage of patients with only asymptomatic AF recurrences increased to 37% (P<0.05) at the 6-month follow-up. An analysis of patient characteristics and arrhythmia patterns failed to identify a specific subset who were at high risk for the development of asymptomatic AF. Conclusions—Even in patients presenting with highly symptomatic AF, asymptomatic episodes may occur and significantly increase after catheter ablation. A symptom-only–based follow-up would substantially overestimate the success rate. Objective measures such as long-term Holter monitoring are needed to identify asymptomatic AF recurrences after ablation.

Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation.

Introduction: The close anatomic relationship of the posterior wall of the left atrium (LA) and the thermosensitive esophagus creates a potential hazard in catheter ablation procedures.

Radiofrequency ablation of accessory pathways. Contemporary success rates and complications in 323 patients.

Das Ziel dieser Studie war es, 17 Jahre nach der ersten Hochfrequenzstrom (HF)-Katheterablation einer akzessorischen Bahn, die gegenwärtig erreichten Erfolgsraten der HF-Ablation akzessorischer Leitungsbahnen zusammen mit den Prozedurdaten und Komplikationsraten zu analysieren. Da bisherige Untersuchungen über die Lokalisation akzessorischer Leitungsbahnen noch auf der alten Nomenklatur basieren, war es ein weiteres Ziel, die Verteilung akzessorischer atrioventrikulärer Leitungsbahnen unter Gebrauch der 1999 von ESC und NASPE eingeführten neuen Nomenklatur zu analysieren. Es wurden die Daten aller Patienten, bei denen zwischen dem 1. 1. 2000 und dem 31. 12. 2003 am Herzzentrum Leipzig eine akzessorische Bahn abladiert wurde, retrospektiv analysiert. Über einen Zeitraum von 4 Jahren wurden an unserem Zentrum insgesamt 336 akzessorische Bahnen bei 323 Patienten abladiert. Gemäß der neuen Nomenklatur wurden die Bahnen eingeteilt in links gelegene, rechts gelegene, septale und paraseptale akzessorische Bahnen. 188 der Bahnen (56%) lagen links, 41 (12%) rechts, 64 (19%) (infero-)paraseptal und 31 (9%) septal oder parahissär. 12 Bahnen (4%) zeigten atypische Verläufe und/oder Eigenschaften und konnten somit nicht klar zugeordnet werden. Die mittlere Prozedurdauer betrug 68±37 Minuten. Die Erfolgsrate betrug insgesamt 98%. Bei 289 der Patienten (89%) konnte die akzessorische Bahn in einer einzigen Untersuchung erfolgreich abladiert werden. Komplikationen traten bei weniger als 2% der behandelten Patienten auf. 17 Jahre nach Durchführung der ersten HF-Katheterablation einer akzessorischen Leitungsbahn hat sich diese als hocheffektive und komplikationsarme kurative Behandlungsmethode etabliert. Die Erfolgsraten sind in den letzten 10 Jahren weiter gestiegen und die Komplikationsraten konnten weiter gesenkt werden. Mit der Einführung der neuen Nomenklatur ist es für den interventionellen Elektrophysiologen leichter geworden, die Lokalisation einer akzessorischen Bahn gemäß der realen anatomischen Lage im Körper festzulegen. 17 years ago the first radiofrequency catheter ablation of an accessory pathway (AP) was performed. The aim of this study was to describe the contemporary success rates and procedure related complication rates of radiofrequency (RF) ablation of accessory pathways (APs). In addition, the present study describes the anatomical distribution of APs according to the new nomenclature introduced by NASPE and ESC in 1999. The analysis included all patients, who underwent RF ablation of an AP in the Heart Center Leipzig between January 2000 and December 2003. Over a 4 year period 336 APs were ablated in 323 patients. 201 APs (60%) presented with antegrade and retrograde conduction and showed preexcitation on ECG. For the remaining 135 APs (40%), only retrograde conduction over the AP was documented. According to the new nomenclature APs were classified as left-sided, right sided, septal and paraseptal APs. 188 APs (56%) were located on the left, 41 (12%) on the right, 64 (19%) in the paraseptal space and 31 APs (9%) presented with a septal or parahissian localization, respectively. Because of atypical course and/or characteristics 12 APs (4%) could not be classified. Ablation of all pathways were successful in 315 patients (98%). In 289 patients (89%) success was achieved within a single ablation session. The left-sided pathways had a re-intervention rate of 5%, which was significantly lower compared to the remaining localizations. The highest re-intervention rate was observed in the septal APs (23%). Complications were observed in less than 2% of all treated patients. 17 years after the first RF catheter ablation of an AP this therapy is established as a highly effective procedure. The success rate has improved to 98% and the complication rate has been minimized to less than 2%. The most frequent localization of APs is left posterior. Left sided APs also presented with the lowest re-intervention rate. The introduction of the new nomenclature in 1999 by NASPE and ESC has simplified the description of the exact anatomical localization of an AP.

