Klaus Gutleben

Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation

AIMS Oesophageal injury has been reported with delivery of radio-frequency lesions at the left atrium posterior wall in catheter ablation procedures for atrial fibrillation (AF). In this observational study we prospectively assessed endoscopical oesophageal wall changes after pulmonary vein antrum isolation (PVAI) in patients presenting for treatment of AF. METHODS AND RESULTS Twenty eight patients (18 men; mean age 55 +/- 11 years) were ablated using either a cooled-tip or an 8 mm tip ablation catheter. Endoscopy of the oesophagus was performed 24 h after PVAI. If oesophageal wall changes were detected post ablation, a proton-pump inhibitor (PPI) was started and repeat endoscopy was considered. Within 24 h post ablation oesophageal wall changes were confirmed in 47% of our study patients. Erythema was identified in 29% and necrotic or ulcer-like changes in 18% of patients. None of study patients experienced left atrial-oesophageal fistula. A significant correlation between Reflux-like symptoms and oesophageal wall changes was demonstrated. Complete recovery of oesophageal lesions was shown in all study patients 2-4 weeks post ablation. CONCLUSION A significant number of patients experienced oesophageal wall injury post PVAI. Initiating PPIs in this group of patients might facilitate recovery of oesophageal wall injuries caused by radio-frequency energy delivery.

Transvenous phrenic nerve stimulation for the treatment of central sleep apnoea in heart failure

AIMS Periodic breathing with central sleep apnoea (CSA) is common in heart failure patients and is associated with poor quality of life and increased risk of morbidity and mortality. We conducted a prospective, non-randomized, acute study to determine the feasibility of using unilateral transvenous phrenic nerve stimulation for the treatment of CSA in heart failure patients. METHODS AND RESULTS Thirty-one patients from six centres underwent attempted transvenous lead placement. Of these, 16 qualified to undergo two successive nights of polysomnography-one night with and one night without phrenic nerve stimulation. Comparisons were made between the two nights using the following indices: apnoea-hypopnoea index (AHI), central apnoea index (CAI), obstructive apnoea index (OAI), hypopnoea index, arousal index, and 4% oxygen desaturation index (ODI4%). Patients underwent phrenic nerve stimulation from either the right brachiocephalic vein (n = 8) or the left brachiocephalic or pericardiophrenic vein (n = 8). Therapy period was (mean ± SD) 251 ± 71 min. Stimulation resulted in significant improvement in the AHI [median (inter-quartile range); 45 (39-59) vs. 23 (12-27) events/h, P = 0.002], CAI [27 (11-38) vs. 1 (0-5) events/h, P≤ 0.001], arousal index [32 (20-42) vs. 12 (9-27) events/h, P = 0.001], and ODI4% [31 (22-36) vs. 14 (7-20) events/h, P = 0.002]. No significant changes occurred in the OAI or hypopnoea index. Two adverse events occurred (lead thrombus and episode of ventricular tachycardia), though neither was directly related to phrenic nerve stimulation therapy. CONCLUSION Unilateral transvenous phrenic nerve stimulation significantly reduces episodes of CSA and restores a more natural breathing pattern in patients with heart failure. This approach may represent a novel therapy for CSA and warrants further study.

First prospective, multi-centre clinical experience with a novel left ventricular quadripolar lead

AIMS Cardiac resynchronization therapy (CRT) is sometimes complicated by elevated pacing thresholds and phrenic nerve stimulation (PNS), both of which may require that the coronary sinus lead be repositioned. The purpose of this study was to evaluate the performance of a novel quadripolar electrode lead and cardiac resynchronization therapy-defibrillator (CRT-D) device that enables electrical repositioning, potentially obviating a lead reposition procedure. METHODS AND RESULTS Patients indicated for CRT were enrolled and received a quadripolar electrode lead and CRT-D device (Quartetmodel 1458Q and Promote Q; St Jude Medical, Sylmar, CA, USA). Electrical data, and the presence of PNS during pacing from each left ventricular (LV) configuration, were documented at pre-hospital discharge and at 1 month. Seventy-five patients were enrolled and 71 were successfully implanted with a Quartetlead. Electrical measurements were stable over the follow-up period. Ninety-seven per cent (64 of 66) of patients had one or more programmable configurations with a threshold < 2.5 V and no PNS vs. 86% (57 of 66) if only conventional bipolar configurations were considered. Physicians were able to use the increased programming options to manage threshold changes and PNS. CONCLUSION The new quadripolar electrode LV lead provides more programming options to address common problems faced when managing CRT patients. Electrical measurements from new vectors are comparable with conventional configurations. Furthermore, 11% of patients in the study suffered PNS on all conventional bipolar vectors.

