Joachim Krug

Higher incidence of esophageal lesions after ablation of atrial fibrillation related to the use of esophageal temperature probes

BACKGROUND Endoscopically detected esophageal lesions (EDELs) have been identified in apparently asymptomatic patients after catheter ablation of atrial fibrillation (AF). The use of esophageal probes to monitor luminal esophageal temperature (LET) during catheter ablation to protect esophageal damage is currently controversial. OBJECTIVE The purpose of this study was to investigate the impact of the use of esophageal temperature probes during AF catheter ablation on the incidence of EDELs. METHODS Eighty consecutive patients (mean age 63.8 ± 11.36 years; 68.8% men) with symptomatic, drug-refractory paroxysmal (n = 52, 65%) or persistent AF who underwent left atrial radiofrequency catheter ablation were prospectively enrolled. Posterior wall ablation was power limited (≤25 W). In the first 40 patients, LET was monitored continuously (group A), whereas no esophageal temperature probe was used in group B (n = 40 patients). Assessment of EDEL was performed by endoscopy within 2 days after radiofrequency catheter ablation. RESULTS Overall, 13 patients (16%) developed EDELs after AF ablation. The incidence of EDELs was significantly higher in group A than group B (30% vs 2.5%, P < .01). Within group A, patients who developed EDEL had higher maximal LET during AF ablation than patients without EDEL (40.97 ± 0.92°C vs 40.14 ± 1.1°C, P = .02). Multivariable logistic regression analysis revealed the use of an esophageal temperature probe as the only independent predictor for the development of EDEL (odds ratio 16.7, P < .01). CONCLUSION The use of esophageal temperature probes in the setting of AF catheter ablation per se appears to be a risk factor for the development of EDEL.

Pulmonary vein isolation with a novel endoscopic ablation system using laser energy

Pulmonary vein isolation (PVI) is the basis of all ablation techniques for paroxysmal atrial fibrillation. Performing conventional radiofrequency ablation for PVI is time consuming and sometimes challenging when using point-by-point applications to create continuous lesions. Small electrically conducting gaps evolving in the ablation lines may cause recurrences of atrial fibrillation or regular atrial re-entry tachycardias. Development of novel anatomically designed ablation catheters for PVI aim to facilitate the ablation procedure, to produce continuous and durable lesions with a limited number of ablation impulses and to reduce the complication rate. The endoscopic laser balloon ablation system (HeartLight® EAS, Cardiofocus Inc.) is the first system that allows direct visual guidance of energy delivery at the antral level of each pulmonary vein and uses a completely new energy source for ablation.

Exchanging Catheters Over a Single Transseptal Sheath During Left Atrial Ablation is Associated with a Higher Risk for Silent Cerebral Events

Background Silent cerebral events (SCE) have been identified on magnetic resonance imaging (MRI) in asymptomatic patients after atrial fibrillation (AF) ablation. Procedural determinants influencing the risk for SCE still remain unclear. Objective Comparing the risk for SCE depending on exchanges of catheters (ExCath) over a single transseptal sheath. Methods 88 Patients undergoing pulmonary vein isolation (PVI) only ablation using either single-tip or balloon-based technique underwent pre- and post-ablation cerebral MRI. Ablations were either performed with double transseptal access and without exchanging catheters over the transseptal sheaths (group 1: no ExCath) or after a single transseptal access and exchanges of therapeutic and diagnostic catheters (group 2: ExCath). Differences in regard to SCE rates were analyzed. Multivariate analysis was performed to identify factors related to the risk for SCE. Results Included patients underwent PVI using single tip irrigated radiofrequency in 41, endoscopic laser balloon in 27 and cryoballoon in 20 cases. Overall SCE were identified in 23 (26%) patients. In group 1 (no ExCath; N=46) 6 patients (13%) and in group 2 (N=42) 17 patients (40%) had documented SCE (p=0.007). The applied ablation technology did not affect SCE rate. In multivariate analysis age (OR 1.1, p=0.03) and catheter exchanges over a single transseptal sheath (OR 12.1, p=0.007) were the only independent predictors of a higher risk for SCE. Conclusions Exchanging catheters over a single transseptal access to perform left atrial ablation is associated with a significantly higher incidence of SCE compared to an ablation technique using different transseptal accesses for therapeutic and diagnostic catheters.

