P. Sommer

Catheter Ablation of Scar-Related Ventricular Tachycardia in Patients with Electrical Storm Using Remote Magnetic Catheter Navigation

Background: A remote magnetic navigation system (MNS) has been used for ablation of ventricular arrhythmias. However, irrigated tip catheter has not been evaluated in large series of patients.

Enhancement of intracardiac navigation by new GPS-guided location system (MediGuide Technologies)

Ventricular tachycardia in patients with structural heart disease is a clinical relevant arrhythmogenic disorder. Many of these patients require a combination of implantable cardioverter-defibrillator (ICD) for prevention of sudden cardiac death with antiarrhythmic medications to decrease the frequency of ventricular tachycardia (VT) episodes. However, ICD cannot prevent arrhythmia episodes and medication has only limited efficacy and in relevant number of patients it has to be discontinued due to multiple side effects. Severalreportsinthelastdecadehaveshownthatinpatientswith frequently recurrent ventricular arrhythmia episodes catheter ablation can be a highly effective therapy as an adjunct to ICD and/or medical treatment. In addition, the SMASH-VT and VTACH trials demonstrates, that prophylactic VT ablation results in a prolonged time to recurrence of VT in patients with stable VT, previous myocardial infarction, and reduced left ventricular ejection fraction. 1,2 According to this data it is hardlysurprising that, besides atrialfibrillation ablation, treatment of ventricular tachycardia is the next big frontier in the field of interventional therapy of cardiac arrhythmias. However, management of ventricular tachycardia is still challenging driven by a complex three-dimensional substrate. Successful treatment requires a comprehensive understanding and visualization of cardiac anatomy and electrical activation. Beside conventional fluoroscopy, 3-D electromagnetic mapping systems have been introduced to facilitate catheter navigation. Currently used techniques have some weaknesses. For instance, fluoroscopy provides only two-dimensional information, where it is difficult to repeatedly guide the catheter to the same area of interest. Thus, with prolonged procedures there is an increased X-ray exposure, adding risk for both the patient and the physician. One limitation of available 3-D-mapping system is failing to sufficiently compensate for respiratory, cardiac cycle, and patient movement and the limited integration on fluoroscopy. Recently, a new intracardiac navigation system (MediGuide TM System) was introduced to overcome this limitation and to merge the key benefits of fluoroscopy and 3-D-mapping system in a unique manner. In the following we are going to introduce this technology and present potential implications on interventional treatment of ventricular arrhythmias.

[Non-fluoroscopic catheter tracking: the MediGuide™ system].

ZusammenfassungIn der Visualisierung von diagnostischen und therapeutischen EP-Kathetern standen bislang die konventionelle Durchleuchtung und 3-D-Mappingsysteme als unabhängige Modalitäten zur Verfügung. Eine neue technologische Plattform (MediGuide™) ermöglicht es nun, eine strahlungsfreie Katheterdarstellung projiziert auf kurze Fluoroskopie-Loops zu erreichen, wodurch die räumliche Auflösung der 3-D-Mappingsysteme mit einer fluoroskopischen Darstellung der Katheter kombiniert werden kann. Zudem kann durch Unterlegung mit Angiographien eine permanente Visualisierung der anatomischen Zielstruktur gewährleistet werden. Wir berichten über die Erfahrungen mit der weltweit ersten MediGuide™-Anlage für die verschiedenen Indikationsfelder in der Elektrophysiologie. Vom typischen Vorhofflattern über Vorhofflimmern bis hin zu ventrikulären Tachykardien und der Implantation von LV-Elektroden im Rahmen von CRT-Implantationen. In einem ersten Schritt konnte unter der Verwendung von diagnostischen Kathetern gezeigt werden, dass sich die Durchleuchtungszeiten bereits dramatisch reduzieren ließen. Die Prozedurdauer wurde nicht wesentlich erhöht und auch eine Zunahme der Komplikationsrate wurde nicht verzeichnet. Seit Mai 2012 sind auch Ablationskatheter mit der MediGuide™-Technologie verfügbar und erste vollständig nicht fluoroskopische Ablationsprozeduren sind erfolgt.AbstractConventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide™) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide™ equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.Conventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide(™)) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide(™) equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.

