Jürgen Tebbenjohanns

High Incidence of Appropriate and Inappropriate ICD Therapies in Children and Adolescents with Implantable Cardioverter Defibrillator

Appropriate and inappropriate therapies of implantable cardioverter defibrillators have a major impact on morbidity and quality of life in ICD recipients, but have not been systematically studied in children and young adults during long‐term follow‐up. ICD implantation was performed in 20 patients at the mean age of 16 ± 6 years, 11 of which had prior surgical repair of a congenital heart defect, 9 patients had other cardiac diseases. Implant indications were aborted sudden cardiac death in six patients, recurrent ventricular tachycardia in 9 patient, and syncope in 5 patients. Epicardial implantation was performed in 6 and transvenous implantation in 14 patients. Incidence, reasons and predictors (age, gender, repaired congenital heart disease, history of supraventricular tachycardia, and epicardial electrode system) of appropriate and inappropriate ICD therapies were analyzed during a mean follow‐up period of 51 ± 31 months range 18‐132 months. There were a total 239 ICD therapies in 17 patients (85%) with a therapy rate of 2.8 per patient‐years of follow‐up. 127 (53%) ICD therapies in 15 (75%) patients were catagorized as appropriate and 112 (47%) therapies in 10 (50%) patients as inappropriate, with a rate of 1.5 appropriate and 1.3 inappropriate ICD therapies per patient‐years of follow‐up. Time to first appropriate therapy was 16 ± 18 months. Appropriate therapies were caused by ventricular fibrillation in 29 and ventricular tachycardia in 98 episodes. Termination was successful by antitachycardia pacing in 4 (3%) and by shock therapy in 123 episodes (97%). Time to first inappropriate therapy was 16 ± 17 months. Inappropriate therapies were caused by supraventricular tachycardia in 77 (69%), T wave oversensing in 19 (17%), and electrode defect in 16 episodes (14%). It caused shocks in 87 (78%) and only antitachycardia pacing in 25 episodes (22%). No clinical variable could be identified as predictor of either appropriate or inappropriate ICD therapies.

Acute and long-term effects of consecutive radiofrequency applications on conduction properties of the subeustachian isthmus in type I atrial flutter.

Effects of Atrial Flutter Ablation. Introduction: Bidirectional conduction block at the subeustachian isthmus predicts long‐term efficacy of atrial flutter ablation. Limited data are available on the incidence and outcome of minor conduction changes such as unidirectional or incomplete block. This prospective study sought to systematically assess discrete acute and long‐term alterations of bidirectional conduction prior to a complete conduction block.

Leitlinien zur Katheterablation

Herausgegeben vom Vorstand der Deutschen Gesellschaftfur Kardiologie – Herz- und Kreislaufforschung e.V.Bearbeitet im Auftrag der Kommission fur Klinische KardiologieM. Borggrefe, M. Bohm, J. Brachmann, H.-R. Figulla, G. Hasenfus,A. Osterspey, K. Rybak, U. Sechtem, S. Silberauserdem H.M. HoffmeisterOnline publiziert: 26. Oktober 2007Prof. Dr. med. Karl-Heinz Kuck (

Pacemaker Function During Radiofrequency Ablation

There are increasing numbers of radiofrequency current ablation procedures being reported. Selected patients have antitachycardia or antibradycardia pacemakers. The pacemaker behavior during and after ablation procedures differs widely. We report on the pacemaker reaction of 25 patients with 13 different devices, most with unipolar electrodes. Sensing failures were observed in 8 (32.0%) and pacing failures in 4 (16.0%) patients. Prolonged pauses and induction of tachyarrhythmias were observed. No pacemaker damage was seen although it is reported by other investigators. We recommend deactivation of implanted generators and an external bipolar pacing electrode. Manufacturers should focus their attention on this problem and protect the generators and their functions for 500 kHz radiofrequency current.

Echocardiographic imaging of coronary sinus diverticula and middle cardiac veins in patients with preexcitation syndrome: impact on radiofrequency catheter ablation of posteroseptal accessory pathways.