Incidence of asymptomatic oesophageal lesions after atrial fibrillation ablation using an oesophageal temperature probe with insulated thermocouples: a comparative controlled study

Aims Oesophageal probes to monitor luminal oesophageal temperature (LET) during atrial fibrillation (AF) catheter ablation have been proposed, but their effects remain unclear. Aim of this study is to evaluate the effects of an oesophageal temperature probe with insulated thermocouples. Methods and results Patients with symptomatic, drug-refractory paroxysmal or persistent AF who underwent left atrial radiofrequency (RF) catheter ablation were prospectively enrolled. Patients were ablated using a single-tip RF contact force ablation catheter. An intraluminal oesophageal temperature probe was used in Group 1. In Group 2, patients were ablated without LET monitoring. Assessment of asymptomatic endoscopically detected oesophageal lesions (EDEL) was performed by oesophagogastroduodenoscopy (EGD) in all patients. Eighty patients (mean age 63.7 ± 10.7 years; men 56%) with symptomatic, drug-refractory paroxysmal (n = 28; 35%) or persistent AF were included. Group 1 and Group 2 patients (n = 40 in each group) were comparable in regard to baseline characteristics, but RF duration on the posterior wall was significantly shorter in Group 1 patients. Overall, seven patients (8.8%) developed EDEL (four ulcerations, three erythema). The incidence of EDEL in Group 1 and Group 2 patients was comparable (7.5 vs. 10%, P = 1.0). No major adverse events were reported in both groups. Conclusion According to these preliminary results, the use of oesophageal temperature probes with insulated thermocouples seems to be feasible in patients undergoing AF RF catheter ablation. The incidence of post-procedural EDEL when using a cut-off of 39°C is comparable to the incidence of EDEL without using a temperature probe.

Elektrischer Sturm in der Notaufnahme: Klinische Pfade

In patients with structural heart disease, occurrence of an electrical storm (ES) is associated with increased mortality acutely and during medium term follow-up. Depending on the underlying heart disease and baseline type of arrhythmia, different clinical pathways have to be followed to reach sustained freedom from ventricular arrhythmia recurrences. Trigger elimination, sympathetic blockade (initially using betablockers and sedation), antiarrhythmic therapy with amiodarone and catheter ablation, treatment of heart failure and invasive hemodynamic support are cornerstones of the treatment. We present an algorithm which may help to organize an optimized treatment for each ES patient, implementing invasive treatment options like coronary angioplasty, catheter ablation and invasive circulatory support. Further studies are necessary to evaluate medium term outcome of such a structured therapy.

[Electrical storm in the emergency room: clinical pathways].

In patients with structural heart disease, occurrence of an electrical storm (ES) is associated with increased mortality acutely and during medium term follow-up. Depending on the underlying heart disease and baseline type of arrhythmia, different clinical pathways have to be followed to reach sustained freedom from ventricular arrhythmia recurrences. Trigger elimination, sympathetic blockade (initially using betablockers and sedation), antiarrhythmic therapy with amiodarone and catheter ablation, treatment of heart failure and invasive hemodynamic support are cornerstones of the treatment. We present an algorithm which may help to organize an optimized treatment for each ES patient, implementing invasive treatment options like coronary angioplasty, catheter ablation and invasive circulatory support. Further studies are necessary to evaluate medium term outcome of such a structured therapy.

Catheter ablation in patients with electrical storm: benefit of a network of cooperating clinics.

