Livio Bertagnolli

Early Referral for Ablation of Scar-Related Ventricular Tachycardia Is Associated With Improved Acute and Long-Term Outcomes Results From the Heart Center of Leipzig Ventricular Tachycardia Registry

Background—The effects of time to referral for catheter ablation (CA) of scar-related ventricular tachycardia (VT) on acute success, VT recurrence, and cardiac mortality are unclear. Methods and Results—We investigated 300 patients after CA of sustained VT. CA was performed within 30 days after the first documented VT in 75 (25%) patients (group 1), between 1 month and 1 year in 84 (28%) patients (group 2), and >1 year after the first VT occurrence in 141 (47%) patients (group 3). The end points were noninducibility of any VT after CA (acute success), VT recurrence and cardiac mortality after 2 years. Acute success was achieved in 66 (88%) patients in group 1, 68 (81%) in group 2, and in 99 (70.2%) in group 3 (P=0.008). During the 2-year follow-up period, VT recurred in 28 (37.3%) patients in group 1, 52 (61.9%) patients in group 2, and 91 (64.5%) patients in group 3 (P<0.0001). Recurrence-free survival was higher in group 1, as compared with group 2 (hazard ratio [HR], 1.85; P=0.009) and group 3 (HR, 2.04; P=0.001). No survival difference was observed between groups 1 and 2 (HR, 0.85; P=0.68) and groups 1 and 3 (HR, 1.13; P=0.73). &bgr;-blocker therapy, VT of ischemic origin, and complete success were associated with VT-free survival. VT recurrence (HR, 1.91; P=0.037) predicted cardiac mortality. Conclusions—CA of scar-related VT performed within 30 days after the first documented VT was associated with improved acute and long-term success. VT recurrence, but not the early referral for CA, was associated with cardiovascular mortality.

Left atrial appendage morphology and thromboembolic risk after catheter ablation for atrial fibrillation

BACKGROUND In patients with atrial fibrillation (AF), left atrial appendage (LAA) morphology has been suggested to modify risk of thromboembolic events (TEs). OBJECTIVE In this study, we tested the hypothesis that a TE after AF catheter ablation is associated with LAA characteristics. METHODS Of 2069 patients included in the Leipzig Heart Center AF Ablation Registry, 15 (0.7%) suffered a TE (excluding events within 30 days) during follow-up (ie, 3.078 patient-years). Those patients were matched for CHA2DS2-VASc criteria with 115 patients without TE, and computed tomography (n = 120) or magnetic resonance imaging (n = 10) data were also compared. LAA volume, morphology (cactus, chicken-wing, windsock, and cauliflower), and takeoff (higher/lower) in relation to the adjacent pulmonary vein were determined. RESULTS After patients were followed for a median period of 24 months, 67% of the patients remained in sinus rhythm. Patients with TE had a higher AF recurrence rate (73% vs 28%; P = .001) and a higher incidence of superior LAA takeoff (ie, higher than that of the left superior pulmonary vein; 80% vs 37%; P = .002), while LAA morphologies and other LAA characteristics were similar between groups. Multivariate Cox regression analysis revealed AF recurrence (hazard ratio 6.2; 95% confidence interval 2.0-19.6; P = .002) and superior LAA takeoff (hazard ratio 4.9; 95% confidence interval 1.4-17.4; P = .014) as TE predictors. There was a negative correlation between heart rate and LAA flow (r = -.22 cm/s per beat/min; P = .016), which was even more pronounced for the superior LAA takeoff (r = -.28 cm/s; P = .045). CONCLUSION AF recurrence and higher LAA takeoff are associated with thromboembolism after AF ablation, while LAA morphology is not. These results may have an implication for improved postablation management.

Impact of left atrial appendage morphology on peri-interventional thromboembolic risk during catheter ablation of atrial fibrillation

BACKGROUND Left atrial appendage (LAA) morphology recently has been suggested to influence thromboembolic risk in patients with atrial fibrillation (AF). OBJECTIVE The purpose of this study was to examine the impact of LAA morphology on peri-interventional thromboembolic events in patients undergoing AF catheter ablation. METHODS Of 2570 consecutive patients undergoing AF ablation, 17 patients with cerebral thromboembolic events within 30 days of AF ablation were selected and matched for CHA2DS2VASc score, peri-interventional anticoagulation, and procedural characteristics with 68 event-free patients. LAA morphology was visualized by cardiac computed tomography and classified into 4 types: cactus, chicken wing, windsock, and cauliflower. RESULTS Baseline, echocardiographic, and procedural characteristics of both patient groups were similar. Patients with embolic complications had a significantly higher incidence of chicken wing morphology compared to event-free controls (65% vs. 21% chicken wing, 18% vs. 24% cactus, 12% vs. 13% windsock, 5% vs. 42% cauliflower, respectively, P < .001), which translates into a >7× higher risk compared to other morphologies (odds ratio 7.2, 95% confidence interval 1.353-38.328, P = .021) when adjusted for possible confounders associated with chicken wing morphology. CONCLUSION LAA chicken wing morphology is associated with higher periprocedural thromboembolic risk in patients undergoing AF ablation. Further studies are needed to determine the mechanisms and possible implications of this observation.

