Matthias Heinke

Successful use of a wearable cardioverter-defibrillator in myocarditis with normal ejection fraction

Sudden cardiac death (SCD) is generally defined as an unexpected death due to cardiovascular causes. In the majority of cardiac arrest patients, a structural or functional abnormality can be identified. Coronary artery disease is the most common cause of SCD [1]. In younger individuals, SCD often occurs during exercise, where hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy accounts for most of these cases [2]. Myocarditis comprises 5–11% of SCD in individuals less than 40 years of age [3]. In these cases, symptoms before the fatal event are rare [4]. Secondary prevention of SCD needs ICD therapy after documented cardiac arrest unless a transient or correctable cause of the arrhythmic trigger can be identified [5]. The treatment strategy for patients with ventricular fibrillation associated with a ‘‘transient’’ or ‘‘correctable’’ cause is not clear. These patients have a similar mortality rate as the survivors of ventricular fibrillation arrest in the observational registry of the AVID trial [6]. In myocarditis complicated by ventricular tachycardia (VT) or ventricular fibrillation (VF), antiarrhythmic drugs or an ICD implantation have not yet been studied in controlled trials. Because acute myocarditis often represents a transient condition from which recovery is common, the implantation of a permanent ICD should not be routine. Current guidelines do not recommend ICD therapy in a patient with acute myocarditis [5]. The debatable content of this statement is demonstrated with this presented case.

Transesophageal left ventricular posterior wall potential in heart failure patients with biventricular pacing / Transösophageales linksventrikuläres Potenzial der posterioren Wand bei Patienten mit Herzinsuffizienz und biventrikulärer Stimulation

Abstract Introduction: Biventricular (BV) pacing is an established therapy for heart failure (HF) patients with intraventricular conduction delay, but not all patients improved clinically. We investigated the interventricular delay (IVD) by means of the transesophageal left ventricular posterior wall potential (LVPWP). Materials and methods, and Results: A total of 18 HF patients (age 62±9 years; 15 males) with NYHA class 3.1±0.3, LV ejection fraction 22±7%, left bundle branch block and a QRS duration (QRSD) of 171±27 ms were analyzed using transesophageal LVPWP before implantation of a BV pacing device. The median follow up was 14±14 months. In 14 responders, IVD was 81±25 ms with a QRSD/IVD ratio of 2.2±0.3 with reclassification of NYHA class 3.1±0.3 to 2.0±0.5 (p<0.001) and an increase in LV ejection fraction from 22±7% to 36±11% (p=0.001) during long-term BV pacing. In four non-responders, transesophageal IVD was significantly smaller at 30±11 ms (p=0.001). Conclusion: Transesophageal IVD may be a useful method to detect responders to BV pacing. Transesophageal LVPWP may be a simple and useful technique to detect clinical responders to BV pacing in HF patients. Zusammenfassung Einleitung: Die biventrikuläre (BV) Stimulation ist eine etablierte Therapie bei Patienten mit Herzinsuffizienz (HF) und intraventrikulärem Leitungsdelay, aber nicht alle Patienten verbessern sich klinisch. Wir haben das interventrikuläre Delay (IVD) mit dem transösophagealen linksventrikulären Potenzial der posterioren Wand (LVPWP) untersucht. Material und Methode und Ergebnisse: Elf HF-Patienten (Alter 62±9 Jahre; 15 Männer) mit NYHA Klasse 3,1±0,3, LV Ejektionsfraktion 22±7%, Linksschenkelblock und QRS-Dauer (QRSD) 171±27 ms wurden mit dem transösophagealen LVPWP vor Implantation eines BV Schrittmachers analysiert. Der Median der Nachuntersuchung betrug 14±14 Monate. Bei 14 Respondern betrug das IVD 81±25 ms mit einem QRSD/IVD Verhältnis von 2,2±0,3. Es verbesserte sich die NYHA Klasse von 3,1±0,3 auf 2,0±0,5 (p<0,001) und erhöhte sich die LV Ejektionsfraktion von 22±7 auf 36±11% (p=0,001) während der BV Stimulation über lange Zeit. Bei 4 Nonrespondern war das transösophageale IVD signifikant geringer mit 30±11 ms (p=0,001). Schlussfolgerung: Das transösophageale IVD stellt möglicherweise eine brauchbare Methode zur Erkennung von Respondern für die BV Stimulation dar. Das transösophageale LVPWP ist möglicherweise eine einfache und brauchbare Technik zur Erkennung von klinischen Respondern für die BV Stimulation bei HF-Patienten.