Nicht fluoroskopische Katheternavigation: das MediGuide™-System

ZusammenfassungIn der Visualisierung von diagnostischen und therapeutischen EP-Kathetern standen bislang die konventionelle Durchleuchtung und 3-D-Mappingsysteme als unabhängige Modalitäten zur Verfügung. Eine neue technologische Plattform (MediGuide™) ermöglicht es nun, eine strahlungsfreie Katheterdarstellung projiziert auf kurze Fluoroskopie-Loops zu erreichen, wodurch die räumliche Auflösung der 3-D-Mappingsysteme mit einer fluoroskopischen Darstellung der Katheter kombiniert werden kann. Zudem kann durch Unterlegung mit Angiographien eine permanente Visualisierung der anatomischen Zielstruktur gewährleistet werden. Wir berichten über die Erfahrungen mit der weltweit ersten MediGuide™-Anlage für die verschiedenen Indikationsfelder in der Elektrophysiologie. Vom typischen Vorhofflattern über Vorhofflimmern bis hin zu ventrikulären Tachykardien und der Implantation von LV-Elektroden im Rahmen von CRT-Implantationen. In einem ersten Schritt konnte unter der Verwendung von diagnostischen Kathetern gezeigt werden, dass sich die Durchleuchtungszeiten bereits dramatisch reduzieren ließen. Die Prozedurdauer wurde nicht wesentlich erhöht und auch eine Zunahme der Komplikationsrate wurde nicht verzeichnet. Seit Mai 2012 sind auch Ablationskatheter mit der MediGuide™-Technologie verfügbar und erste vollständig nicht fluoroskopische Ablationsprozeduren sind erfolgt.AbstractConventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide™) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide™ equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.Conventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide(™)) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide(™) equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.

[Therapeutic management of non-valvular atrial fibrillation. Update 2013].

ZusammenfassungJeder Zehnte der über 65-Jährigen in der westlichen Welt wird von Vorhofflimmern betroffen sein. Wichtigstes Ziel bei Patienten mit Vorhofflimmern ist die Verhinderung thrombembolischer Komplikationen durch eine suffiziente und am Risikoprofil (CHA2DS2-Vasc-Score) des Patienten ausgerichtete Antikoagulation sowie die Behandlung zusätzlicher kardiovaskulärer Erkrankungen. Der Leidensdruck bestimmt das weitere Therapiekonzept. Dabei kann der/die behandelnde Arzt/Ärztin eine frequenzkontrollierende Strategie mit einer maximalen Ruheherzfrequenz von 110/min und/oder rhythmuserhaltende Methoden wie Kardioversion, Antiarrhythmika und Katheterablation einsetzen, um die Symptome des Patienten zu mindern. Inwiefern der Erhalt des Sinusrhythmus bei Vorhofflimmerpatienten die Prognose verbessert, wird in laufenden Studien derzeit untersucht.AbstractIn western countries one in ten of elderly persons (> 65 years old) will develop atrial fibrillation. The main goal in atrial fibrillation therapy is the prophylaxis of thromboembolic complications through anticoagulation according to the individual risk profile (CHA2DS2-Vasc score) of patients and treatment of cardiovascular comorbidities. Symptoms during atrial fibrillation guide the further therapeutic concept. Doctors can deploy a rate control strategy with a heart rate at rest less than 110/min and/or a rhythm control strategy with cardioversion, antiarrhythmic drugs and catheter ablation to alleviate complaints. To what extent maintaining the sinus rhythm improves the prognosis of atrial fibrillation patients is part of ongoing trials.In western countries one in ten of elderly persons (> 65 years old) will develop atrial fibrillation. The main goal in atrial fibrillation therapy is the prophylaxis of thromboembolic complications through anticoagulation according to the individual risk profile (CHA2DS2-Vasc score) of patients and treatment of cardiovascular comorbidities. Symptoms during atrial fibrillation guide the further therapeutic concept. Doctors can deploy a rate control strategy with a heart rate at rest less than 110/min and/or a rhythm control strategy with cardioversion, antiarrhythmic drugs and catheter ablation to alleviate complaints. To what extent maintaining the sinus rhythm improves the prognosis of atrial fibrillation patients is part of ongoing trials.

