Patrick Müller

Acute and early outcomes of focal impulse and rotor modulation (FIRM)-guided rotors-only ablation in patients with nonparoxysmal atrial fibrillation

BACKGROUNDnFocal impulse and rotor modulation (FIRM)-guided ablation targets sites that are thought to sustain atrial fibrillation (AF).nnnOBJECTIVEnThe purpose of this study was to evaluate the acute and mid-term outcomes of FIRM-guided only ablation in patients with nonparoxysmal AF.nnnMETHODSnWe prospectively enrolled patients with persistent and long-standing persistent (LSP) AF at three centers to undergo FIRM-guided only ablation. We evaluated acute procedural success (defined as AF termination, organization, or ≥10% slowing), safety (incidence of periprocedural complications), and long-term success (single-procedure freedom from atrial tachycardia [AT]/AF off antiarrhythmic drugs [AAD] after a 2-month blanking period).nnnRESULTSnTwenty-nine patients with persistent (N = 20) and LSP (N = 9) AF underwent FIRM mapping. Rotors were presents in all patients, with a mean of 4 ± 1.2 per patient (62% were left atrial); 1 focal impulse was identified. All sources were successfully ablated, and overall acute success rate was 41% (0 AF termination, 2 AF slowing, 10 AF organization). There were no major procedure-related adverse events. After a mean 5.7 months of follow-up, single-procedure freedom from AT/AF without AADs was 17%.nnnCONCLUSIONnIn nonparoxysmal AF patients, targeted ablation of FIRM-identified rotors is not effective in obtaining AF termination, organization, or slowing during the procedure. After mid-term follow-up, the strategy of ablating FIRM-identified rotors alone did not prevent recurrence from AT/AF.

Higher incidence of esophageal lesions after ablation of atrial fibrillation related to the use of esophageal temperature probes

BACKGROUNDnEndoscopically detected esophageal lesions (EDELs) have been identified in apparently asymptomatic patients after catheter ablation of atrial fibrillation (AF). The use of esophageal probes to monitor luminal esophageal temperature (LET) during catheter ablation to protect esophageal damage is currently controversial.nnnOBJECTIVEnThe purpose of this study was to investigate the impact of the use of esophageal temperature probes during AF catheter ablation on the incidence of EDELs.nnnMETHODSnEighty consecutive patients (mean age 63.8 ± 11.36 years; 68.8% men) with symptomatic, drug-refractory paroxysmal (n = 52, 65%) or persistent AF who underwent left atrial radiofrequency catheter ablation were prospectively enrolled. Posterior wall ablation was power limited (≤25 W). In the first 40 patients, LET was monitored continuously (group A), whereas no esophageal temperature probe was used in group B (n = 40 patients). Assessment of EDEL was performed by endoscopy within 2 days after radiofrequency catheter ablation.nnnRESULTSnOverall, 13 patients (16%) developed EDELs after AF ablation. The incidence of EDELs was significantly higher in group A than group B (30% vs 2.5%, P < .01). Within group A, patients who developed EDEL had higher maximal LET during AF ablation than patients without EDEL (40.97 ± 0.92°C vs 40.14 ± 1.1°C, P = .02). Multivariable logistic regression analysis revealed the use of an esophageal temperature probe as the only independent predictor for the development of EDEL (odds ratio 16.7, P < .01).nnnCONCLUSIONnThe use of esophageal temperature probes in the setting of AF catheter ablation per se appears to be a risk factor for the development of EDEL.

Heart failure in severe aortic valve stenosis: prognostic impact of left ventricular ejection fraction and mean gradient on outcome after transcatheter aortic valve implantation.

This prospective study aimed to evaluate the prognostic impact of left ventricular ejection fraction (LVEF) and aortic mean gradient patterns on outcome after transcatheter aortic valve implantation (TAVI).

