Jochem Stockinger

Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation? Results From a Prospective Randomized Study

Background— Pulmonary vein (PV) isolation is a promising new treatment for atrial fibrillation (AF). We hypothesized that isolation of large areas around both ipsilateral PVs with verification of conduction block is more effective than the isolation of each individual PV. Methods and Results— A total of 110 patients, 67 with paroxysmal AF and 43 with persistent AF, were randomly assigned to undergo either isolation of each individual PV or isolation of large areas around both ipsilateral PVs. The isolation of each individual PV was an electrophysiologically guided, ostial segmental ablation with a 64-pole basket catheter or a 20-pole circular mapping catheter (group I). Isolation of large areas was performed around the 2 ipsilateral veins with a nonfluoroscopic navigation system and a circular 20-pole mapping catheter for verification of conduction block (group II). In both groups, an irrigated-tip ablation catheter (25 to 35 W) was used to achieve complete isolation. Procedure and ablation times were longer in group II, whereas fluoroscopic time was significantly shorter (P≤0.001). After a follow-up period of 15±4 months, 27 patients in group I (49%) and 37 patients in group II (67%) remained free of symptoms of AF and had no AF or atrial flutter during repetitive Holter monitoring without antiarrhythmic drug treatment after a single procedure (P≤0.05). Conclusions— The rate of success was significantly higher and fluoroscopy times were significantly lower in the group with large isolation areas around both ipsilateral PVs than in those who underwent individual PV isolation.

Feasibility and Safety of Pulmonary Vein Isolation Using a New Mapping and Navigation System in Patients With Refractory Atrial Fibrillation

Background—Ostial pulmonary vein (PV) isolation by radiofrequency (RF) catheter ablation can cure patients with atrial fibrillation (AF); however, this procedure carries the risk of PV stenosis. The aim of this study was to assess the feasibility of a new mapping and navigation technique using a multipolar basket catheter (BC) for PV isolation in patients with refractory AF and to analyze its safety with regard to PV stenosis at long-term follow-up. Methods and Results—We studied 55 patients (mean age, 53±11 years; 40 male) with drug-refractory AF (paroxysmal, n=37; persistent, n=18). A 64-pole BC was placed transseptally into each of the accessible PVs. By use of a nonfluoroscopic navigation system, the ablation catheter was guided to the BC electrodes at the PV ostium, with earliest activation during sinus rhythm. RF was delivered by use of maximum settings of temperature at 50°C and power at 30 W. The end point of the procedure was the complete elimination of all distal and fragmented ostial PV potentials. Of 165 targeted veins, 163 were successfully isolated with a mean RF duration of 720±301 seconds per vein. At 1-year follow-up, 62% of the patients were in sinus rhythm without antiarrhythmic drugs. Contrast-enhanced magnetic resonance angiography revealed 2 PV stenoses of >25% out of 165 treated vessels. Conclusions—The use of a multipolar BC allowed effective and safe PV isolation by combining 3D mapping and navigation. At 1-year follow-up, 62% of the patients were in sinus rhythm without antiarrhythmic drugs, and the incidence of relevant diameter reduction of the treated PVs was 1.2%.

AV NODAL RE-ENTRY TACHYCARDIA IN ELDERLY PATIENTS : CLINICAL PRESENTATION AND RESULTS OF RADIOFREQUENCY CATHETER ABLATION THERAPY

