Mattias Roser

Potential lifetime cost-effectiveness of catheter-based renal sympathetic denervation in patients with resistant hypertension

AIMS Recent studies have demonstrated the safety and efficacy of catheter-based renal sympathetic denervation (RDN) for the treatment of resistant hypertension. We aimed to determine the cost-effectiveness of this approach separately for men and women of different ages. METHODS AND RESULTS A Markov state-transition model accounting for costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness was developed to compare RDN with best medical therapy (BMT) in patients with resistant hypertension. The model ran from age 30 to 100 years or death, with a cycle length of 1 year. The efficacy of RDN was modelled as a reduction in the risk of hypertension-related disease events and death. Analyses were conducted from a payers perspective. Costs and QALYs were discounted at 3% annually. Both deterministic and probabilistic sensitivity analyses were performed. When compared with BMT, RDN gained 0.98 QALYs in men and 0.88 QALYs in women 60 years of age at an additional cost of €2589 and €2044, respectively. As the incremental cost-effectiveness ratios increased with patient age, RDN consistently yielded more QALYs at lower costs in lower age groups. Considering a willingness-to-pay threshold of €35 000/QALY, there was a 95% probability that RDN would remain cost-effective up to an age of 78 and 76 years in men and women, respectively. Cost-effectiveness was influenced mostly by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN non-responders, and the procedure costs of RDN. CONCLUSION Renal sympathetic denervation is a cost-effective intervention for patients with resistant hypertension. Earlier treatment produces better cost-effectiveness ratios.

Insular Cortex Lesions, Cardiac Troponin, and Detection of Previously Unknown Atrial Fibrillation in Acute Ischemic Stroke Insights From the Troponin Elevation in Acute Ischemic Stroke Study

Background and Purpose— Detection rates of paroxysmal atrial fibrillation (AF) after acute ischemic stroke increase with duration of ECG monitoring. To date, it is unknown which patient group may benefit most from intensive monitoring strategies. Therefore, we aimed to identify predictors of previously unknown AF during in-hospital ECG monitoring. Methods— All consecutive patients with imaging-confirmed ischemic stroke admitted to our tertiary care hospital from February 2011 to December 2013 were registered prospectively. Patients received continuous bedside ECG monitoring for at least 24 hours. Detection of previously unknown AF during in-hospital ECG monitoring was obtained from medical records. Patients with AF on admission ECG or known history of AF were excluded from analysis. Results— Among 1228 patients (median age, 73 years; median National Institutes of Health Stroke Scale, 4; 43.4% women), previously unknown AF was detected in 114 (9.3%) during a median time of continuous ECG monitoring of 3 days (interquartile range, 2–4 days). Duration of monitoring (P<0.01), older age (P<0.01), history of hypertension (P=0.03), insular cortex involvement (P<0.01), and higher high-sensitivity cardiac troponin T (P=0.04) on admission were independently associated with subsequent detection of AF in a multiple regression analysis. Addition of high-sensitivity cardiac troponin T, insular cortex stroke, or both to the CHADS2 score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke [2P]) significantly improved c-statistics from 0.63 to 0.68 (P=0.01), 0.70 (P<0.01), and 0.72 (P<0.001), respectively. Conclusions— Insular cortex involvement, higher admission high-sensitivity cardiac troponin T, older age, hypertension, and longer monitoring are associated with new detection of AF during in-hospital ECG monitoring. Patients with higher high-sensitivity cardiac troponin T or insular cortex involvement may be candidates for prolonged ECG monitoring.

Intraprocedural reconstruction of the left atrium and pulmonary veins as a single navigation tool for ablation of atrial fibrillation: A feasibility, efficacy, and safety study