Nonthyroidal Illness Syndrome in Cardiac Illness Involves Elevated Concentrations of 3,5-Diiodothyronine and Correlates with Atrial Remodeling

Background: Although hyperthyroidism predisposes to atrial fibrillation, previous trials have suggested decreased triiodothyronine (T3) concentrations to be associated with postoperative atrial fibrillation (POAF). Therapy with thyroid hormones (TH), however, did not reduce the risk of POAF. This study reevaluates the relation between thyroid hormone status, atrial electromechanical function and POAF. Methods: Thirty-nine patients with sinus rhythm and no history of atrial fibrillation or thyroid disease undergoing cardiac surgery were prospectively enrolled. Serum concentrations of thyrotropin, free (F) and total (T) thyroxine (T4) and T3, reverse (r)T3, 3-iodothyronamine (3-T1AM) and 3,5-diiodothyronine (3,5-T2) were measured preoperatively, complemented by evaluation of echocardiographic and electrophysiological parameters of cardiac function. Holter-ECG and telemetry were used to screen for POAF for 10 days following cardiac surgery. Results: Seven of 17 patients who developed POAF demonstrated nonthyroidal illness syndrome (NTIS; defined as low T3 and/or low T4 syndrome), compared to 2 of 22 (p < 0.05) patients who maintained sinus rhythm. In patients with POAF, serum FT3 concentrations were significantly decreased, but still within their reference ranges. 3,5-T2 concentrations directly correlated with rT3 concentrations and inversely correlated with FT3 concentrations. Furthermore, 3,5-T2 concentrations were significantly elevated in patients with NTIS and in subjects who eventually developed POAF. In multivariable logistic regression FT3, 3,5-T2, total atrial conduction time, left atrial volume index and Fas ligand were independent predictors of POAF. Conclusion: This study confirms reduced FT3 concentrations in patients with POAF and is the first to report on elevated 3,5-T2 concentrations in cardiac NTIS. The pathogenesis of NTIS therefore seems to involve more differentiated allostatic mechanisms.

Safety and Effectiveness of a Novel Vascular Closure Device: A Prospective Study of the ExoSeal Compared to the Angio-Seal and ProGlide

Purpose: To prospectively assess the safety and efficacy of a novel absorbable vascular closure device (ExoSeal) in patients undergoing cardiac catheterization with femoral access compared to the established collagen-based (Angio-Seal) and suture-mediated (ProGlide) closure devices. Methods: This prospective, observational, dual-center, non-randomized, non-blinded study enrolled 1013 patients (65.1±11.8 years) undergoing cardiac catheterization via a common femoral artery access in which hemostasis was achieved using a vascular closure device (255 Angio-Seal, 258 ProGlide, and 500 ExoSeal). In hospital complications (bleeding, hematoma, pseudoaneurysm, vessel occlusion, dissection, and arteriovenous fistula) of the puncture site and device failures (persistent bleeding) were recorded and compared for ExoSeal vs. the established devices (Angio-Seal + ProGlide). Results: There were more complications after utilization of ExoSeal compared to established devices (3.6% vs. 1.2%, p=0.012). No significant difference was observed in the device success rate between the established vascular closure devices (96.3%) and the novel device (94.8%, p=0.28). Considering each closure system, Angio-Seal had the lowest complication rate (0.4%) and the highest efficacy (99.2%); the latter differed significantly from ExoSeal (94.8%, p=0.001). Logistic regression analysis revealed a >3-fold odds of complications when using ExoSeal, which remained unchanged in multivariate analysis. Conclusion: Utilization of the novel vascular closure device is associated with a higher complication rate and a similar device failure rate compared to collagen-based and suture-mediated devices, with Angio-Seal having the lowest complication and device failure rates.