BackgroundModification of AV nodal conduction by means of radiofrequency catheter ablation has become the accepted mode of therapy for patients with symptomatic AV nodal re-entry tachycardias (AVN-RT). The published results demonstrate high success rates and a low incidence of severe complications. However, published series have primarily dealt with relatively young patient populations. Little is known about the efficacy and risks of radiofrequency catheter ablation of AVN-RT in the elderly. MethodsWe retrospectively analysed our data of 404 patients who underwent a catheter ablation therapy for AVN-RT between 1992 and June 1997. Nine patients were excluded from further analysis because of presence of more than one tachycardia mechanism. The ablation procedure was performed at the time of the diagnostic electrophysiologic study. ResultsThe mean age of 395 patients undergoing catheter ablation for AVN-RT was 52.3 years (19–90 years); 85 patients were 65 years old or older. Compared with the younger subgroup, these elderly patients (mean age 70.4 years) more often had organic heart disease (coronary heart disease with or without myocardial infarction 19.3% versus 2.6%; P < 0.02), more often had syncopes or presyncopes with AVN-RT (43.2% versus 29.8%; P < 0.05), had more hospitalisations and emergency treatments because of their symptoms (56.8% versus 39.5%; P < 0.05) although the cycle length of the induced AVN-RT was significantly shorter in the younger patient group (325 ms versus 368 ms; P < 0.001). Slow pathway ablation was performed in 94% of the young and 82% of the elderly (P < 0.001). In 1 7.5% of the elderly patients versus 6.5% of the young (P < 0.05) the fast pathway approach was chosen as the first therapy or tried after an unsuccessful approach to the slow pathway. The overall success rate (96.8% in the young and 95.3% in the elderly) and the recurrence rate (5.8% in the elderly versus 4.9% in the young) were similar in both patient groups. There were no differences regarding the total procedure of fluoroscopy time, radiation exposure or the incidence of high-degree AV-block necessitating pacemaker implantation (2.3% in the elderly versus 1.6% in the young). ConclusionsIn patients older than 65 years, AVN-RT may lead to severe, sometimes life-threatening symptoms, despite the fact that the tachycardia is not as fast as in younger patients. Radiofrequency catheter ablation can be performed effectively and safely and should be offered to these patients as first-choice therapy.

Effects of circumferential ostial radiofrequency lesions on pulmonary vein activation recorded with a multipolar basket catheter.

Aims: Two different ablation procedures are performed to cure patients of atrial fibrillation (AF): (1) the electrophysiological pulmonary vein (PV) isolation, and (2) the anatomical circumferential ablation of all four PV ostia. The aim of this study was to determine the effects of circumferential radiofrequency lesions around the ostia on PV activation.

Predictors of Atrial Tachyarrhythmias in Subjects with Type 1 ECG Pattern of Brugada Syndrome

Background: Previous studies have demonstrated a high incidence of atrial tachyarrhythmias (ATs) in patients with Brugada syndrome (BS). The present study aimed to investigate whether various 12‐lead electrocardiogram (ECG) and electrophysiological parameters may help to differentiate subjects with a high probability to develop ATs.

Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway

Objective — The present study aimed to evaluate the diagnostic value of specific ECG markers in the differentiation of common type atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) via a concealed accessory pathway. Methods — One hundred and ten ECGs with paroxysmal narrow QRS complex, short RP tachycardia were evaluated. Subjects with overt ventricular pre-excitation during sinus rhythm were excluded from the study. The mechanism of arrhythmia was established during the electrophysiological study and confirmed by the efficacy of radiofrequency ablation. Results — Of the 110 patients, 74 displayed common type AVNRT and 36 AVRT. Predictors of AVNRT were the presence of pseudo r’-waves in lead V1 [sensitivity 39.19%; specificity 97.14%; positive predictive value (PPV) 96.67%; negative predictive value (NPV) 43.04%] and pseudo S-waves in inferior leads (sensitivity 28.38%; specificity 94.29%; PPV 91.30%; NPV 38.37%). In the setting of visible P-waves, an RP interval ≤ 90 ms favoured the diagnosis of AVNRT (sensitivity 57.14%; specificity 80.65%). Predictors of AVRT were QRS alternans (sensitivity 50%; specificity 89.19%; PPV 69.23%; NPV 78.57%) as well as ST-segment alterations during tachycardia. The overall sensitivity, specificity, PPV and NPV of ST-segment depression for discriminating AVRT from AVNRT were 97.22%, 58.11%, 53.03%, 97.73%, respectively. Similarly, the sensitivity, specificity, PPV and NPV of ST-segment elevation in lead aVR were 94.44%, 58.11%, 52.31%, and 95.56%, respectively. Multiple logistic regression analysis showed that ST-segment depression [(odds ratio (OR): 12.67, 95% confidence interval (CI): 1.77-90.81, P = 0.011)] and QRS alternans (OR: 9.43, 95% CI: 1.38-64.37, P = 0.022) displayed the highest predictive ability favouring the diagnosis of AVRT. Conclusions — Twelve-lead ECG parameters may help to differentiate the mechanism of supraventricular tachycardia prior to the ablation procedure.