Termination of Tachycardias by Transesophageal Electrical Pacing

To evaluate the therapeutic significance of noninvasive transesophageal pacing for termination of tachycardias the method of rapid atrial or ventricular transesophageal pacing was used in 233 patients with different tachycardiac arrhythmias. We were able to terminate atrial flutter in 136 of 162 patients by transesophageal rapid atrial stimulation (conversion to sinus rhythm in 75 cases, induction of atrial fibrillation in 61 cases). Atrial tachycardias were interrupted in 17 of 23 patients (sinus rhythm in 11 cases, atrial fibrillation in six cases). AV reciprocating/AV nodal supravenrricular reentry tachycardias were terminated in 62 of 63 patients (sinus rhythm in 58 cases, atrial fibrillation in four cases). By transesophageal rapid ventricular pacing ventricular tachycardias could be terminated in ten of 15 patients. The success rate of transesophageal pacing was influenced by the pacing rate, by the type of tachycardiac arrhythmia inclusive by the type of atrial flutter and by the tachycardias cycle length. Because the success rates are comparable with invasive technique and the procedure is simpler, the noninvasive transesophageal antitachycardiac pacing should be respected as the method of the first choice in patients with supraven‐tricular tachycardias.

Bundle Branch Reentrant Tachycardia Treated by Transvenous Catheter Ablation of the Right Bundle Branch

Recurrent episodes of ventricuiar tachycardia not responding to medical treatment occurred in a 56‐year‐old man. Electrophysiological investigation showed ventricular tachycardia due to bundle branch reentry. Using a method similar to catheter ablation of the atrioventricular junction, ablation of the right bundle branch was performed by an electrical shock of 250 joules. While before the ablation ventricular tachycardia occurred several times a day and its induction by programmed ventricular stimulation was facilitated by the administration of antiarrhythmic drugs, no initiation of ventricular tachycardia was possible after ablation of the right bundle branch. Over a follow‐up of 30 months the patient has not suffered from tachycardia and the right bundle branch block persists.

Termination of atrial flutter by directed transesophageal atrial pacing during transesophageal echocardiography / Terminierung von Vorhofflattern mit gerichteter transösophagealer Vorhofstimulation bei transösophagealer Echokardiographie