Radiofrequency ablation of accessory pathways

Das Ziel dieser Studie war es, 17 Jahre nach der ersten Hochfrequenzstrom (HF)-Katheterablation einer akzessorischen Bahn, die gegenwärtig erreichten Erfolgsraten der HF-Ablation akzessorischer Leitungsbahnen zusammen mit den Prozedurdaten und Komplikationsraten zu analysieren. Da bisherige Untersuchungen über die Lokalisation akzessorischer Leitungsbahnen noch auf der alten Nomenklatur basieren, war es ein weiteres Ziel, die Verteilung akzessorischer atrioventrikulärer Leitungsbahnen unter Gebrauch der 1999 von ESC und NASPE eingeführten neuen Nomenklatur zu analysieren. Es wurden die Daten aller Patienten, bei denen zwischen dem 1. 1. 2000 und dem 31. 12. 2003 am Herzzentrum Leipzig eine akzessorische Bahn abladiert wurde, retrospektiv analysiert. Über einen Zeitraum von 4 Jahren wurden an unserem Zentrum insgesamt 336 akzessorische Bahnen bei 323 Patienten abladiert. Gemäß der neuen Nomenklatur wurden die Bahnen eingeteilt in links gelegene, rechts gelegene, septale und paraseptale akzessorische Bahnen. 188 der Bahnen (56%) lagen links, 41 (12%) rechts, 64 (19%) (infero-)paraseptal und 31 (9%) septal oder parahissär. 12 Bahnen (4%) zeigten atypische Verläufe und/oder Eigenschaften und konnten somit nicht klar zugeordnet werden. Die mittlere Prozedurdauer betrug 68±37 Minuten. Die Erfolgsrate betrug insgesamt 98%. Bei 289 der Patienten (89%) konnte die akzessorische Bahn in einer einzigen Untersuchung erfolgreich abladiert werden. Komplikationen traten bei weniger als 2% der behandelten Patienten auf. 17 Jahre nach Durchführung der ersten HF-Katheterablation einer akzessorischen Leitungsbahn hat sich diese als hocheffektive und komplikationsarme kurative Behandlungsmethode etabliert. Die Erfolgsraten sind in den letzten 10 Jahren weiter gestiegen und die Komplikationsraten konnten weiter gesenkt werden. Mit der Einführung der neuen Nomenklatur ist es für den interventionellen Elektrophysiologen leichter geworden, die Lokalisation einer akzessorischen Bahn gemäß der realen anatomischen Lage im Körper festzulegen. 17 years ago the first radiofrequency catheter ablation of an accessory pathway (AP) was performed. The aim of this study was to describe the contemporary success rates and procedure related complication rates of radiofrequency (RF) ablation of accessory pathways (APs). In addition, the present study describes the anatomical distribution of APs according to the new nomenclature introduced by NASPE and ESC in 1999. The analysis included all patients, who underwent RF ablation of an AP in the Heart Center Leipzig between January 2000 and December 2003. Over a 4 year period 336 APs were ablated in 323 patients. 201 APs (60%) presented with antegrade and retrograde conduction and showed preexcitation on ECG. For the remaining 135 APs (40%), only retrograde conduction over the AP was documented. According to the new nomenclature APs were classified as left-sided, right sided, septal and paraseptal APs. 188 APs (56%) were located on the left, 41 (12%) on the right, 64 (19%) in the paraseptal space and 31 APs (9%) presented with a septal or parahissian localization, respectively. Because of atypical course and/or characteristics 12 APs (4%) could not be classified. Ablation of all pathways were successful in 315 patients (98%). In 289 patients (89%) success was achieved within a single ablation session. The left-sided pathways had a re-intervention rate of 5%, which was significantly lower compared to the remaining localizations. The highest re-intervention rate was observed in the septal APs (23%). Complications were observed in less than 2% of all treated patients. 17 years after the first RF catheter ablation of an AP this therapy is established as a highly effective procedure. The success rate has improved to 98% and the complication rate has been minimized to less than 2%. The most frequent localization of APs is left posterior. Left sided APs also presented with the lowest re-intervention rate. The introduction of the new nomenclature in 1999 by NASPE and ESC has simplified the description of the exact anatomical localization of an AP.