Response to Letter Regarding Article, “Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation? Results From a Prospective Randomized Study”

In their letter regarding our article,1 Drs Kriatselis and Roser suggest that large isolation during circumferential ablation can only be proved using 2 circumferential mapping catheters, 1 in each ipsilateral …

Nicht-medikamentöse Therapie von Herzrhythmusstörungen

Nicht-medikamentose Therapieverfahren haben in den vergangenen 20 Jahren einen zunehmenden Stellenwert bei der Behandlung von Herzrhythmusstorungen erlangt, z.T. haben sie die medikamentose Therapie vollstandig verdrangt. Das gilt z. B. fur die Behandlung symptomatischer Bradykardien mittels Herzschrittmacher. Aber auch im Bereich tachykarder Herzrhythmusstorungen sind sie z.T. nicht nur eine Alternative zur medikamentosen Therapie, sondern durfen schon heute als Therapie I.Wahl gelten. Das gilt insbesondere fur die Katheterablationsbehandlungen supraventrikularerTachykardien, aber auch fur die Implantation automatischer Kardioverter/Defibrillatoren in der Sekundarprophylaxe des plotzlichen Herztodes oder als primar prophylaktische Therapie bei ausgewahlten Hochrisikopatienten.

3-D-Mapping der Pulmonalvenen mit einem multipolaren Basketkatheter

Hintergrund:Vorhofflimmern wird überwiegend durch Trigger in den Pulmonalvenen induziert und unterhalten.Patienten und Methodik:In der vorliegenden Studie wurde die elektrische Aktivierung der Pulmonalvenen bei 65 Patienten (43 Männer, 22 Frauen, mittleres Alter 54 ± 12 Jahre) mit therapieresistentem Vorhofflimmern (paroxysmal n = 42, persistierend n = 23) mit Hilfe eines 64-poligen Basketkatheters untersucht.Ergebnisse:75% der arrhythmogenen Pulmonalvenen zeigten bei ektopen Entladungen ein stabiles und für die einzelne Vene spezifisches Aktivierungsmuster. Durch die gezielte ostiale Hochfrequenzkatheterablation von im Mittel 2,3 ± 1,1 separierten Leitungswegen konnten 187 von 190 Pulmonalvenen erfolgreich elektrisch vom Vorhof aus isoliert werden. 55% (36/65) der Patienten sind nach 12 Monaten ohne Antiarrhythmika im Sinusrhythmus, 67% (28/42) der Patienten mit paroxysmalem Vorhofflimmern. Mittels Kernspintomographie fand sich nach 1 Jahr nur eine bedeutsame Pulmonalvenenstenose von > 50%.Schlussfolgerung:Pulmonalvenen zeigen sowohl bei ektopen Entladungen als auch im Sinusrhythmus ein spezifisches Aktivierungsmuster. Durch die gezielte Ablation von im Mittel 2,3 ± 1,1 separierten Leitungsbahnen konnten 187 von 190 Pulmonalvenen erfolgreich ostial isoliert werden.Background:Focal discharges from pulmonary veins are the major sources of paroxysmal atrial fibrillation. The aim of this study was to analyze the activation pattern of pulmonary veins during sinus rhythm and ectopy with the help of a multipolar basket catheter and to disconnect them from the left atrium by localized radiofrequency catheter ablation.Patients and Methods:We studied 65 patients (43 male, 