Johannes Heintze

Left heart pacing--experience with several types of coronary vein leads.

Our experience with 121 coronary vein (CV) leads in 116 patients shows that CV leads are the leads of choice for pacing the left ventricle (LV). The information gained from pre-operative venous angiography permits individual selection of the most appropriate lead model for each case. The use of steerable electrophysiology catheters facilitates guide catheter cannulation of the coronary sinus (CS) when the anatomy is difficult and reduces the risk of complications. By selecting the CV lead model most suitable for each individual patient, we achieved successful implantation in 99.1% of patients. In this day and age, epicardial electrodes should be restricted to cases with CS anomalies which make CS cannulation impossible, and to LV lead implantation during heart surgery.

Coronary vein balloon angioplasty forleft ventricular pacemaker lead implantation

OBJECTIVES Retrospective analysis of five cases of coronary vein balloon angioplasty performed to allow insertion of left ventricular pacing leads. BACKGROUND Coronary vein stenoses or an insufficient vessel caliber can preclude transvenous placement of coronary vein leads. METHODS We compared our total patient population (n = 218), in whom we implanted coronary vein leads, to those five patients who required coronary vein angioplasty to allow lead placement. Standard over-the-wire coronary artery balloon angioplasty catheters were used to dilate the vessel to 2.5 mm (n = 3) or 3.5 mm (n = 2). RESULTS Transvenous lead placement succeeds in >99% of patients. Four cases of target vein stenoses and one case of a vein of insufficient caliber were successfully treated by balloon angioplasty. There were no complications. CONCLUSIONS Coronary vein angioplasty is an effective and safe technique to permit transvenous left ventricular pacing lead insertion in cases of target vein stenoses or insufficient target vein caliber.

Cryoballoon Pulmonary Vein Isolation Supported by Intracardiac Echocardiography: Integration of a Nonfluoroscopic Imaging Technique in Atrial Fibrillation Ablation

Intracardiac Echo Supported Cryoballoon Ablation. Introduction: Cryoballoon ablation has been adopted for pulmonary vein (PV) isolation (PVI) in many centers. Complete occlusion of PV by an adequately sized balloon is crucial for effectiveness of cryoenergy delivery. The aim of this study was to evaluate intracardiac echocardiography (ICE) as an alternative imaging technique compared to angiographic imaging in cryoballoon PVI.

Implantation of Active Fixation Leads in Coronary Veins for Left Ventricular Stimulation: Report of Five Cases

Background: Securing transvenous left ventricular (LV) pacing leads without an active fixation mechanism in proximal coronary vein (CV) segments is usually challenging and frequently impossible. We investigated how active fixation leads can be safely implanted in this location, how to avoid perforating the free wall of the CV, and how to recognize and respond to perforations.

Cardioverter-defibrillator implantation in the catheterization laboratory: Initial experiences in 48 patients

The exponential increase in cardioverter-defibrillator implantations has resulted in a need for safe implantations that do not require long waiting periods. We report intraoperative and follow-up results in 48 patients with ventricular tachyarrhythmias who underwent cardioverter-defibrillator implantation in the catheterization laboratory. Twenty-six (54%) patients had their first cardioverter-defibrillator implant (group 1), and 22 (46%) patients underwent pulse-generator replacement (group 2). In all patients, cardioverter-defibrillator implant or pulse-generator replacement was performed with the patient under general anesthesia. In 25 (96%) of 26 patients in group 1, cardioverter-defibrillator implantation was possible with a mean defibrillation threshold of 13 +/- 8 J. One patient had a defibrillation threshold of > 25 J, and therefore cardioverter-defibrillator implant was not achieved. This patient underwent epicardial device implantation 1 day later. Another patient in group 1 had vessel rupture (vena subclavia) intraoperatively. During a mean follow-up of 2 +/- 1 months, two patients died from congestive heart failure 2 and 4 months after device implantation. An infection occurred in one patient in group 2, 3 months after generator replacement. In conclusion, these data show that in the majority of patients cardioverter-defibrillator implantation in the catheterization laboratory is safe and has a low complication rate and therefore can generally be recommended.

[Analysis of inter- and intraventricular asynchrony by tissue Doppler echocardiography].

