Patrick Nagel

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.

Atrial standstill in sinus node disease due to extensive atrial fibrosis: impact on dual chamber pacemaker implantation.

AIMS Atrial standstill is characterized by the absence of atrial activity. We report about a series of cases, in which conventional atrial pacemaker lead implantation in patients with symptomatic sinus node disease failed due to lack of excitable right atrial tissue, thus, prompting the diagnosis of atrial standstill. We hypothesized that mapping of the atria with subsequent identification of myocardium still amenable to atrial pacing would allow dual chamber pacemaker implantation. METHODS AND RESULTS In four patients, atrial lead implantation failed. In these patients, spontaneous or fibrillatory electrical activity was absent but the atria could not be captured despite high stimulation voltages at conventional atrial sites. We suspected partial or complete atrial standstill and subsequently confirmed this hypothesis by conventional (n = 1) or electroanatomical mapping (n = 3). Areas of fibrotic tissue were present in all patients as identified by lack of spontaneous electrical activity and inability of local electrical capture via the mapping catheter. Surviving atrial tissue, which could be electrically captured with subsequent conduction of activity to the atrioventricular (AV) node, was present in three patients. Successful targeted atrial lead implantation at these sites was achieved in all these patients. Isolated sinus node activity without conduction to the atria was found in one patient. CONCLUSION Partial atrial standstill may be present and prevent atrial lead implantation in patients with sinus node disease. In these patients, recognition of partial atrial standstill and identification of surviving muscular islets with connection to the AV node by mapping studies may still allow synchronous AV sequential pacing.

Apixaban, rivaroxaban, and dabigatran use in patients undergoing catheter ablation for atrial fibrillation using the second-generation cryoballoon

Data are limited on the safety of periprocedural anticoagulation with novel oral anticoagulants (NOACs) in patients undergoing pulmonary vein isolation (PVI) using the second‐generation cryoballoon (CB) for the treatment of atrial fibrillation.

Successful intraprocedural anticoagulation with bivalirudin during pulmonary vein isolation in a patient with known heparin-induced thrombocytopenia type II

We report the case of a 56‐year‐old female who presented with symptomatic paroxysmal atrial fibrillation. Anamnestic heparin‐induced thrombocytopenia (HIT) type II was suspected, and a rapid diagnostic test showed antibodies against platelet factor 4. The heparin‐induced platelet activation‐assay was negative. Radiofrequency pulmonary vein isolation with intraprocedural anticoagulation using bivalirudin was ultimately performed. Dosing was controlled by monitoring the activated clotting time. Post‐procedural blood tests were normal. There were no thromboembolic or bleeding events. Bivalirudin is a therapeutic option for anticoagulation during pulmonary vein isolation procedures in patients with a history of HIT type II.

Wide QRS complex tachycardia in a patient with ischemic cardiomyopathy and prior ventricular tachycardia ablation

CASE REPORT This article reports the case of a 76-year-old patient with multiple implantable cardioverter defibrillator (ICD) interventions of the single chamber ICD. On admission the 12-lead electrocardiogram (ECG) documented a wide QRS complex tachycardia without clearly identifiable P waves. The patient had previously had two ventricular tachycardia (VT) ablations due to VT storms. The resting ECG revealed a sinus rhythm with a wide QRS complex. During the electrophysiological investigation typical atrial flutter could be detected and an ablation of the cavotricuspid isthmus was performed. During the follow-up period, the patient has been free from tachycardia. CONCLUSION The case described emphasizes that a differentiation between supraventricular tachycardia (SVT) and VT based on a stored ECG without an atrial channel can be challenging.

Cryoballoon ablation in the elderly: one year outcome and safety of the second-generation 28mm cryoballoon in patients over 75 years old

Aims The efficacy of the second-generation cryoballoon (CB) ablation in patients with atrial fibrillation (AF) has been demonstrated previously. Data on the efficacy of CB ablation in elderly patients is missing. The aim of this study was to evaluate the long-term success rate of pulmonary vein isolation (PVI) in patients ≥75 years vs. <75 years using the second-generation 28mm CB. Methods and results Eighty patients [n = 40 ≥75 years (Group 1); n = 40 <75 years (Group 2)] with paroxysmal [n = 37 (46%) or persistent (n = 43 (54%)] AF were included. Median follow-up was 12 [6;18] months (Group 1 vs. 13 [6;27]) months (Group 2; P = 0.8). PVI was performed in all patients using cryoablation. Follow-up was obtained using 24h-Holter monitoring or via an implanted loop recorder or pacemaker. CHA2DS2VASc-Score (Group 1: 4 [4;5] vs. Group 2: 2 [1;3], P < 0.001) and HASBLED-Score (Group 1: 2 [2;3] and Group 2: 2 [1;3], (P = 0.009)) differed significantly between the two groups. Mean fluoroscopy time was 22.9 [16.3;31.9] in Group 1 and 24.5 [19.1;30.6] in Group 2 (P = 0.75), and mean procedure time was 125 min [105;151] in Group 1 and 130.5 min [117.5;147.3] in Group 2 (P = 0.66). Arrhythmia recurrence was similar in Group 1 and Group 2 (12/40 (30%) vs. 10/40 (25%) (P = 0.62). One transient ischaemic attack occurred in Group 2. No further major complications were documented in this patients cohort. Conclusion CB ablation in patients ≥75 years has favourable success rates and similar complication rates compared with patients <75 years.