Structured pain management reduces patient discomfort after catheter ablation and rhythm device surgery

The goal was to test the effectiveness of a structured pain management programme after invasive electrophysiological interventions in cardiology including ablation of atrial fibrillation (AF) or ventricular tachycardia (VT) and implantation, or explantation, of pacemakers or implantable cardioverter defibrillators.

[Long-term results of catheter ablation of atrial fibrillation: cure or just palliation?].

Knowing the pitfalls when evaluating the long-term results after catheter ablation of atrial fibrillation enables a critical analysis of the outcome presented in numerous studies on this topic. Nevertheless, catheter ablation is a long-term successful and safe therapeutic procedure for symptomatic atrial fibrillation, especially for patients with paroxysmal atrial fibrillation. In patients with persistent symptomatic atrial fibrillation, the decision for ablation has to be made with caution due to a higher recurrence rate and higher likelihood for multiple procedures.ZusammenfassungDie Kenntnis über die Stolpersteine bei der Beurteilung von Langzeitergebnissen nach der Ablationsbehandlung von Vorhofflimmern ermöglicht ein kritisches Hinterfragen der in Studien erzielten Resultate. Dennoch ist die Katheterablation ein sicheres und langfristig zielführendes Verfahren bei der Therapie des symptomatischen Vorhofflimmerns v. a. für Patienten mit paroxysmalem Vorhofflimmern. Bei Patienten mit persistierendem symptomatischem Vorhofflimmern muss die Entscheidung zur Ablationsbehandlung aufgrund der höheren Rezidivraten und häufigeren Notwendigkeit wiederholter Eingriffe mit Bedacht getroffen werden.AbstractKnowing the pitfalls when evaluating the long-term results after catheter ablation of atrial fibrillation enables a critical analysis of the outcome presented in numerous studies on this topic. Nevertheless, catheter ablation is a long-term successful and safe therapeutic procedure for symptomatic atrial fibrillation, especially for patients with paroxysmal atrial fibrillation. In patients with persistent symptomatic atrial fibrillation, the decision for ablation has to be made with caution due to a higher recurrence rate and higher likelihood for multiple procedures.

Patientenselektion zur Katheterablation von Vorhofflimmern: von paroxysmal bis lang andauernd

Atrial fibrillation (AF) is the arrhythmia that causes most arrhythmia-associated hospitalisations in the western world. In Germany it affects approximately 3 million people. The limited success rates of drug treatment stimulated an exploration of interventional treatment options for AF. As our knowledge on initiating triggers and perpetuating substrate of AF expanded, catheter ablation techniques have been developed. In this article we review the patient selection criteria according to the current guidelines, and discuss established and recently found risk factors for recurrences of AF and complications by catheter ablation that may influence current patient selection for catheter ablation of AF.

