Marcell Clemens

Transcranial Measurement of Cerebral Microembolic Signals During Pulmonary Vein Isolation A Comparison of Two Ablation Techniques

Background—Pulmonary vein isolation has increasingly been used to cure atrial fibrillation, but concerns have recently been raised that subclinical brain damage may occur because of microembolization during these procedures. We compared the occurrence of bubble formation seen on intracardiac echocardiography and the microembolic signals (MESs) detected by transcranial Doppler on the use of different ablation techniques and anticoagulation strategies. Methods and Results—This prospective study included 35 procedures in 34 consecutive patients (age, 52; SD, 12.8 years; female:male 9:25). Pulmonary vein isolation was performed with a cryoballoon and the conventional anticoagulation protocol (activated clotting time >250 s) in 10 procedures (group 1), with a multipolar duty-cycled radiofrequency pulmonary group 2), and with regime a pulmonary vein ablation catheter with an aggressive anticoagulation (activated clotting time >320 s) in 13 procedures (group 3). The mean total numbers of MESs detected during the procedures were 833.7 (SD, 727.4) in group 1, 3142.6 (SD, 1736.4) in group 2, and 2204.6 (SD, 1078.1) in group 3 (P=0.0005). MESs were detected mostly during energy delivery in the pulmonary vein ablation catheter groups, whereas a relatively even distribution of emboli formation was seen during cryoballoon ablations. A significant correlation was found in all groups between the degree of bubble formation on intracardiac echocardiography and the number of MESs (P=0.0000). Conclusions—Duty-cycled radiofrequency ablation is associated with significantly more MESs, even when more aggressive anticoagulation is applied. With both techniques most of these microemboli are gaseous in nature.

The prevalence of obesity is increased in patients with late compared with early onset psoriasis

PURPOSE We compared the clinical and epidemiologic characteristics of early and late onset psoriasis with an emphasis on potential differences in the comorbidities associated with each subtype. METHODS An observational, multicenter study was performed, and associations between the age at the time of diagnosis and binary comorbidity outcomes were evaluated using multiple logistic regression analysis adjusted for age and other relevant confounders. RESULTS An increased prevalence of positive family history, psoriatic arthritis, and depression was observed in patients with early onset psoriasis. On the other hand, late onset psoriasis was more frequently associated with obesity and elevated waist circumference compared with early onset form. Elderly psoriatic patients (at the age of 75 years) with late onset psoriasis are at an especially high risk for obesity compared with individuals at the same age with an early onset disease. CONCLUSIONS The increased frequency of psoriasis in the family of early onset patients may suggest that manifestation of psoriasis at younger age is driven by strong genetic influence. However, such a remarkable association of abdominal obesity with late onset psoriasis may suggest that obesity can be one of the acquired factors that may predispose for the development of psoriasis in the elderly.

New perspectives in the renin-angiotensin-aldosterone system (RAAS) IV: circulating ACE2 as a biomarker of systolic dysfunction in human hypertension and heart failure.

Background Growing evidence exists for soluble Angiotensin Converting Enzyme-2 (sACE2) as a biomarker in definitive heart failure (HF), but there is little information about changes in sACE2 activity in hypertension with imminent heart failure and in reverse remodeling. Methods, Findings Patients with systolic HF (NYHAII-IV, enrolled for cardiac resynchronisation therapy, CRT, n = 100) were compared to hypertensive patients (n = 239) and to a healthy cohort (n = 45) with preserved ejection fraction (EF>50%) in a single center prospective clinical study. The status of the heart failure patients were checked before and after CRT. Biochemical (ACE and sACE2 activity, ACE concentration) and echocardiographic parameters (EF, left ventricular end-diastolic (EDD) and end-systolic diameter (ESD) and dP/dt) were measured. sACE2 activity negatively correlated with EF and positively with ESD and EDD in all patients populations, while it was independent in the healthy cohort. sACE2 activity was already increased in the hypertensive group, where signs for imminent heart failure (slightly decreased EF and barely increased NT-proBNP levels) were detected. sACE2 activities further increased in patients with definitive heart failure (EF<50%), while sACE2 activities decreased with the improvement of the heart failure after CRT (reverse remodeling). Serum angiotensin converting enzyme (ACE) concentrations were lower in the diseased populations, but did not show a strong correlation with the echocardiographic parameters. Conclusions Soluble ACE2 activity appears to be biomarker in heart failure, and in hypertension, where heart failure may be imminent. Our data suggest that sACE2 is involved in the pathomechanism of hypertension and HF.