Abstract Introduction: The purpose of this study was to evaluate termination of atrial flutter (AFL) by directed rapid transesophageal atrial pacing (TAP) with and without simultaneous transesophageal echocardiography (TEE) performed using a novel TEE tube electrode. Materials and methods, and Results: A total of 16 AFL patients (age 63±12 years; 13 males) with mean AFL cycle length of 224±24 ms (n=12) and mean ventricular cycle length of 448±47 ms (n=12) were analyzed using either an esophageal TO electrode (n=10) or a novel TEE tube electrode consisting of a tube with four hemispherical electrodes that is pulled over the echo probe (n=6). AFL could be terminated by directed rapid TAP using an esophageal TO electrode, leading to induction of atrial fibrillation (AF) (n=6), induction of AF and spontaneous conversion to sinus rhythm (SR) (n=3), and with conversion to SR (n=1). AFL could also be terminated by directed rapid TAP using the TEE tube electrode, with induction of AF (n=3) or induction of AF and spontaneous conversion to SR (n=3). Conclusion: AFL can be terminated by directed rapid TAP with hemispherical electrodes with and without simultaneous TEE. TAP with the directed TEE tube electrode is a safe, simple, and useful method for terminating AFL. Zusammenfassung Einleitung: Die Terminierung von Vorhofflattern (AFL) mit gerichteter hochfrequenter transösophagealer Vorhofstimulation (TAP) wurde mit und ohne simultane transösophageale Echokardiographie (TEE) mit einer neuen TEE-Schlauchelektrode evaluiert. Material und Methode und Ergebnisse: 16 AFL Patienten (Alter 63±12 Jahre; 13 Männer) mit einer mittleren AFL-Periodendauer von 224±24 ms (n=12) und einer mittleren ventrikulären Periodendauer von 448±47 ms (n=12) wurden mittels Ösophaguselektrode „TO” (n=10) oder neuer „TEE-Schlauchelektrode”, die aus einem Schlauch mit 4 halbkugelförmigen Elektroden besteht und über die Echokardiographiesonde gezogen wird (n=6), analysiert. AFL konnte mit gerichteter hochfrequenter TAP und TO-Elektrode durch Induktion von Vorhofflimmern (AF) (n=6), Induktion von AF mit spontaner Konversion in den Sinusrhythmus (SR) (n=3) und Konversion in den SR (n=1) terminiert werden. AFL konnte mit gerichteter hochfrequenter TAP und TEE-Schlauchelektrode durch Induktion von AF (n=3) und Induktion von AF mit spontaner Konversion in den SR (n=3) terminiert werden. Schlussfolgerung: AFL kann durch gerichtete hochfrequente TAP mit halbkugelförmigen Elektroden mit und ohne simultane TEE terminiert werden. TAP mit der gerichteten TEE-Schlauchelektrode ist eine sichere, einfache und praktikable Methode zur Terminierung von AFL.

Balloon Electrode Catheter for Transesophageal Atrial Pacing and Transesophageal EGG Recording

A new balloon electrode catheter (10 French) with five or six balloon electrodes placed on the cardiac side was developed for transesophageal atrial pacing and bipolar ECG recording. The diameter of the hemispheric electrodes is 6 mm and the length of the esophageal balloon is 10 cm. The transesophageal atrial pacing threshold was measured with the balloon electrode catheter by transesophageal programmed atrial stimulation (TPS) (n = 54). At the onset of TPS, the feeling, capture fn = 54), and pain voltage threshold (n = 6) were measured by increasing the amplitude of the pacing voltage during high rate bipolar atrial pacing and bipolar atrial ECG recording. In 38 TPS, the capture threshold was lower than the feeling threshold (n = 28). In 16 TPS, the capture threshold was higher than the feeling threshold. In conclusion, painless atrial pacing and excellent ECG recording can be achieved with a multipolar esophageal balloon electrode catheter with a low pacing voltage amplitude and a high P wave amplitude.

Optimization of the atrioventricular delay during cardiac resynchronization therapy using a device for non-invasive measurement of cardiac index at rest and during exercise

AIMS It is not clear whether cardiac resynchronization therapy (CRT) should only be optimized at rest or whether it is necessary to perform CRT optimization during exercise. Our study aims to answer this question by using an inert gas rebreathing method (Innocor®). METHODS AND RESULTS Twenty-seven patients with congestive heart failure and implanted CRT devices were included in the study. The aetiology of the heart failure was ischaemic in nine (33%) patients. Patients had low left ventricular ejection fraction (29 ± 8%) and enlarged LV end-diastolic diameters (63 ± 7 mm). Atrioventricular delay (AVD) was optimized at rest according to cardiac index (CI), measured by inert gas rebreathing (Innocor®). Thereafter, patients performed standardized, steady-state bicycle exercise at 30 W in sitting body position. Three AVDs were tested during exercise in a random sequence: optimized resting AVD (AVD(opt)) according to baseline measurement; AVD(opt) - 30 ms; and AVD(opt) + 30 ms. Cardiac index was measured in each AVD by inert gas rebreathing. Cardiac index increased significantly during exercise. However, neither AVD(opt) shortening nor prolongation during exercise had significant effect on CI (shortening of AVD(opt) - 30 ms was accompanied by a reduction of CI of 4.8%, prolongation of AVD(opt) + 30 ms was accompanied by a reduction of CI of 7.7%). CONCLUSION Shortening or lengthening of the AVD during exercise has no impact on CI in CRT patients. On the basis of our results, we conclude that in CRT patients the AVD should be programmed, fixed even during exercise.