BACKGROUND Pulmonary vein (PV) isolation is a technically challenging intervention. For this reason, integration of three-dimensional imaging with computed tomography (CT) or magnetic resonance imaging (MRI) in order to enhance effectiveness and safety has been widely adopted. A novel imaging approach--intraprocedural rotational angiography and reconstruction of the left atrium and PVs--is feasible and provides high anatomic accuracy. OBJECTIVE The purpose of this study was to prove the feasibility, safety, and efficacy of this imaging approach as a single navigation tool for PV isolation. METHODS Forty-four patients (25 men and 19 women; age 57 +/- 11 years) with atrial fibrillation (AF) who presented for PV isolation were studied. Rotational angiography during adenosine-induced ventricular asystole was performed under sedation with propofol. The left atrium and PVs were reconstructed by three-dimensional atriography using specialized software (EP navigator prototype, Philips Medical Systems). Three-dimensional atriography was used as a single navigation tool for guiding PV isolation. RESULTS Of 176 PVs, 174 (99%) were isolated. Total procedural and fluoroscopy times were 192 +/- 46 minutes and 44 +/- 12 minutes, respectively. During follow-up of 6 +/- 3 months, 31 (70%) patients were free of symptoms and had no evidence of AF without any antiarrhythmic medication. MRI examination of 41 patients at 3-month follow-up excluded PV stenosis. No major complications occurred. CONCLUSION Three-dimensional atriography is a novel intraprocedural three-dimensional imaging technique that is based on rotational angiography. It can be safely and effectively used as a single navigation tool for performing PV isolation.

Intraprocedural Imaging of Left Atrium and Pulmonary Veins: A Comparison Study between Rotational Angiography and Cardiac Computed Tomography

Background: Atrial fibrillation (AF) ablation is facilitated by anatomical visualization of the left atrium (LA) and the pulmonary veins (PVs). The purpose of this study was to compare accuracy, radiation exposure, and costs between three‐dimensional atriography (3D‐ATG) and cardiac computed tomography (CCT).

Ectopic atrial tachycardias with early activation at His site: radiofrequency ablation through a retrograde approach

AIMS The purpose of this study was to evaluate a retrograde approach for radiofrequency (RF) ablation of ectopic atrial tachycardias (EATs) with an early atrial activation at the His site. METHODS AND RESULTS This study included 12 patients with EAT. During tachycardia, earliest atrial activation was recorded at the His site at a standard catheter setting. Activation mapping was performed in the right atrium and along the mitral annulus and at the aortic root after retrograde insertion of the ablation catheter over the ascending aorta. In five patients, earliest atrial activation was recorded at the mitral annulus (in two patients at the superior-lateral annulus and in three patients at the inferior-medial annulus). In four of these patients, EAT could be successfully treated by RF ablation through the retrograde approach, whereas in one patient, a transseptal puncture was performed in order to achieve a stable catheter position. In seven patients, RF ablation at the non-coronary aortic sinus eliminated the tachycardia. During a follow-up period of 14 +/- 8 months, there was no tachycardia recurrence. CONCLUSION In patients with EATs and early atrial activation at the His site, tachycardia may arise in the non-coronary aortic sinus or from the mitral annulus. Radiofrequency energy ablation can be performed through a retrograde approach in the majority of these patients and is safe and effective in eliminating this type of tachycardia.

Cost-Effectiveness of Paclitaxel-Coated Balloon Angioplasty in Patients With Drug-Eluting Stent Restenosis

The economic impact of drug‐eluting stent (DES) in‐stent restenosis (ISR) is substantial, highlighting the need for cost‐effective treatment strategies.

Left Ventricular Cardiac Hemangioma Presenting With Atypical Chest Pain

A 54-year-old male patient presented with atypical chest pain and exertional dyspnea. The physical examination and chest x-ray were unremarkable; the ECG showed sinus rhythm with left-axis deviation and a pathological Sokolow-Index with concomitant ST-depression in leads I, aVL, and V5–V6. Transthoracic echocardiography revealed the presence of a homogenously echodense, mobile left ventricular mass (dimensions: 15×12 mm) attached to the intraventricular septum (Figure, E). Cardiac magnetic resonance imaging was performed for tissue characterization: On T1-weighted imaging (Figure, A), the mass was isointense compared with the left ventricular myocardium, whereas on T2-weighted imaging (Figure, B), homogeneously bright signal intensity was found. No signs of infiltrative growth were seen. During first-pass infusion of a gadolinium-containing contrast agent, no relevant signal intensity increase could be detected; however, on postcontrast imaging (delayed enhancement technique), some contrast agent uptake was detected. Figure. A, T1-weighted imaging with fast-spin echo and blackblood suppression in 4-chamber view. The tumor has an intermediate signal …

Incidence of MRI-detected brain lesions and neurocognitive function after electrical cardioversion in anticoagulated patients with persistent atrial fibrillation