OMRAN, H., et al.: Echocardiographic Imaging of Coronary Sinus Diverticula and Middle Cardiac Veins in Patients with Preexcitation Syndrome: Impact on Radiofrequency Catheter Ablation of Posteroseptal Accessory Pathways. To determine the value of echocardiography for identifying coronary sinus (CS) diverticula and middle cardiac veins (MCVs) in patients with posteroseptal accessory pathways (PAPs), transthoracic (TTE) and transesophageal echocardiography (TEE) were performed in 18 consecutive patients with PAP and in 15 control subjects with left lateral accessory pathway before CS angiography. The size, shape, and location of CS diverticula and MCV were described and compared to angiography. TEE and angiography were concordant for the identification of diverticula (n = 5) and agreed for depicting MCV in 22 of the 27 cases. TTE revealed 4 of 5 diverticula and identified 4 of 27 MCV (P < 0.001). Fourteen MCV but no diverticula were found in the control subjects. There was no significant difference between transesophageal and angiographic measurements for the width (23.5 ± 4.9 vs 26.8 ± 6.6 mm) and height (13.5 ± 3.8 vs 15.7 ± 3.4 mm) of the diverticula, and the width (3.5 ± 0.7 vs 3.7 ± 0.6 mm) of MCV. TEE underestimated the length of the MCV (12.0 ± 1.8 vs 27.2 ± 6.0, P < 0.001). Delivery of radiofrequency energy within the neck of a diverticulum or within an MCV was successful in 5 of 5, and 6 of 13 cases in patients with PAPs, respectively. In conclusion, echocardiography was as reliable as angiography for detecting and describing CS diverticula and MCV in patients with preexcitation syndrome. Echocardiography is recommended prior to electrophysiological study because it may simplify radiofrequency catheter ablation.

Prospective study of retrograde coronary venography in patients with posteroseptal and left-sided accessory atrioventricular pathways.

The morphologic features of the coronary vein system was prospectively studied with retrograde venography in 117 patients with left-sided (78 patients) and posteroseptal accessory pathway (39). Findings were compared with accessory pathway localization. A mean of 3.3 +/- 1.5 venous branches draining into the coronary sinus or the great cardiac vein could be visualized. The morphologic condition was described and classified. Incidence, morphologic condition, and distribution did not differ between left-sided and posteroseptal accessory pathway. Venous abnormalities including ectasy, diverticulum, narrowing, angulation, and hypoplasia occurred in 22.2%. Diverticulum and narrowing were present in posteroseptal accessory pathway only and always related to the successful ablation site. In patients with left-sided accessory pathway, ectasy, angulation, and hypoplasia were found. Anomalies were less frequent (9% vs 43.6%, p < 0.001) and had no relation to accessory pathway localization. However, the successful ablation site was in 42.3% located < 5 mm to an angiographically visualized venous branch. In conclusion, posteroseptal accessory pathways are often related to coronary sinus abnormalities. In patients with a left-sided accessory pathway venous malformation is uncommon, whereas a close anatomic relation exists between accessory pathway localization and venous ventricular branches.

Ablation of atrioventricular nodal reentrant tachycardia in the elderly: results from the German Ablation Registry

BACKGROUND Catheter ablation (CA) is considered the treatment of choice for patients with atrioventricular nodal reentrant tachycardia (AVNRT). However, there is a tendency to avoid CA in the elderly because of a presumed increased risk of periprocedural atrioventricular (AV) nodal block. OBJECTIVE The purpose of this prospective registry was to assess age-related differences in the efficacy and safety of CA within a large population with AVNRT. METHODS A total of 3,234 consecutive patients from 48 German trial centers who underwent CA of AVNRT between March 2007 and May 2010 were enrolled in this study. The cohort was divided into three age groups: <50 years (group 1, n = 1,268 [39.2%]; median age = 40 [30.0-45.0] years, 74.1% women), 50-75 years old (group 2, n = 1,707 [52.8%]; 63.0 [58.0-69.0] years, 63.0% women), and > 75 years old (group 3, n = 259 [8.0%]; 79.0 [77.0-82.0] years, 50.6% women). RESULTS CA was performed with radiofrequency current (RFC) in 97.7% and cryoablation technology in 2.3% of all cases. No differences were observed among the three groups with regard to primary CA success rate (98.7% vs. 98.8 % vs. 98.5%; P = .92) and overall procedure duration (75.0 minutes [50.0-105.0]; P = .93). Hemodynamically stable pericardial effusion occurred in five group 2 (0.3%) and two group 3 (0.8%) patients but in none of the group 1 (P <.05) patients. Complete AV block requiring permanent pacemaker implantation occurred in two patients in group 1 (0.2%) and six patients in group 2 (0.4%) but none in group 3 (P = 0.41). During a median follow-up period of 511.5 days (396.0-771.0), AVNRT recurrence occurred in 5.7% of all patients. Patients >75 years (group 3) had a significantly longer hospital stay (3.0 days [2.0-5.0]) compared with group 1 (2.0 days [1.0-2.0]) or group 2 (2.0 days [1.0-3.0]) patients (P <.0001). CONCLUSION CA of AVNRT is highly effective and safe and does not pose an increased risk for complete AV block in patients over 75 years of age, despite a higher prevalence of structural heart disease. Antiarrhythmic drug therapy is often ineffective in this age group; thus, CA for AVNRT should be considered the preferred treatment even in elderly patients.