Left Ventricular Lead Position and Nonspecific Conduction Delay Are Predictors of Mortality in Patients During Cardiac Resynchronization Therapy

BACKGROUND Cardiac resynchronization therapy (CRT) is an established treatment of severe systolic heart failure with intraventricular conduction delay. The influence on mortality of the left ventricular (LV) pacing site and the type of bundle-branch block during CRT is unclear. OBJECTIVES This study investigates the clinical significance of LV lead position, as well as nonspecific conduction delay, in CRT. METHODS 143 consecutive patients (mean age, 63.9 ± 8.9 years; 121 men) underwent implantation of a CRT device according to established criteria. At the time of implantation, the LV lead position and the type of bundle-branch block were recorded. The etiology of the heart failure was ischemic in 49 patients (34.3%) and nonischemic in 94 patients (65.7%). RESULTS After a median follow-up of 19 months, 39 patients (27.3%) died, most of them (72%) of cardiovascular causes. The mortality was significantly higher in patients with an anterior or anterolateral LV lead position (P = 0.03). Multivariate analysis suggests that an anterior or anterolateral LV lead position, a nonspecific conduction delay, male sex, and a New York Heart Association functional class worse than III, are all independent predictors of mortality during the follow-up period. CONCLUSION LV lead position and nonspecific conduction delay are predictors of mortality in patients during cardiac resynchronization therapy.

Esophageal Balloon Electrode Catheter for Transthoracic Recording of His‐Bundle Potential with Transesophageal Atrial Pacing

To evaluate the influence of transesophageal atrial pacing of the transthoracic His potential identification, we combined signal‐averaged ECG with transesophageal atrial pacing with low threshold for pacing averaging ECG recording. A tripolar 10 French esophageal balloon electrode catheter, with one cylindrical electrode on the tip of the catheter and two balloon electrodes on the cardiac side of the catheter, used in 53 patients, allowed a painless transesophageal atrial pacing and a high signal to noise distance in the signal‐averaged ECG. Transesophageal atrial pacing allowed in 37 of 53 patients an identification of His potential by increasing the distance between the end of the atrial potential and the onset of the His potential in the pacing averaging ECG. The esophageal balloon electrode catheter allowed a painless transesophageal atrial pacing with low threshold for atrial capture during a long pacing time and a high signal to noise distance in the pacing averaging ECG. The increasing of the heart rate with transesophageal atrial pacing allowed the transthoracic identification of the His potential in the pacing averaging ECG.

[Implantation of a re-synchronization device in a patient with persistent left superior vena cava-a case report].

SummaryWe report an implantation of a cardiac resynchronisation system in a patient with persistent left superior vena cava. This anomaly occurs in 0.3 to 0.5% of healthy individuals and remains usually asymptomatic. Variations of the superior vena cava should be considered in venous catheterization and other procedures such as implantation of pacemaker and ICD systems as well as port catheter insertion. In resynchronisation systems, persistent left superior vena cava can be an obstacle for cannulation of the coronary sinus and placement of a transvenous left ventricular lead.ZusammenfassungWir berichten über die Implantation eines Resynchronisationssystems bei einem Patient mit persistierender oberer Hohlvene. Diese Variante tritt mit einer Häufigkeit von 0,3 to 0,5% auf und ist in der Regel asymptomatisch. Varianten der oberen Hohlvene können die Anlage zentralvenöser Zugänge sowie die Implantation von Herzschrittmachern, ICD- und Portsystemen behindern und haben Konsequenzen für die Elektrodenplatzierung der linksventrikulären Elektrode von Resynchronisationssystemen.