Stable secondary arrhythmias late after intraoperative radiofrequency ablation of atrial fibrillation: incidence, mechanism, and treatment.

Introduction: Intraoperative radiofrequency (RF) ablation is an effective treatment of atrial fibrillation (AF). However, secondary arrhythmias late after ablation may complicate the patients course. We report on the incidence, mechanisms, and treatment of gap‐related atrial flutter and other secondary arrhythmias during long‐term follow‐up.

Paraseptal accessory pathway in Wolff-Parkinson- White-Syndrom: ablation from the right, from the left or within the coronary sinus/middle cardiac vein?

Aims: In 1999 the consensus statement “living anatomy of the atrioventricular junctions” was published. With that new nomenclature the former posteroseptal accessory pathway (APs) are termed paraseptal APs. The aim of this study was to identify ECG features of manifest APs located in this complex paraseptal space.Methods and Results: ECG characteristics of all patients who underwent radiofrequency ablation of an AP during a 3 year period were analyzed. Of the 239 patients with one or more APs, 30 patients had a paraseptal AP with preexcitation. Compared to APs within the coronary sinus (CS) or the middle cardiac vein (MCV) the right sided paraseptal APs significantly more often showed an isoelectric delta wave in lead II and/or a negative delta wave in aVR. The left sided paraseptal APs presented a negative delta wave in II significantly more often compared to the right sided APs.Conclusions: According to the site of radiofrequency ablation, paraseptal APs are classified into 4 subgroups: paraseptal right, paraseptal left, inside the CS or inside the MCV. Subtle differences in preexcitation patterns of the delta wave as well as of the QRS complex exist. However, the definitive localization of APs remains reserved to the periinterventional intracardiac electrogram analysis.