Impact of the Local Atrial Electrogram in AV Nodal Reentrant tachycardia: Abaltion Versus Modification of the Slow Pathway

Electrogram in AVNRT. Introduction: The purpose of this study was to determine the predictors of successful ablation versus modification sites of the slow pathway in patients with AV nodal reentrant tachycardia. Complete elimination of slow pathway conduction (“ablation”) is considered to be an appropriate endpoint during radiofrequency (RF) current delivery, whereas the persistence of residual slow pathway conduction with or without single echo beats (“modification”) may be indicative of tachycardia recurrence.

Effects of antiarrhythmic drugs on epicardial defibrillation energy requirements and the rate of defibrillator discharges.

Antiarrhythmic drugs are commonly used with the implantable cardioverter/defibrillator to treat recurrent ventricular tachyarrhythmias. Since various antiarrhythmic drugs have been reported to alter defibrillation threshold, an important question is whether the device will provide adequate energy for defibrillation during long‐term follow‐up and to what extent antiarrhythmic drug treatment will affect defibrillation energy requirements. To answer these questions, the defibrillation thresholds were determined in 20 patients using an epicardial patch‐patch lead configuration at the time of implantation and at the time of pulse generator replacement. During a mean follow‐up period of 24 ± 6 months, the defibrillation threshold increased significantly from 14.2 ± 3.7 joules to 18.3 ± 5.5 joules in the entire group (P < 0.05). This increase in defibrillation threshold was due to a marked elevation of defibrillation energy requirements in the subgroup of patients taking amiodarone compared with patients receiving mexiletine. Based on these results it is mandatory to retest defibrillation threshold at any time of pulse generator replacement to guarantee continued effectiveness. In particular, if amiodarone treatment is initiated after implantation of a defibrillator, it is recommended to reevaluate defibrillation threshold to ensure an adequate margin of safety.

German ablation registry: Cryoballoon vs radiofrequency ablation in paroxysmal atrial fibrillation—One-year outcome data

BACKGROUND Although radiofrequency (RF) ablation has long been the standard of care for atrial fibrillation (AF) ablation, cryoballoon technology has emerged as a feasible approach with promising results. Prospective multicenter registry data referring to both ablation technologies in AF ablation are lacking so far. OBJECTIVE The purpose of this study was to report data from the German ablation registry with respect to efficacy and safety in pulmonary vein ablation with different energy sources for paroxysmal AF after 1-year follow-up. METHODS A total of 2306 patients with symptomatic paroxysmal AF from the German ablation registry were included in this analysis. The cohort was divided into two groups according to the ablation energy source used: cryoballoon and RF ablation. MACCE was defined as a combination of death, myocardial infarction, or stroke. RESULTS AF recurrence rate after a single ablation procedure at 1 year follow-up was not significantly different between the two groups (45.8% after cryoablation and 45.4% after RF ablation, P = .87). Also, the rate of patients without AF recurrence and free of antiarrhythmic drug at 12-month follow-up was similar (cryoablation 44.2% and RF 41.4%, P = .25). MACCE occurred with an incidence of 0.7% within 500 days after cryoablation and 1.4% after RF ablation (P = .30). Persistent phrenic nerve palsy was more common after cryoablation compared to RF ablation (1.1% vs. 0.3%, P <.05). CONCLUSION AF recurrence rate at 1-year follow-up was similar in RF ablation compared to cryoablation, whereas the spectrum and relevance of complications were significantly different between the two ablation methods. This finding might influence the choice of ablation method offered to the individual paroxysmal AF patient.