IMPACT OF LEFT ATRIAL APPENDAGE MORPHOLOGY ON PER-INTERVENTIONAL THROMBOEMBOLIC RISK DURING CATHETER ABLATION OF ATRIAL FIBRILLATION

Very recently, left atrial appendage (LAA) morphology has been suggested to influence thromboembolic risk in patients with atrial fibrillation (AF). This study examines the impact of LAA morphology on per-interventional thromboembolic events in patients undergoing AF catheter ablation. Of 2,570

Acute electrocardiographic differences between Takotsubo cardiomyopathy and anterior ST elevation myocardial infarction.

BACKGROUND The aim of this study was to compare ECG findings between anterior ST elevation myocardial infarction (STEMI) and Takotsubo cardiomyopathy (TC) in a similar sample of postmenopausal women. METHODS Between 2008 and 2011, 27 patients with TC were retrospectively enrolled and matched with 27 STEMI patients with the same age and sex taken from the prospective database of our laboratory. RESULTS The absence of abnormal Q waves, the ST depression in aVR and the lack of ST elevation in V1 were significantly associated with TC (respectively: 52% vs 18%, p=0.01; 47% vs 11%, p=0.01; 80% vs 41%, p=0.01). The combination of these ECG findings identified TC with a specificity of 95% and a positive predictive value of 85.7%. CONCLUSIONS The ECG on admission may be useful to distinguish TC from anterior STEMI. The combination of three ECG findings identifies patients with TC with high specificity and positive predictive value.

Efficacy and safety of remote magnetic catheter navigation vs. manual steerable sheath-guided ablation for catheter ablation of atrial fibrillation: a case-control study

AIMS Data comparing remote magnetic catheter navigation (RMN) to manual catheter navigation (MCN) using steerable sheath for ablation of atrial fibrillation (AF) is lacking. The aim of the present case-control study was to seek AF recurrence data after AF ablation using RMN in comparison to MCN using steerable sheath in patients with either paroxysmal or persistent AF. METHODS AND RESULTS This study comprised 140 patients with AF (50% paroxysmal). Seventy were ablated utilizing RMN and 70 with MCN. Primary endpoint was defined as the time to first recurrence after index procedure. After 28.8 ± 18.9 months of follow-up, more patients in the MCN group using steerable sheath remained free of recurrence compared with RMN group [(59.1 vs. 40%, respectively, P = 0.031), in patients with persistent AF P = 0.057, while in patients with paroxysmal AF, P = 0.18]. Index procedure time (223.6 ± 44.2 vs. 170.8 ± 51.8 min, P < 0.001) and radiofrequency application time (75.4 ± 20.9 vs. 56.6 ± 24.9 min, P < 0.001) were longer in the RMN group; however, the respective total fluoroscopy time (13.7 ± 7.8 vs. 36.6 ± 12.7 min, P < 0.001) was significantly shorter. In multivariable Cox-regression analysis, RMN was the only factor independently associated with shorter time to first recurrence during follow-up (P = 0.048). Complication rate did not differ significantly between groups (P = 0.056), although the incidence of significant pericardial effusion was higher in the MCN group (3 cases vs. 0 in RMN group). CONCLUSION Although in patients with persistent AF, the recurrence rate is higher in RMN group, the outcome is comparable between RMN and MCN groups in patients with paroxysmal AF. A multicentre prospective randomized study is warranted to clarify this issue.

Preliminary experience with high-density electroanatomical mapping for ablation of atrial fibrillation - Comparison of mini-basket and novel open irrigated magnetic ablation catheter in consecutive patients.