22 female, mean age 54 ± 12 years) with drug-refractory atrial fibrillation (paroxysmal n = 42, persistent n = 23). A 64-pole basket catheter (Figure 1) with a diameter of 31 or 38 mm (Constellation®, Boston Scientific) was placed transseptally into the pulmonary veins to record its activation during ectopic beats and during sinus rhythm or coronary sinus pacing (Figure 2). The ablation catheter was placed as ostial as possible next to the electrodes showing the earliest pulmonary vein activation during sinus rhythm or coronary sinus pacing (Figures 3 and 4a). The radiofrequency energy was delivered with a maximum temperature of 50 °C and a maximum power of 30 W. In 32 patients, an irrigated-tip catheter (Thermocool®, Biosense-Webster) was used. Endpoint of the procedure was the complete elimination of all distal pulmonary vein potentials during sinus rhythm (Figure 4b).Results:The mean number of procedures per patients was 1.25, mean procedure time 236 ± 79 min, and mean fluoroscopy time 40 ± 17 min, respectively. In 16 veins, repetitive discharges (more than three) could be recorded under stable conditions (Figures 2 and 5). In twelve of these 16 pulmonary veins (75%), the activation pattern during ectopic beats was identical in the same vein, but different from one vein to another (Figure 2). In four veins, changing activation patterns were observed in the same vein. Focal atrial fibrillation was recorded in four pulmonary veins (Figures 6 and 7). A total of 187 out of 190 mapped veins were successfully isolated at the ostium by ablating 2.3 ± 1.1 separated conduction pathways. In 16 patients, a second EP study was performed for recurrence of atrial fibrillation. Recovery of conduction of a previously isolated pulmonary vein was identified as the primary reason for recurrence of atrial fibrillation. The second reason were ostial foci, localized proximal to the ablation line (Figure 8). Complications and Follow-Up: One pericardial tamponade occurred. Carbonization on the splines of the basket catheter—observed in twelve cases with use of a nonirrigated-tip catheter—was prevented by use of irrigated-tip catheters. At 12 months, 36 out of 65 patients (55%) are in sinus rhythm without antiarrhythmic drug use, 28 of 42 patients (67%) with paroxysmal atrial fibrillation. Only one pulmonary vein stenosis > 50% was detected by angiomagnetic resonance imaging 1 year after the procedure.Conclusion:75% of the arrhythmogenic pulmonary veins showed a stable and specific pattern during repetitive ectopic activity. Ostial ablation of 2.3 ± 1.1 separated conduction pathways from the left atrium into the pulmonary veins resulted in complete conduction block in 187 of 190 veins.

3-D-Mapping der Pulmonalvenen mit einem multipolaren Basketkatheter@@@3-D Mapping of Pulmonary Veins Using a Multipolar Basket Catheter. Implications for Catheter Ablation of Atrial Fibrillation: Bedeutung für die Katheterablation von Vorhofflimmern