BACKGROUND After electrical cardioversion (eCV) in patients with atrial fibrillation (AF), the risk for clinically apparent cerebral thromboembolism is increased in the subsequent weeks. To date, there is little evidence on the incidence of acute brain lesions (ABL) detected with cerebral magnetic resonance imaging (MRI) after eCV, in particular in patients treated with the Non-Vitamin K Antagonist oral anticoagulants (NOAC). AIMS The aim of this pilot study was to evaluate the incidence of MRI-detected ABL, as well as the neuro-cognitive function after eCV in patients with persistent AF using NOACs as compared to phenprocoumon. METHODS AND RESULTS 50 consecutive patients with persistent AF (mean age 69.6±3.5years, 26 male) were evaluated in this prospective study. Cerebral 3Tesla MRI and neuro-cognitive assessment using the National Institutes of Health Stroke Scale (NIHSS) score and the Montreal Cognitive Assessment Test (MoCA) were performed in all patients within 24h before eCV and after a median follow-up duration of 14days (Q1: 13, Q3: 19days). Patients were treated with an OAC for at least 4weeks after eCV and according to the CHA2DS2-Vasc-score thereafter. Thirty-nine patients were treated with NOACs (Dabigatran 10/50 [20%], Apixaban 21/50 [42%] and Rivaroxaban 8/50 [16]) and 11/50 patients with Phenprocoumon (22%). No patient developed ABL on cerebral MRI at the 2-week follow-up. Neurological as well as cognitive function were similar before and 2weeks after eCV (NIHSS-score: p=0.35; MoCa score: p=0.21). CONCLUSION Electrical CV in patients with persistent AF, in particular when treated with NOACs, carries a low risk for the development of MRI-detected ABL or neurocognitive decline. CLINICAL TRIALS REGISTRATION GermanClinicalTrialsRegister number: DRKS00010460.

Electromagnetic Interference of Avalanche Transceivers with Cardiac Pacemakers and Implantable Cardioverter Defibrillators

Avalanche transceivers are essentials tools in locating persons who were buried by an avalanche. In the past few years, avalanche transceivers have become widely available and affordable, but it is largely unknown whether they are a source of electromagnetic interference for implanted cardiac devices. We aimed to determine the potential interaction between avalanche transceivers and pacemakers or implantable cardioverter defibrillators (ICDs).

[Magnetic resonance imaging and implantable cardiac devices. Current status and future perspectives of MR-compatible systems].

ZusammenfassungKonventionelle Herzschrittmacher und implantierbare Cardioverter-Defibrillatoren (ICD) galten lange Zeit als Kontraindikation für die Magnetresonanztomographie (MRT). Die Entwicklung von MR-kompatiblen Systemen stellt eine wichtige Innovation dar, da sie für Device-Patienten den Zugang zu MR-Untersuchungen deutlich verbessert. Die gefahrlose Anwendung der MR-kompatiblen Technologie erfordert allerdings ein detailliertes Verständnis der streng definierten kardiologischen und radiologischen Rahmenbedingungen, die im Vorfeld und während der Durchführung einer MR-Untersuchung einzuhalten sind. Der vorliegende Artikel gibt einen Überblick über problematische MR-Interaktionen mit implantierten Devices, erläutert die wesentlichen Aspekte MR-kompatibler Schrittmacher- und ICD-Systeme, analysiert deren aktuellen klinischen Stellenwert und bietet einen kritischen Ausblick.AbstractConventional pacemakers and implantable cardioverter-defibrillators (ICD) have always been regarded as a contraindication to magnetic resonance imaging (MRI). MR-compatible systems represent a recent and particularly important innovation, since they will provide device patients with significantly improved access to MR examinations. However, the safe application of MR-compatible technology requires a detailed understanding of the strictly defined cardiologic and radiologic requirements and conditions that are to be adhered to before and during an MR examination. The present article gives an overview of problematic MR interactions with implanted devices, illustrates the most important aspects of MR-compatible pacemaker and ICD systems, analyzes their current clinical status, and offers a critical perspective.Conventional pacemakers and implantable cardioverter-defibrillators (ICD) have always been regarded as a contraindication to magnetic resonance imaging (MRI). MR-compatible systems represent a recent and particularly important innovation, since they will provide device patients with significantly improved access to MR examinations. However, the safe application of MR-compatible technology requires a detailed understanding of the strictly defined cardiologic and radiologic requirements and conditions that are to be adhered to before and during an MR examination. The present article gives an overview of problematic MR interactions with implanted devices, illustrates the most important aspects of MR-compatible pacemaker and ICD systems, analyzes their current clinical status, and offers a critical perspective.