Catheter ablation has been shown to be an effective treatment for rhythm stabilization in patients with multiple ventricular arrhythmia episodes called electrical storm (ES). These procedures may be complex and are usually only performed in highly specialized and experienced centers. Still the optimum timing for catheter ablation in ES remains unclear.Early access to perform acute ablation should be considered in patients who are not rhythm stabilized with antiarrhythmic medical treatment. Also patients with hemodynamic compromise (cardiogenic shock) are candidates for an early interventional strategy. In specialized centers it is consensus to perform catheter ablation in these patients as early as eligible especially when considering a high early and late mortality without interventional management. Establishing a structured protocol for treatment and admission to EP centers has helped to further reduce pre-ablation mortality and may optimize treatment of ES. Large scale networking to optimize and structure access to experienced electrophysiology centers is of importance to create a basis for optimizing treatment strategies.ZusammenfassungDie Katheterablation bei Patienten mit gehäuften anhaltenden ventrikulären Arrhythmien (elektrischer Sturm, ES) hat sich als effektive Therapie herausgestellt, ein möglichst frühzeitiger Zugang zur Ablation erscheint gerade vor dem Hintergrund der hohen Spätmortalität und Rezidivraten sinnvoll. Der optimale Zeitpunkt für diese komplexe Prozedur ist allerdings noch unklar. Als komplexe Ablationsprozedur wird die Ablation bei ES nur in wenigen erfahrenen Zentren mit hoher Expertise durchgeführt. Initiale Versuche einer frühzeitigen Verlegung dieser Patienten in diese Zentren durch zuweisende Kliniken hat zu einer Verbesserung der Versorgung von Patienten mit ES geführt. Man kann ein frühzeitiges elektives Ablationsvorgehen noch innerhalb des stationären Erstaufenthalts nach Auftreten eines ES nach Rhythmusstabilisierung von einer Akut-Ablation, durchgeführt zur Rhythmusstabilisierung, unterscheiden.Innerhalb einer Klinik sollte eine Stufenplan zur Festlegung der Behandlungsstrategie erarbeitet werden. Aktuell wird in einem überregionalen Netzwerk von interventionellen elektrophysiologischen Zentren in Bayern ein Etappen-Therapie-Plan entwickelt, der unter anderem auch die Katheterablation als essentiellen Bestandteil beinhaltet. Im Rahmen der einzelnen teilnehmenden Zentren ist eine optimierte Versorgung der ES-Patienten mittels invasiver kardiologischer Therapieoptionen inklusive der interventionellen Elektrophysiologie initiiert. Somit wird versucht, flächendeckend diesen Patienten ein frühzeitiger Zugang zur Katheterablation zu ermöglichen.Insgesamt erscheint somit ein Netzwerk kooperierender Kliniken zur Optimierung und Strukturierung des Zugang zu erfahrenen elektrophysiologischen Zentren entscheidend als Basis einer optimierten Therapiestrategie.

TECHNOLOGICAL, PROCEDURAL AND PATIENT CHARACTERISTICS DETERMINE THE RISK FOR SILENT CEREBRAL LESIONS IN PATIENTS UNDERGOING ATRIAL FIBRILLATION ABLATION

Silent cerebral lesions (SCL) have been identified on magnetic resonance imaging (MRI) in asymptomatic patients after atrial fibrillation (AF) ablation. SCL represent irreversible cerebral damage, comparative analysis using a consistent MRI definition is missing and factors influencing the risk of

Elektrischer Sturm in der Notaufnahme: Klinische Pfade@@@Electrical storm in the emergency room: clinical pathways

In patients with structural heart disease, occurrence of an electrical storm (ES) is associated with increased mortality acutely and during medium term follow-up. Depending on the underlying heart disease and baseline type of arrhythmia, different clinical pathways have to be followed to reach sustained freedom from ventricular arrhythmia recurrences. Trigger elimination, sympathetic blockade (initially using betablockers and sedation), antiarrhythmic therapy with amiodarone and catheter ablation, treatment of heart failure and invasive hemodynamic support are cornerstones of the treatment. We present an algorithm which may help to organize an optimized treatment for each ES patient, implementing invasive treatment options like coronary angioplasty, catheter ablation and invasive circulatory support. Further studies are necessary to evaluate medium term outcome of such a structured therapy.

INCIDENCE OF SILENT CEREBRAL LESIONS USING DIFFERENT ABLATION TECHNOLOGIES

Cerebral lesions (SCL) have been detected on post interventional magnetic resonance imaging (MRI) in asymptomatic patients after atrial fibrillation (AF) ablation procedures. The present study evaluates incidence and potential contributing factors for SCL in a large cohort of patients undergoing