BACKGROUND Recently, a novel electroanatomic mapping system enabling rapid and automatic acquisition of high-resolution maps has been introduced. Previous reports focused on system use in combination with a mini-basket catheter. However, a novel system-specific, magnet-enabled ablation catheter eliminates the need for the mini-basket catheter and can potentially reduce procedure complexity and cost. Here we present our first experience from two consecutive case series using both procedural settings. METHODS In 14 consecutive patients (67±9years, 5 male) with paroxysmal (n=10) or persistent AF (n=4) undergoing de-novo (n=8) or repeat (n=6) AF ablation, left atrial electroanatomical maps were acquired with a mini-basket and in 22 patients (64±9years, 17 male) with paroxysmal (n=4) or persistent AF (n=18) undergoing de-novo (n=12) or repeat (n=10) AF ablation with the new ablation catheter. RESULTS Both complete (7.9 [IQR 4.5-16.2] vs 18.8 [IQR 12.0-25.5] minutes, p=0.005) and partial maps (3.0 [IQR 2.0-4.6] vs 4.5 [IQR 2.0-6.0] minutes, p=0.014) acquired with mini-basket required significantly shorter mapping time and had higher point density: 8832±4809 vs 4460±3914 (p=0.014) and 2483±1774 vs 1111±1926 data points (p=0.002) in partial maps. However, procedural (201±52 vs 159±29min, p=0.004) and fluoroscopy time (33±11 vs 25±6min, p=0.005) was significantly higher in the mini-basket group. Procedural endpoints and complications rates were similar in both groups. CONCLUSION The high-density mapping system can successfully be used with both mini-basket catheters and ablation catheters employed for electro-anatomic reconstruction of the left atrium. While mapping is faster and point density higher with the mini-basket, procedure and fluoroscopy times are longer. The clinical significance of those findings needs to be investigated in future and larger studies.

Idiopathic Premature Ventricular Contraction Conducting Over a Ventricle Myocardial Extension from the Pulmonary Artery.

Ventricle myocardial extensions (VMEs) from the right ventricular outflow tract to the pulmonary artery (PA) serve as arrhythmogenic foci for idiopathic ventricular arrhythmias (VAs). Although an autopsy study revealed the heterogeneity of the VME, only the electrocardiographic features of PA‐VAs arising from septal VMEs have been discussed. Here, we describe a case of idiopathic PA‐VAs conducting over a VME accompanied by unique ventricle activation patterns, which contributed to the appearance of an S wave in the inferior limb leads despite an arrythmogenic focus in the outflow tract.

Positional ventricular tachycardia in left ventricular assist device: a new frontier in ventricular tachycardia ablation

A left ventricular assist device (LVAD) was implanted in a 54-year-old male patient with severe acute heart failure stemming from dilated cardiomyopathy. Immediately after implant, his condition improved and he could be weaned from mechanical ventilation. However, mobilization was not possible because with any shift away from the …

Predictors of ventricular arrhythmia after left ventricular assist device implantation: A large single-center observational study

BACKGROUND Ventricular arrhythmias (VAs) are common in patients after left ventricular assist device (LVAD) implantation. OBJECTIVE The purpose of this study was to determine the predictors of VAs and their impact on mortality in LVAD patients. METHODS A total of 98 consecutive patients with an implantable cardioverter-defibrillator (ICD) (86 [88%] male, mean age 57 ± 10 years), 57 [58%] with nonischemic dilated cardiomyopathy) who had received an LVAD between May 2011 and December 2013 at our institution were included in the study. RESULTS Mean left ventricular ejection fraction and left ventricular end-diastolic diameter were 20% ± 8% and 73 ± 11 mm, respectively. Seventy-three patients (75%) had atrial fibrillation (AF). During the 12 months before LVAD implantation, 38 patients (39%) had experienced ≥1 episode of VAs (11.5 ± 20) requiring ICD therapies. The number of patients with VAs was comparable among all types of ICDs (P = .48). During the 12-month follow-up after LVAD implantation, 48 patients (49%) experienced ≥1 episode of VAs (30 ± 98) with appropriate ICD therapies. The prevalence of VAs was significantly higher among patients with pre-LVAD VAs compared to those without VAs during the year before LVAD implantation (66% vs 38%; P = .008). In a binary multiple logistic regression analysis, pre-LVAD VAs (hazard ratio 5.36, 95% confidence interval 2.0-14.3; P = .001) and AF (hazard ratio 3.1, 95% confidence interval 1.1-11.9; P = .024) predicted post-LVAD VAs. CONCLUSION Pre-LVAD VAs and AF predict the occurrence of VAs after LVAD implantation. According to the latest data on the negative impact of post-LVAD VAs on all-cause mortality, further studies should clarify the reasonability of maintaining sinus rhythm in patients with AF and/or prophylactic catheter ablation of ventricular tachycardias before LVAD implantation.