Rationale and design of the BUDAPEST-CRT Upgrade Study: A prospective, randomized, multicentre clinical trial

Abstract Aims There is lack of conclusive evidence from randomized clinical trials on the efficacy and safety of upgrade to cardiac resynchronization therapy (CRT) in patients with implanted pacemakers (PM) or defibrillators (ICD) with reduced left ventricular ejection fraction (LVEF) and chronic heart failure (HF). The BUDAPEST-CRT Upgrade Study was designed to compare the efficacy and safety of CRT upgrade from conventional PM or ICD therapy in patients with intermittent or permanent right ventricular (RV) septal/apical pacing, reduced LVEF, and symptomatic HF. Methods and results The BUDAPEST-CRT study is a prospective, randomized, multicentre, investigator-sponsored clinical trial. A total of 360 subjects will be enrolled with LVEF ≤ 35%, NYHA functional classes II–IVa, paced QRS ≥ 150 ms, and a RV pacing ≥ 20%. Patients will be followed for 12 months. Randomization is performed in a 3:2 ratio (CRT-D vs. ICD). The primary composite endpoint is all-cause mortality, a first HF event, or less than 15% reduction in left ventricular (LV) end-systolic volume at 12 months. Secondary endpoints are all-cause mortality, all-cause mortality or HF event, and LV volume reduction at 12 months. Tertiary endpoints include changes in quality of life, NYHA functional class, 6 min walk test, natriuretic peptides, and safety outcomes. Conclusion The results of our prospective, randomized, multicentre clinical trial will provide important information on the role of cardiac resynchronization therapy with defibrillator (CRT-D) upgrade in patients with symptomatic HF, reduced LVEF, and wide-paced QRS with intermittent or permanent RV pacing. Clinical trials.gov identifier NCT02270840.

Pacemaker‐Mediated Tachycardia over the Upper Rate Limit in a Biventricular Pacemaker System: What is the Mechanism?

Case Presentation A 51-year-old man with nonischemic dilated cardiomyopathy, a low ejection fraction (25%), and New York Heart Association class III heart failure was referred to our Department for cardiac resynchronization therapy. His electrocardiogram (ECG) showed an atypical right bundle branch block and left posterior hemiblock morphology, with a QRS duration of 160 ms (Fig. 1), and with intraand inter-ventricular dyssynchrony. A biventricular pacemaker (Stratos LV, Biotronik, Berlin, Germany) was implanted with a bipolar left ventricular (LV) lead positioned in the proximal segment of the anterior vein in the absence of an appropriate lateral or posterior branch. The LV threshold was 3.5 V at 1 ms and the output was programmed to 6 V at 1 ms. One week later, the patient was admitted with sustained regular wide QRS complex tachycardia at 167 beats/min, an almost identical QRS axis in the frontal plane and similar QRS complexes as compared with the baseline nonpaced ECG (Fig. 1). Intracardiac signals during the tachycardia through device interrogation are presented in Figure 2 (left). Prompt termination of the tachycardia was achieved with an iv bolus of adenosine (6 mg). At testing, the atrial and right ventricular (RV) leads showed excellent sensing and capture parameters, with a further increase in the LV threshold, since the implantation and only intermittent capture at the programmed values. Tachycardia with identical morphology to the presenting arrhythmia was reinitiated during the LV capture threshold test (Fig. 3, left). What is the mechanism of this tachycardia?

Catheter Ablation of Ventricular Tachycardia as the First-Line Therapy in Patients With Coronary Artery Disease and Preserved Left Ventricular Systolic Function: Long-Term Results

Patients with coronary artery disease (CAD), relatively preserved left ventricular ejection fraction (LVEF), and hemodynamically tolerated ventricular tachycardia (VT) may benefit from catheter ablation as the first‐line treatment. Our aim was to analyze the long‐term results of VT ablation in this population.

Long-term arrhythmia variability after monomorphic ventricular tachycardia in patients with an implantable cardioverter defibrillator.

Background:  Arrhythmia burden in patients receiving an implantable cardioverter defibrillator (ICD) after monomorphic ventricular tachycardia (mVT) is higher than in patients with other indications. We investigated the long‐term arrhythmia profile in this subset of patients.

Correlation of body mass index and responder status in heart failure patients after cardiac resynchronization therapy: Does the obesity paradox exist?

Abstract Aims: We investigated the influence of body mass index (BMI) on the prevalence of responder status in chronic heart failure patients after cardiac resynchronization therapy (CRT). Methods: Data on 169 patients with resynchronization therapy were analyzed. Patients were categorized on the basis of the BMI measured at device implantation according to the WHO classification, as normal (BMI: 18.5–24.9 kg/m2), overweight (BMI: 25–29.9 kg/m2) or obese (BMI:≥30 kg/m2). Patients were considered responders if left ventricular ejection fraction was increased by at least 5% at 6-month follow-up. Results: The mean age in the study population was 60.9±10.86 years (females 29%). The BMI subgroups did not exhibit any significant differences in baseline characteristics (age, gender, left ventricular ejection fraction or NYHA class). Elevated BMIs were associated with higher prevalence of responder status (overweight: 71.4%, obese: 63.0%) relative to subjects with a normal BMI (44.7%) (p=0.015). Conclusions: In t...

Impact of Atrial Fibrillation on Natriuretic Peptides: An Invasive Atrial Hemodynamic Study

Natriuretic peptide (NP) plasma concentrations are increased in patients with atrial fibrillation (AF) compared with patients in sinus rhythm (SR). However, it is poorly understood whether the increase of NPs is intrinsic to the AF or whether it is caused by the left atrial pressure (LAP) overload

Catheter ablation of idiopathic ventricular ectopy in the vicinity of the His bundle under the septal leaflet of the tricuspid valve

A 59-year-old female with frequent, drug-refractory ventricular premature beats (VPBs) was referred for catheter ablation. On her resting ECG, monomorphic VPBs were present in bigeminic pattern with axis similar to sinus rhythm, transition zone in lead V3 and slurring …