Exchanging Catheters Over a Single Transseptal Sheath During Left Atrial Ablation is Associated with a Higher Risk for Silent Cerebral Events

Background Silent cerebral events (SCE) have been identified on magnetic resonance imaging (MRI) in asymptomatic patients after atrial fibrillation (AF) ablation. Procedural determinants influencing the risk for SCE still remain unclear. Objective Comparing the risk for SCE depending on exchanges of catheters (ExCath) over a single transseptal sheath. Methods 88 Patients undergoing pulmonary vein isolation (PVI) only ablation using either single-tip or balloon-based technique underwent pre- and post-ablation cerebral MRI. Ablations were either performed with double transseptal access and without exchanging catheters over the transseptal sheaths (group 1: no ExCath) or after a single transseptal access and exchanges of therapeutic and diagnostic catheters (group 2: ExCath). Differences in regard to SCE rates were analyzed. Multivariate analysis was performed to identify factors related to the risk for SCE. Results Included patients underwent PVI using single tip irrigated radiofrequency in 41, endoscopic laser balloon in 27 and cryoballoon in 20 cases. Overall SCE were identified in 23 (26%) patients. In group 1 (no ExCath; N=46) 6 patients (13%) and in group 2 (N=42) 17 patients (40%) had documented SCE (p=0.007). The applied ablation technology did not affect SCE rate. In multivariate analysis age (OR 1.1, p=0.03) and catheter exchanges over a single transseptal sheath (OR 12.1, p=0.007) were the only independent predictors of a higher risk for SCE. Conclusions Exchanging catheters over a single transseptal access to perform left atrial ablation is associated with a significantly higher incidence of SCE compared to an ablation technique using different transseptal accesses for therapeutic and diagnostic catheters.

Therapeutic implications of gender differences in supraventricular cardiac arrhythmias: lessons of life cannot be learned in a day

A steadily increasing number of catheter ablations to treat atrial arrhythmia are being performed each year. Interestingly, only a minor proportion of these patients are female, as indicated in recent reports. The reasons for this gender difference are difficult to explain and may be related to interand intra-gender differences in the occurrence and incidence of supraventricular tachycardias (SVTs), disparities in clinical presentation of male and female patients and gender-specific decisions for optimal therapy or differences in the efficacy of invasive therapy. In this context, it appears crucial that clinical electro physiologists increase their awareness of potential gender differences and their implications for making the correct diagnosis and selecting the optimal treatment [1–6].

Reverse Remodelling of the Atria After Treatment of Obstructive Sleep Apnoea with Continuous Positive Airway Pressure: Evidence from Electro-mechanical and Endocrine Markers

BACKGROUNDnRecent studies have suggested a strong association between obstructive sleep apnoea (OSA) and atrial fibrillation (AF). However, the impact of continuous positive airway pressure (CPAP) therapy on reverse atrial remodelling in patients with OSA is poorly understood. We aimed to determine the impact of CPAP therapy on total atrial conduction time measured by PA tissue Doppler imaging (TDI) interval in patients without history of AF.nnnMETHODS AND RESULTSnThirty-five patients with first diagnosed OSA (group 1) and 20 reference patients without OSA (group 2) were prospectively enrolled. Group 1 was divided into 25 patients with starting CPAP therapy (intervention group) and 10 patients without CPAP therapy (control group). PA-TDI interval, measured by tissue Doppler imaging, and B-type natriuretic-peptide (BNP) were determined at baseline and repeated after 30 days in group 1. Patients with OSA had a significantly longer PA-TDI interval (131.4±16.0 ms vs. 120.1±6.4 ms, p<0.001) compared to reference patients. PA-TDI interval shortened significantly after 30 days of CPAP therapy (131±17.1 ms vs. 124.6±15.7 ms, p<0.001), whereas no significant change was found in the control group (132.6±13.6 ms vs. 133.2±13.1 ms, p=0.31) and BNP-levels decreased significantly (39.1±50.7 pg/ml vs. 28.2±42.4 pg/ml, p<0.01), while BNP-levels remained unaffected after 30 days in control group (31.5±20 pg/ml vs. 34.4±20.5 pg/ml, p=0.41).nnnCONCLUSIONSnChange in PA-TDI interval, as an indirect surrogate marker of atrial remodelling, suggests reverse atrial remodelling in patients with OSA and treated by CPAP. This effect may ensue from decreased atrial pressure or volume overload, as indicated by significantly reduced BNP levels. These observations suggest that the substrate pre-disposing to AF may be reversible and moreover can be measured by PA-TDI interval and BNP.