Electroanatomic Mapping of the Endocardium

Abstract.The electroanatomic mapping system Carto® with its combination of anatomic and electrophysiologic information has substantially improved our understanding of arrhythmia mechanisms and substrates in patients with ventricular tachycardia (VT) and structural heart disease. Identification of the individual arrhythmogenic substrate and successful ablation guided by the combination of sinus rhythm voltage mapping and conventional electrophysiologic techniques like pace and activation/entrainment mapping are best described for patients with recurrent VT in remote myocardial infarction. In about 75–90% of the patients, the target VT can be ablated with acute success and the patients remain free of any VT recurrence in up to 75%. First results of electroanatomically guided ablation in patients with arrhythmogenic right ventricular dysplasia are promising. Data on ablation of VT in other structural heart diseases are very limited, since the arrhythmogenic substrate is very diffuse, e. g., in dilated cardiomyopathy, or there are only small patient numbers, e. g., for cardiac sarcoidosis or monomorphic VT after repair of congenital heart disease.In this article, the current status of electroanatomically guided endocardial mapping and ablation of VT in patients with structural heart disease is described.Zusammenfassung.Die kurative Therapie ventrikulärer Tachykardien (VT) ist immer noch eine große Herausforderung in der interventionellen Elektrophysiologie. Eine detaillierte Beschreibung des arrhythmogenen Substrats und eine individuell angepasste Ablationsstrategie sind bedeutsam für den Ablationserfolg, insbesondere bei Patienten mit struktureller Herzerkrankung. Das elektroanatomische Mappingsystem Carto® mit der Kombination von anatomischen und elektrophysiologischen Informationen hat das Verständnis von Arrhythmiemechanismen und -substraten insbesondere bei Patienten mit struktureller Herzerkrankung und VT deutlich erweitert und eine erfolgreiche Ablation in vielen Fällen, z. B. von nicht induzierbaren, hämodynamisch nicht tolerierten oder pleomorphen Tachykardien, erst ermöglicht. Die Identifizierung des individuellen Arrhythmiesubstrats und erfolgreiche Ablation durch eine Kombination von Sinusrhythmus- Voltagemapping und konventionellen elektrophysiologischen Techniken wie Entrainment- und Aktivierungsmapping sind am eingehendsten für VT bei Patienten mit koronarer Herzerkrankung und abgelaufenem Infarkt beschrieben. Bei etwa 75–90% dieser Patienten lassen sich die Ziel-VT akut erfolgreich durch Ablation therapieren, und bis zu 75% bleiben auch im Verlauf rezidivfrei. Erste Ergebnisse zur elektroanatomisch geführten Ablation von VT bei Patienten mit arrhythmogener rechtsventrikulärer Dysplasie sind sehr erfolgversprechend. Zur Ablation von VT bei anderen strukturellen Herzerkrankungen liegen bisher sehr nur wenige Daten vor, zum einen aufgrund schwieriger Ablationsbedingungen bei sehr diffusem Substrat, wie bei Patienten mit dilatativer Kardiomyopathie, und zum anderen aufgrund sehr geringer Patientenzahlen, z. B. bei Patienten mit kardialer Beteiligung bei Sarkoidose oder mit korrigierten kongenitalen Vitien.In diesem Artikel wird der derzeitige Stand des elektroanatomisch geführten endokardialen Mappings und der Ablation von VT bei Patienten mit struktureller Herzerkrankung beschrieben.

Häufige ventrikuläre Tachykardie : Antiarrhythmika oder Ablation?

ZusammenfassungAntiarrhythmische Medikamente werden bei einem großen Prozentsatz der Patienten mit einem internen Kardioverter-Defibrillator (ICD) eingesetzt. Kürzlich publizierte oder vorgestellte randomisierte Studien zeigen eine signifikante Reduk tion von adäquaten und inadäquaten ICD-Therapien, insbesondere der Schockabgaben, bei Behandlung der Patienten mit Amiodaron, Sotalol oder Azimilid. Neben weiteren erwünschten Wirkungen der Antiarrhythmika wie Verlangsamung von zuvor hämodynamisch nicht tolerierten ventrikulären Tachykardien (VTs), Abnahme der Anzahl an Synkopen, verbesserter Überstimulation und Reduktion von supraventrikulären Tachykardien müssen unerwünschte Effekte wie die Verlangsamung der VTs unter die ICD-Detektionsgrenze ebenfalls berücksichtigt werden. Deshalb muss die Wahl der antiarrhythmischen Therapie bzw. die Notwendigkeit der Katheterablation bei jedem ICD-Patienten individuell unter Berücksichtigung der spezifischen klinischen und elektrophysiologischen Umstände erfolgen, d. h. unter Beachtung der Häufigkeit und Zykluslänge der VTs, der ICD-Detektionsgrenzen, möglicher Diskriminierungsprobleme gegenüber supraventrikulären Tachykardien, ihrer klinischen Präsentation sowie der möglichen Effekte auf die Defibrillationsschwelle und die linksventrikuläre Funktion. Die Katheterablation muss neben der klinischen Präsentation zudem die Art des arrhythmogenen Substrats berücksichtigen. In vielen Fällen werden die antiarrhythmische medikamentöse Therapie und die Katheterablation nicht alternativ, sondern ergänzend verwendet.AbstractAntiarrhythmic drugs are used in at least 50% of patients who received an implantable cardioverter defibrillator (ICD). The potential indications for antiarrhythmic drug treatments in patients with an ICD are generally the following: reduction of the number of ventricular tachycardias (VTs) or episodes of ventricular fibrillation and therefore reduction of the number of ICD therapies, most importantly, the number of disabling ICD shocks. Accordingly, the quality of life should be improved and the battery life of the ICD extended. Moreover, antiarrhythmic drugs have the potential to increase the tachycardia cycle length to allow termination of VTs by antitachycardia pacing and reduction of the number of syncopes. In addition, supraventricular arrhythmias can be prevented or their rate controlled. Recently published or reported trials have shown the efficacy of amiodarone, sotalol and azimilide to significantly reduce the number of appropriate and inappropriate ICD shocks in patients with structural heart disease. However, the use of antiarrhythmic drugs may also have adverse effects: an increase in the defibrillation threshold, an excessive increase in the VT cycle length leading to detection failure. In this situation and when antiarrhythmic drugs are ineffective or have to be stopped because of serious side effects, catheter ablation of both monomorphic stable and pleomorphic and/or unstable VTs using modern electroanatomic mapping systems should be considered. The choice of antiarrhythmic drug treatment and the need for catheter ablation in ICD patients with frequent VTs should be individually tailored to specific clinical and electrophysiological features including the frequency, the rate, and the clinical presentation of the ventricular arrhythmia. Although VT mapping and ablation is becoming increasingly practical and efficacious, ablation of VT is mostly done as an adjunctive therapy in patients with structural heart disease and ICD experiencing multiple shocks, because the recurrence and especially the occurrence of “new” VTs after primarily successful ablation with time and disease progression have precluded a widespread use of catheter ablation as primary treatment.