Bronchial Injury After Atrial Fibrillation Ablation Using the Second-Generation Cryoballoon

Cryoballon ablation of atrial fibrillation may be associated with bronchial damage, but the factors causing this are poorly characterized.1–5 Eleven consecutive patients were included in this prospective, single-center pilot study (German Clinical Trials Register No. DRKS00011273). All patients experienced paroxysmal (n=9; 82%) or persistent atrial fibrillation and were treated with the second-generation 28 mm cryoballon (Medtronic, Inc, Minneapolis, MN). The day after cryoballon ablation, a bronchoscopy was performed to assess for bronchial injury (BI) in all patients. In addition, body plethysmography was conducted before and after the procedure. The evaluations of the bronchoscopies were performed in a blinded fashion by 2 independent pulmonologists (R.-H.H., M.P.). This study conforms to the guiding principles of the Declaration of Helsinki of 2014 and was approved by the local ethics committee (EA/111/16). In all 11 patients (6 women; mean age, 66±8.8 years), pulmonary vein isolation (PVI) of all pulmonary veins (PVs) was successfully performed. Preexisting diseases were coronary artery disease (9.1%) and arterial hypertension (55%). The mean left atrial diameter was 50.4±7.2 mm. Five patients (45%) were under anticoagulation with apixaban and 6 (55%) with rivaroxaban. The mean CHA2DS2-Vasc Score was 1.9±1.1. The procedure was performed under deep sedation using propofol, midazolam, and fentanyl. All patients were breathing spontaneously. After transseptal puncture, anatomic localization of the PVs was identified with intravenous contrast injection under fluoroscopy. The Achieve catheter (Medtronic, …

Breitkomplex-Tachykardie bei einem Patienten mit ischämischer Kardiomyopathie und stattgehabter Ablation einer ventrikulären Tachykardie

CASE REPORT This article reports the case of a 76-year-old patient with multiple implantable cardioverter defibrillator (ICD) interventions of the single chamber ICD. On admission the 12-lead electrocardiogram (ECG) documented a wide QRS complex tachycardia without clearly identifiable P waves. The patient had previously had two ventricular tachycardia (VT) ablations due to VT storms. The resting ECG revealed a sinus rhythm with a wide QRS complex. During the electrophysiological investigation typical atrial flutter could be detected and an ablation of the cavotricuspid isthmus was performed. During the follow-up period, the patient has been free from tachycardia. CONCLUSION The case described emphasizes that a differentiation between supraventricular tachycardia (SVT) and VT based on a stored ECG without an atrial channel can be challenging.

Identification of active atrial fibrillation sources and their discrimination from passive rotors using electrographical flow mapping

BackgroundThe optimal ablation approach for the treatment of persistent atrial fibrillation (AF) is still under debate; however, the identification and elimination of AF sources is thought to play a key role. Currently available technologies for the identification of AF sources are not able to differentiate between active rotors or focal impulse (FI) and passive circular turbulences as generated by the interaction of a wave front with a functional obstacle such as fibrotic tissue.ObjectivesThis study introduces electrographic flow (EGF) mapping as a novel technology for the identification and characterization of AF sources in humans.MethodsTwenty-five patients with AF (persistent: n = 24, long-standing persistent: n = 1; mean age 70.0 ± 8.3 years, male: n = 17) were included in this prospective study. Focal impulse and Rotor-Mapping (FIRM) was performed in addition to pulmonary vein isolation using radiofrequency in conjunction with a 3D-mapping-system. One-minute epochs were exported from the EP-recording-system and re-analyzed using EGF mapping after the procedure.Results44 potential AF sources (43 rotors and one FI) were identified with FIRM and 39 of these rotors were targeted for ablation. EGF mapping verified 40 of these patterns and identified 24/40 (60%) as active sources while 16/40 (40%) were classified as passive circular turbulences. Four rotors were not identified by EGF mapping.ConclusionEGF is the first method to identify active AF sources during AF ablation procedures in humans and discriminate them from passive rotational phenomena, which occur if the excitation wavefront passes conduction bariers. EGF mapping may allow improved guidance of AF ablation procedures.

Prospective randomized study evaluating the effects of PerClot® (Polysaccharide Hemostatic System) application in patients with high bleeding risk undergoing cardiac rhythm device implantation

BACKGROUND Thus far, the topic hemostatic agent PerClot® is used for surgical procedures. Data about the use of PerClot® for cardiac-rhythm-devices (CRD) implantation are missing. The aim of this study was to evaluate the safety and efficacy of PerClot® in patients with high bleeding risk. METHODS AND RESULTS In this prospective randomized study we planned to include 150 patients admitted for CRD-Implantation receiving anticoagulation and/or dual-antiplatelet-therapy. Participants were randomized to receive PerClot® versus standard-of-care. The primary endpoint was the incidence of pocket hematoma. Safety endpoint was pocket infection. After a planned safety-interim-analysis the study was terminated early because of safety concerns. 51 patients were included. The two groups were comparable with regard to age (73±11years vs. 74±10years; p=0.71), CHA2DS2VASc (3.6±1.5 vs. 4.0±1.5; p=0.27) and HASBLED-Score (2.4±1.1 vs. 2.5±1.0; p=0.98), CRD or procedure type, anticoagulant or anti-platelet therapy. The use of PerClot® resulted in a higher incidence of postoperative fever (7 (28%) vs. 0 (0%); p=0.004), higher C-Reactive Protein (66.1±50.5mg/l vs. 25.9±22.5mg/l; p=0.002); and higher postoperative white blood cell count (13.5±4.3/nl vs. 8.8±2.6/nl; p<0.001). Hematoma formation did not differ significantly (p=0.14). Reoperation was not necessary in any patient. CONCLUSION This first randomized controlled study for the topical use of the hemostatic agent PerClot® in CRD implantation was terminated early by the safety monitoring board because of an augmented rate of fever and inflammatory markers in the PerClot® group. The addition of PerClot® does not suggest a benefit with regard to the frequency of pocket hematoma.