Cardiac resynchronization therapy (CRT) is a promising non-pharmacological treatment option for patients (pts) with severe severe heart failure (CHF), systolic left ventricular (LV) dysfunction, and ventricular conduction abnormalities (VCA). Pt selection for CRT, however, is still controversial. Tissue Doppler echocardiography (TDE) can be used to analyze regional wall motion with high temporal resolution. In 33 CHF pts with VCA (QRS width ≥140 ms) and 20 normal probands, left and right ventricular (RV) filling and emptying were analyzed by flow and tissue Doppler to assess regional (anterior, lateral, inferior, and septal) asynchrony within the LV as well as asynchrony between the RVand LV. All time measurements were corrected for a heart rate of 60 bpm. Results Maximum interventricular and segmental intraventricular delay was 30 ms in the normals. LV asynchrony, defined as a regional delay of ≥40 ms, was found in 29/33 (88%) of the CHF pts, in 4 cases there was synchronous LV contraction despite VCA. In the pts with LV asynchrony, 22 (67%) showed the maximum delay in the lateral wall, 7 (21%) in the septum. Inter- and intra-ventricular asynchrony correlated weakly. In many CHF pts with VCA, there is a delay both between the two ventricles, and among different LV regions. Predominantly but not exclusively, the LV lateral wall shows the maximum intra-LV delay. Some CHF pts, however, seem to have a synchronous LV contraction despite VCA. TDE thus adds important information for pt selection with respect to CRT. Die kardiale Resynchronisationstherapie (CRT) ist eine vielversprechende nichtmedikamentöse Therapieoption für Patienten (Pat.) mit schwerer Herzinsuffizienz (CHF), systolischer linksventrikulärer (LV-)Pumpfunktionsstörung und gestörter Erregungsausbreitung (EAS). Die Präzision der Patientenselektion für die CRT ist jedoch noch nicht befriedigend. Mittels Gewebe-Dopplerechokardiographie (TDE) ist die regionale Analyse des LV-Kontraktionsablaufs mit hoher zeitlicher Auflösung möglich. Wir überprüfen bei 33 CHF-Pat. mit EAS (Breite des QRS-Komplexes ≥140 ms) und 20 Normalpersonen Parameter der rechts-(RV-) und linksventrikulären Füllung und Entleerung mittels Fluss- und Gewebe-Doppler mit dem Ziel, eine mechanische Asynchronie innerhalb des LV (anteriore, laterale, inferiore und septale Region) bzw. eine interventrikuläre (RV-LV-)Asynchronie zu charakterisieren. Alle Zeitmessungen wurden auf eine Frequenz von 60/min korrigiert. Ergebnisse Die maximale inter- bzw. intraventrikuläre Asynchronie betrug bei den Normalpersonen 30 ms. Eine LV-Asynchronie, definiert als eine regionale Verzögerung um ≥40 ms, fand sich bei 29/33 (88%) der CHF-Pat., in 4 Fällen kontrahierte der LV jedoch trotz EAS synchron. Bei den Pat. mit LV-Asynchronie wies in 22 Fällen (67%) die laterale Wand, in 7 Fällen (21%) das Septum die maximale Verzögerung auf. Zwischen inter- und intraventrikulärer Asynchronie bestand nur eine schwache Korrelation. Bei CHF-Pat. mit EAS besteht vielfach eine zeitliche Latenz sowohl zwischen LV- und RVAuswurf als auch zwischen verschiedenen LV-Regionen. Vorwiegend, aber nicht ausschließlich betrifft die maximale Kontraktionsverzögerung die laterale Wand. Einige CHF-Pat. zeigen trotz EAS eine mechanisch synchrone Kontraktion. Die TDE kann somit wertvolle Informationen zur Selektion von CHF-Pat. liefern, die von der CRT profitieren könnten.

Epicardial and Nonthoracotomy Defibrillation Lead Systems Combined with a Cardioverter Defibrillator

The intraoperative and long‐term results were reviewed in 67 patients who underwent implantation of the Ventritex Cadence defibrillator with either epicardial patch (EPI, 25 patients) or nonthoracotomy CPI Endotak (ENDO, 42 patients) defibrillation lead systems. In the ENDO group, 35 patients (83 %) had a defibrillation threshold (DFT) of ≤ 20 joules and did not require a subcutaneous patch. Intraoperatively, the DFT was 13 ± 9 joules (mean ± SD) for EPI and 15 ± 8 joules for ENDO (P = NS). There was no perioperative death in either group. During a mean follow‐up of 12 ± 8 months, there was no sudden death, and four patients died from congestive heart failure (3 EPI, 1 ENDO). During follow‐up, 875 spontaneous arrhythmia episodes (AE) occurred in 15 of 25 EPI patients (60%). versus 652 in 28 of 42 ENDO patients (67%; P = NS). Ventricular tachycardia at a rate ≥ 222 beats/min or ventricular fibrillation represented 167 AE for EPI (19%) and 182 AE for ENDO (28%), and was terminated by the first shock in 76% and 75% of attempts, respectively. Ventricular tachycardia at a rate ≥ 222 beats/min represented a total of 1,178 AE and antitachycardia pacing was successful in 660 of 708 AE (93%) with EPI and 414 of 470 AE (88%) with ENDO lead systems (P= NS). Therefore, a nonthoracotomy approach using the Cadence V‐100 is safe and effective and has clinical results that are not significantly different from epicardial defibrillation lead systems.