Therapeutisches Management des nichtvalvulären Vorhofflimmerns

ZusammenfassungJeder Zehnte der über 65-Jährigen in der westlichen Welt wird von Vorhofflimmern betroffen sein. Wichtigstes Ziel bei Patienten mit Vorhofflimmern ist die Verhinderung thrombembolischer Komplikationen durch eine suffiziente und am Risikoprofil (CHA2DS2-Vasc-Score) des Patienten ausgerichtete Antikoagulation sowie die Behandlung zusätzlicher kardiovaskulärer Erkrankungen. Der Leidensdruck bestimmt das weitere Therapiekonzept. Dabei kann der/die behandelnde Arzt/Ärztin eine frequenzkontrollierende Strategie mit einer maximalen Ruheherzfrequenz von 110/min und/oder rhythmuserhaltende Methoden wie Kardioversion, Antiarrhythmika und Katheterablation einsetzen, um die Symptome des Patienten zu mindern. Inwiefern der Erhalt des Sinusrhythmus bei Vorhofflimmerpatienten die Prognose verbessert, wird in laufenden Studien derzeit untersucht.AbstractIn western countries one in ten of elderly persons (> 65 years old) will develop atrial fibrillation. The main goal in atrial fibrillation therapy is the prophylaxis of thromboembolic complications through anticoagulation according to the individual risk profile (CHA2DS2-Vasc score) of patients and treatment of cardiovascular comorbidities. Symptoms during atrial fibrillation guide the further therapeutic concept. Doctors can deploy a rate control strategy with a heart rate at rest less than 110/min and/or a rhythm control strategy with cardioversion, antiarrhythmic drugs and catheter ablation to alleviate complaints. To what extent maintaining the sinus rhythm improves the prognosis of atrial fibrillation patients is part of ongoing trials.In western countries one in ten of elderly persons (> 65 years old) will develop atrial fibrillation. The main goal in atrial fibrillation therapy is the prophylaxis of thromboembolic complications through anticoagulation according to the individual risk profile (CHA2DS2-Vasc score) of patients and treatment of cardiovascular comorbidities. Symptoms during atrial fibrillation guide the further therapeutic concept. Doctors can deploy a rate control strategy with a heart rate at rest less than 110/min and/or a rhythm control strategy with cardioversion, antiarrhythmic drugs and catheter ablation to alleviate complaints. To what extent maintaining the sinus rhythm improves the prognosis of atrial fibrillation patients is part of ongoing trials.

Therapeutisches Management des nichtvalvulären Vorhofflimmerns@@@Therapeutic management of non-valvular atrial fibrillation: Update 2013@@@Update 2013

ZusammenfassungJeder Zehnte der über 65-Jährigen in der westlichen Welt wird von Vorhofflimmern betroffen sein. Wichtigstes Ziel bei Patienten mit Vorhofflimmern ist die Verhinderung thrombembolischer Komplikationen durch eine suffiziente und am Risikoprofil (CHA2DS2-Vasc-Score) des Patienten ausgerichtete Antikoagulation sowie die Behandlung zusätzlicher kardiovaskulärer Erkrankungen. Der Leidensdruck bestimmt das weitere Therapiekonzept. Dabei kann der/die behandelnde Arzt/Ärztin eine frequenzkontrollierende Strategie mit einer maximalen Ruheherzfrequenz von 110/min und/oder rhythmuserhaltende Methoden wie Kardioversion, Antiarrhythmika und Katheterablation einsetzen, um die Symptome des Patienten zu mindern. Inwiefern der Erhalt des Sinusrhythmus bei Vorhofflimmerpatienten die Prognose verbessert, wird in laufenden Studien derzeit untersucht.AbstractIn western countries one in ten of elderly persons (> 65 years old) will develop atrial fibrillation. The main goal in atrial fibrillation therapy is the prophylaxis of thromboembolic complications through anticoagulation according to the individual risk profile (CHA2DS2-Vasc score) of patients and treatment of cardiovascular comorbidities. Symptoms during atrial fibrillation guide the further therapeutic concept. Doctors can deploy a rate control strategy with a heart rate at rest less than 110/min and/or a rhythm control strategy with cardioversion, antiarrhythmic drugs and catheter ablation to alleviate complaints. To what extent maintaining the sinus rhythm improves the prognosis of atrial fibrillation patients is part of ongoing trials.In western countries one in ten of elderly persons (> 65 years old) will develop atrial fibrillation. The main goal in atrial fibrillation therapy is the prophylaxis of thromboembolic complications through anticoagulation according to the individual risk profile (CHA2DS2-Vasc score) of patients and treatment of cardiovascular comorbidities. Symptoms during atrial fibrillation guide the further therapeutic concept. Doctors can deploy a rate control strategy with a heart rate at rest less than 110/min and/or a rhythm control strategy with cardioversion, antiarrhythmic drugs and catheter ablation to alleviate complaints. To what extent maintaining the sinus rhythm improves the prognosis of atrial fibrillation patients is part of ongoing trials.