ABL02: PERCEPTION OF ATRIAL FIBRILLATION BEFORE AND AFTER RADIOFREQUENCY CATHETER ABLATION: CLINICAL RELEVANCE OF ASYMPTOMATIC ARRHYTHMIA RECURRENCE BASED ON A DETAILED ANALYSIS OF MORE THAN 75.000 HOURS OF ECG-RECORDINGS

Background Due to the investigative nature of AF catheter ablation, currently only highly symptomatic patients are treated. Remarkable success rates have been reported repeatedly. However, the follow up strategies measuring that outcome are largely based on symptomaticity. Therefore the present study aimed on analyzing the perception of AF in 114 pts. before and after a left atrial catheter ablation using the CARTO System. Methods A digital 7-d-ECG was recorded prior to ablation, right after ablation, after 3 months, after 6 months and after 12 months. During the 7-d-ECG the pts. hourly registered quality and duration of any symptoms in a certain patients log. Palpitation, dyspnoea, dizziness and chest pain were taken as surrogates of AF. Subsequently the amount of time with symptomatic AF, asymptomatic (ASYM) AF, symptomatic SR and ASYM SR was measured. Additionally the individual AF episode was classified as either symptomatic or ASYM. Results For more than 75000 hours of ECG recording symptoms and rhythm were correlated. Prior ablation 54% of the time in AF and 22% of the AF episodes were ASYM. After ablation the proportion of ASYM AF episodes increased from 22% to 53% of all AF episodes. Watching the individual patient ASYM AF was common in 65% of all pts. with AF before and after catheter ablation. Nevertheless, the percentage of pts. with only ASYM AF during the 7-d-ECG increased from 10% prior ablation to 36% 6 months after ablation. Conclusions Pts. with highly symptomatic AF also exhibit a substantial amount of ASYM arrhythmia (54% of AF time, 22% of AF episodes). After ablation the amount of ASYM AF increased, with half of the episodes being ASYM. Furthermore, 36% of the pts. with AF recurrences at the 6 months follow up were completely ASYM during that 7-d-ECG. Our data show, that a judgement on the efficacy of percutaneus AF ablation based on patients symptoms substantially overestimates the success rate. Objective follow up strategies, applied in a close manner, are needed for a through measurement of the real outcome.