Atrial fibrillation in carcinoid heart disease

Sirs: A 68-year-old man with mitral valve replacement but former mitral regurgitation II (left atrial size 39 mm) and coronary artery sclerosis suffered syncope due to a sustained ventricular tachycardia. Before this event, the patient had neither palpitations nor was arrhythmia documented by Holter ECGs. A single chamber cardioverter/defibrillator (SJM, Atlas VR) was implanted. Routine abdominal ultrasound did not reveal pathologic findings at that

Intracardiac echocardiography for registration of rotational angiography-based left atrial reconstructions: a novel approach integrating two intraprocedural three-dimensional imaging techniques in atrial fibrillation ablation

AIMS Image integration of three-dimensional (3D) reconstructions of left atrial (LA) and pulmonary vein (PV) anatomy into electroanatomical mapping (EAM) plays a major role in atrial fibrillation (AF) ablation. Point-by-point EAM is commonly used for registration of imported LA and PV anatomy. We aimed to assess the accuracy of intraprocedural rotational angiography-based LA imaging registered by spatial reconstruction of intracardiac echocardiography (ICE) in patients undergoing AF ablation. METHODS AND RESULTS Twenty-two patients (11 males, 66 ± 12 years) were studied. Reconstructions of LA and PVs based on rotational angiography were registered by a second 3D reconstruction based on ICE. In a second step, EAM points were added to ICE 3D reconstructions. A 3D image of the LA and PVs was reconstructed in all patients by both imaging modalities. Rotational angiography and ICE-based LA 3D reconstructions took 11.5 ± 5.2 and 20.4 ± 11.2 min, respectively. A total of 17 ± 6 two-dimensional ICE fans were used for spatial reconstruction of ICE. The deviation between the two 3D shells was 2.6 ± 0.5 mm. Integration of 78 ± 58 EAM points into ICE 3D reconstruction did not significantly reduce the deviation to rotational angiography-based reconstructions (2.7 ± 0.6 mm). All PVs were isolated successfully. CONCLUSIONS Intraprocedural 3D reconstruction of LA and PVs for ablation of AF is feasible based on both rotational angiography and ICE. LA reconstructions based on rotational angiography can accurately be registered using 3D ICE shells. Additional EAM does not enhance accuracy. Therefore, registration of rotational angiography-based 3D reconstructions by 3D reconstructions from ICE seems to be an alternative technique to support AF ablation.

Cardiac Resynchronization Therapy: Long-Term Alternative to Cardiac Transplantation?

BACKGROUND Cardiac transplantation remains the gold standard for treating end-stage heart failure. However, because of donor shortage and posttransplant complications alternative options are needed. METHODS We investigated the impact of cardiac resynchronization therapy on clinical outcome in 545 patients with left bundle-branch block and interventricular asynchrony, who fulfilled the cardiac criteria for cardiac transplantation listing. Primary end point was heart failure death. Secondary end points were New York Heart Association class, functional (cardiopulmonary exercise tolerance, 6-minute hall walk distance), and morphologic (left ventricular end-diastolic diameter) factors. RESULTS The average follow-up period was 39.6 months (standard deviation, 26.1 months). In total, 1,784 years of observation were accrued. The percentage of nonresponders (no functional and morphologic improvement during follow-up) was 21.2%. One-year and 3-year freedom from heart failure death was 92.3% and 77.3%, respectively. Functional variables improved, but the left ventricular end-diastolic diameter decreased during the first 6 months of cardiac resynchronization therapy only in patients who survived during follow-up. Under cardiac resynchronization therapy, 42.5% (n = 34) of the cardiac transplantation candidates with atrial fibrillation at baseline returned to sinus rhythm. CONCLUSIONS Our data suggest that cardiac resynchronization therapy is a reliable long-term therapeutic option for the treatment of end-stage heart failure and intraventricular asynchrony.