Three-dimensional left atrial and esophagus reconstruction using cardiac C-arm computed tomography with image integration into fluoroscopic views for ablation of atrial fibrillation: Accuracy of a novel modality in comparison with multislice computed tomography

BACKGROUND Visualization of the left atrium (LA) and pulmonary veins (PVs) is crucial in PV isolation (PVI). Additional delineation of the esophagus might avoid severe side effects. Cardiac C-arm computed tomography (DynaCT Cardiac, Siemens AG, Forchheim, Germany) has been introduced as a novel intraprocedural imaging modality based on a rotational angiography. OBJECTIVES The purpose of this study was to prove the quantitative accuracy of DynaCT Cardiac as compared with multislice CT (MSCT) in imaging of the LA and PV in patients undergoing PVI. METHODS Thirty-four consecutive patients (22 male, age 64 +/- 12 years) with symptomatic atrial fibrillation (AF) and indication for PVI were studied. Diameters of the PV, the LA appendage (LAA), and the descending aorta were measured, and the position of the esophagus was defined using preprocedural MSCT and intraprocedural DynaCT Cardiac. RESULTS There was a significant correlation between both measurements for diameters of the LAA (r = 0.86, P <.05), PV (r = 0.98, P <.05), and the descending aorta (r = 0.98, P <.05). The overall correlation of vessel diameters was r = 0.99. The LA volumes correlation was r = 0.86 and P <.05. A significant difference of the esophageal position was found between preprocedural MSCT and intraprocedural DynaCT Cardiac (r = 0.53, P <.05). CONCLUSIONS DynaCT Cardiac is a novel intraprocedural rotational angiographic technique. It is highly accurate in displaying crucial structures for PVI in comparison with the results of MSCT. Therefore, DynaCT Cardiac can be used as an alternative imaging technique to improve PVI accuracy.

Role of left ventricular scar and Purkinje-like potentials during mapping and ablation of ventricular fibrillation in dilated cardiomyopathy.

Background: Purkinje‐like potentials (PLPs) have been described as important contributors to initiation of ventricular fibrillation (VF) in patients with normal hearts, ischemic cardiomyopathy, and early after‐myocardial infarction.

Acute effects of multisite left ventricular pacing on mechanical dyssynchrony in patients receiving cardiac resynchronization therapy.

BACKGROUND A novel quadripolar left ventricular (LV) pacing lead has the ability to deliver multisite LV pacing (MSLV). We set out to characterize the safety and changes in acute mechanical dyssynchrony with MSLV in cardiac resynchronization therapy (CRT) patients. METHODS AND RESULTS Prospective multicenter study in 52 patients receiving CRT. An acute pacing protocol comprising 8 MSLV configurations covering a range of delays was compared with conventional CRT (baseline). Transthoracic tissue Doppler imaging (TDI) was used to measure the standard deviation of time to peak contraction of 12 LV segments (Ts-SD) and delayed longitudinal contraction. No ventricular arrhythmia occurred in any of the 52 patients. Complete TDI datasets were collected in 41 patients. Compared with baseline: 1) The mean Ts-SD was significantly lower for the optimal MSLV configuration (35.3 ± 36.4 vs 50.2 ± 29.1 ms; P < .001); 2) at least 1 MSLV configuration exhibited a significant dyssynchrony improvement in 63% of patients; and 3) the mean number of LV segments with delayed longitudinal contractions was significantly reduced with the optimal MSLV configuration (0.37 ± 7.99 vs 2.20 ± 0.19; P < .001). CONCLUSIONS Acute MSLV was acutely safe, and a proportion of MSLV vectors resulted in a significant reduction in echocardiographic dyssynchrony compared with conventional CRT.

Image-integration of intraprocedural rotational angiography-based 3D reconstructions of left atrium and pulmonary veins into electroanatomical mapping: accuracy of a novel modality in atrial fibrillation ablation.

DynaCT Cardiac Integration into Electroanatomical Mapping.  Introduction: Exact visualization of complex left atrial (LA) anatomy is crucial for safety and success rates when performing catheter ablation of atrial fibrillation (AF). The aim of our study was to validate the accuracy of integrating rotational angiography‐based 3‐dimensional (3D) reconstructions of LA and pulmonary vein (PV) anatomy into an electroanatomical mapping (EAM) system.

MAGNETICALLY GUIDED IRRIGATED GOLD-TIP CATHETER ABLATION OF PERSISTENT ATRIAL FIBRILLATION -SAFETY, FEASIBILITY AND OUTCOME IN MID-TERM FOLLOW-UP

Background: Magnetically guided irrigated ablation has been introduced for atrial fibrillation (AF) ablation. However, data on ablation of persistent AF is scarce and first generation platinum-iridium catheters were burdened by char formation at the catheter tip. Furthermore, energy transmission of these catheters may be suboptimal. Irrigated gold-tip catheters have been introduced to overcome these problems

CRYOBALLOON ABLATION OF PAROXYSMAL ATRIAL FIBRILLATION GUIDED BY INTRACARDIAC ECHOCARDIOGRAPHY: PREDICTION OF ACUTE SUCCESS BY A NON-FLUOROSCOPIC IMAGING TECHNIQUE

Background: Cryoballoon ablation has been adopted for pulmonary vein (PV) isolation in many centers. Complete occlusion of PV and adequate balloon size are essential for effectiveness of cryoenergy delivery. Traditionally decision for balloon sizes and confirmation of PV occlusion is based on PV angiography. The aim of this study was to replace repetitive angiographic imaging by intracardiac echocardiography (ICE) and to demonstrate its usefulness for balloon guiding and monitoring of PV peak flow velocity.