Hintergrund:Vorhofflimmern wird überwiegend durch Trigger in den Pulmonalvenen induziert und unterhalten.Patienten und Methodik:In der vorliegenden Studie wurde die elektrische Aktivierung der Pulmonalvenen bei 65 Patienten (43 Männer, 22 Frauen, mittleres Alter 54 ± 12 Jahre) mit therapieresistentem Vorhofflimmern (paroxysmal n = 42, persistierend n = 23) mit Hilfe eines 64-poligen Basketkatheters untersucht.Ergebnisse:75% der arrhythmogenen Pulmonalvenen zeigten bei ektopen Entladungen ein stabiles und für die einzelne Vene spezifisches Aktivierungsmuster. Durch die gezielte ostiale Hochfrequenzkatheterablation von im Mittel 2,3 ± 1,1 separierten Leitungswegen konnten 187 von 190 Pulmonalvenen erfolgreich elektrisch vom Vorhof aus isoliert werden. 55% (36/65) der Patienten sind nach 12 Monaten ohne Antiarrhythmika im Sinusrhythmus, 67% (28/42) der Patienten mit paroxysmalem Vorhofflimmern. Mittels Kernspintomographie fand sich nach 1 Jahr nur eine bedeutsame Pulmonalvenenstenose von > 50%.Schlussfolgerung:Pulmonalvenen zeigen sowohl bei ektopen Entladungen als auch im Sinusrhythmus ein spezifisches Aktivierungsmuster. Durch die gezielte Ablation von im Mittel 2,3 ± 1,1 separierten Leitungsbahnen konnten 187 von 190 Pulmonalvenen erfolgreich ostial isoliert werden.Background:Focal discharges from pulmonary veins are the major sources of paroxysmal atrial fibrillation. The aim of this study was to analyze the activation pattern of pulmonary veins during sinus rhythm and ectopy with the help of a multipolar basket catheter and to disconnect them from the left atrium by localized radiofrequency catheter ablation.Patients and Methods:We studied 65 patients (43 male, 22 female, mean age 54 ± 12 years) with drug-refractory atrial fibrillation (paroxysmal n = 42, persistent n = 23). A 64-pole basket catheter (Figure 1) with a diameter of 31 or 38 mm (Constellation®, Boston Scientific) was placed transseptally into the pulmonary veins to record its activation during ectopic beats and during sinus rhythm or coronary sinus pacing (Figure 2). The ablation catheter was placed as ostial as possible next to the electrodes showing the earliest pulmonary vein activation during sinus rhythm or coronary sinus pacing (Figures 3 and 4a). The radiofrequency energy was delivered with a maximum temperature of 50 °C and a maximum power of 30 W. In 32 patients, an irrigated-tip catheter (Thermocool®, Biosense-Webster) was used. Endpoint of the procedure was the complete elimination of all distal pulmonary vein potentials during sinus rhythm (Figure 4b).Results:The mean number of procedures per patients was 1.25, mean procedure time 236 ± 79 min, and mean fluoroscopy time 40 ± 17 min, respectively. In 16 veins, repetitive discharges (more than three) could be recorded under stable conditions (Figures 2 and 5). In twelve of these 16 pulmonary veins (75%), the activation pattern during ectopic beats was identical in the same vein, but different from one vein to another (Figure 2). In four veins, changing activation patterns were observed in the same vein. Focal atrial fibrillation was recorded in four pulmonary veins (Figures 6 and 7). A total of 187 out of 190 mapped veins were successfully isolated at the ostium by ablating 2.3 ± 1.1 separated conduction pathways. In 16 patients, a second EP study was performed for recurrence of atrial fibrillation. Recovery of conduction of a previously isolated pulmonary vein was identified as the primary reason for recurrence of atrial fibrillation. The second reason were ostial foci, localized proximal to the ablation line (Figure 8). Complications and Follow-Up: One pericardial tamponade occurred. Carbonization on the splines of the basket catheter—observed in twelve cases with use of a nonirrigated-tip catheter—was prevented by use of irrigated-tip catheters. At 12 months, 36 out of 65 patients (55%) are in sinus rhythm without antiarrhythmic drug use, 28 of 42 patients (67%) with paroxysmal atrial fibrillation. Only one pulmonary vein stenosis > 50% was detected by angiomagnetic resonance imaging 1 year after the procedure.Conclusion:75% of the arrhythmogenic pulmonary veins showed a stable and specific pattern during repetitive ectopic activity. Ostial ablation of 2.3 ± 1.1 separated conduction pathways from the left atrium into the pulmonary veins resulted in complete conduction block in 187 of 190 veins.