Incidence of asymptomatic oesophageal lesions after atrial fibrillation ablation using an oesophageal temperature probe with insulated thermocouples: a comparative controlled study

AimsnOesophageal probes to monitor luminal oesophageal temperature (LET) during atrial fibrillation (AF) catheter ablation have been proposed, but their effects remain unclear. Aim of this study is to evaluate the effects of an oesophageal temperature probe with insulated thermocouples.nnnMethods and resultsnPatients with symptomatic, drug-refractory paroxysmal or persistent AF who underwent left atrial radiofrequency (RF) catheter ablation were prospectively enrolled. Patients were ablated using a single-tip RF contact force ablation catheter. An intraluminal oesophageal temperature probe was used in Group 1. In Group 2, patients were ablated without LET monitoring. Assessment of asymptomatic endoscopically detected oesophageal lesions (EDEL) was performed by oesophagogastroduodenoscopy (EGD) in all patients. Eighty patients (mean age 63.7 ± 10.7 years; men 56%) with symptomatic, drug-refractory paroxysmal (n = 28; 35%) or persistent AF were included. Group 1 and Group 2 patients (n = 40 in each group) were comparable in regard to baseline characteristics, but RF duration on the posterior wall was significantly shorter in Group 1 patients. Overall, seven patients (8.8%) developed EDEL (four ulcerations, three erythema). The incidence of EDEL in Group 1 and Group 2 patients was comparable (7.5 vs. 10%, P = 1.0). No major adverse events were reported in both groups.nnnConclusionnAccording to these preliminary results, the use of oesophageal temperature probes with insulated thermocouples seems to be feasible in patients undergoing AF RF catheter ablation. The incidence of post-procedural EDEL when using a cut-off of 39°C is comparable to the incidence of EDEL without using a temperature probe.

Reverse atrial remodeling in patients who maintain sinus rhythm after electrical cardioversion: evidence derived from the measurement of total atrial conduction time assessed by PA-TDI interval

BackgroundA key mechanism of atrial fibrillation (AF) is atrial remodeling. Total atrial conduction time non-invasively assessed via tissue Doppler imaging (PA-TDI interval) may reflect the degree of electrical and structural atrial remodeling. The purpose of this study was to determine whether the PA-TDI interval is an independent predictor of recurrent AF after successful electrical cardioversion (eCV) and if it suggests reverse atrial remodeling.MethodsFifty-one patients (meanxa0±xa0SD 66xa0±xa010.6xa0years; 35xa0% women) with persistent AF and successful eCV were prospectively enrolled. The PA-TDI interval was measured 6xa0h and 90xa0days post-cardioversion. AF relapse was determined via 7-day Holter-ECG immediately after eCV and repeated after 90xa0days.ResultsEarly recurrent AF (within 7xa0days) occurred in 21 patients (41.2xa0%), whereas after 90-day follow-up 26 patients (51xa0%) had AF recurrence. PA-TDI interval was longer in patients with AF recurrence within 90xa0days compared to patients who remained in sinus rhythm (SR) (149.1xa0±xa08.3 vs. 129.8xa0±xa010.9xa0ms, pxa0<xa00.0001). Optimal cut-off values for recurrent AF after 7 or 90xa0days from ROC analysis were 142 and 143xa0ms, respectively. Furthermore, the PA-TDI interval decreased significantly from baseline in those who remained in SR (129.8xa0±xa010.9 vs. 125.8xa0±xa010xa0ms, pxa0<xa00.0001), whereas the PA-TDI interval increased in patients who developed AF after 90xa0days (149.1xa0±xa08.3 vs. 152xa0±xa09xa0ms, pxa0<xa00.0001).ConclusionsThe PA-TDI interval is an independent predictor of early and mid-term AF recurrence after eCV. Moreover, our data suggests reverse atrial remodeling in those patients who remained in stable SR.