Philipp Attanasio

Effects of deep sedation on cardiac electrophysiology in patients undergoing radiofrequency ablation of supraventricular tachycardia: impact of propofol and ketamine

AIMS Propofol is commonly used as an anaesthetic during catheter ablation. Bradycardia and termination of supraventricular tachycardia (SVT) under propofol are reported. Ketamine is used for cardiac catheterization procedures and increases heart rate and blood pressure. Our study aimed to determine the effects of propopfol and ketamine on atrial electrophysiology. METHODS AND RESULTS Thirty-one patients undergoing electrophysiological study prior to SVT ablation were enrolled. Patients received a combination of propofol/midazolam (n = 10), ketamine/midazolam (n = 9), or midazolam alone (n = 12). Electrophysiological study was performed before and after administration of the anaesthetic agents. Blood pressure, corrected sinus node recovery time, Wenckebach cycle length, and atrial conduction time were measured. We found a significant increase in heart rate, systolic, and diastolic blood pressure and a significant shortening of atrial conduction time after administration of ketamine compared with propofol and the control. Results for ketamine, propofol and the control, respectively: mean (SD) change in heart rate was 12.4 (8.3), -1.4 (8), and 1 (7.5) b.p.m. (P = 0.002); mean (SD) change in systolic blood pressure was 19.2 (8.1), -22 (9), and 0.1 (5.7) mmHg (P < 0.001); mean (SD) change in diastolic blood pressure was 6.6 (9.7), -7.8 (2.9), and 2.3 (4.5) mmHg (P = 0.001); and mean (SD) change in atrial conduction time was -13.7 (16.4), 4.5 (11.1), and -0.3 (3.8) ms (P = 0.008). No significant affection of sinus node or antrioventricular node function was seen. CONCLUSION Our results show stimulatory effects of ketamine on heart rate, atrial conduction, and blood pressure. Ketamine, therefore, may be beneficial in patients with pre-existing hypotension and bradycardia.

Clinical Significance of the Assessment of the Systolic and Diastolic Myocardial Function of the Left Atrium in Patients With Paroxysmal Atrial Fibrillation and Low CHADS2 Index Treated With Catheter Ablation Therapy

The purpose of this study was to determine the clinical significance of the assessment of the diastolic and systolic myocardial function of the left atrium in patients with paroxysmal atrial fibrillation (AF) and low CHADS(2) scores treated with catheter ablation therapy. In a cohort of 84 symptomatic patients with paroxysmal AF and low CHADS(2) scores (≤1), the clinical significance of the systolic and diastolic myocardial function of the left atrium (assessed using 2-dimensional speckle-tracking echocardiography) were studied to predict the risk for recurrence of AF after catheter ablation therapy in the course of a follow-up period of ≥1 year. During a mean follow-up period of 19.2 ± 5.4 months, patients with left atrial (LA) myocardial diastolic dysfunction (LA strain <18.8%) had a significantly higher rate of recurrence of AF (42.4% vs 9.8%, p <0.05) compared to those without LA diastolic dysfunction. In line with this finding, patients with impaired LA myocardial systolic function (LA strain rate >-0.85 s(-1)) had worse outcomes after catheter ablation therapy than those with normal LA systolic function (rate of recurrence of AF 42.9% vs 12.5%, respectively, p <0.05). In relation to these results, in a logistic regression analysis including co-morbidities, left ventricular dysfunction, LA enlargement, and LA myocardial alterations, diastolic and systolic LA myocardial dysfunction were the principal variable associated with the recurrence of AF (odds ratios 6.8 and 5.2, respectively). In conclusion, in symptomatic patients with paroxysmal AF and low CHADS(2) scores, these findings suggest that the assessment of diastolic and systolic LA myocardial function using 2-dimensional speckle-tracking echocardiography could be of great utility to distinguish those patients with high or low risk for recurrence of AF after catheter ablation therapy.

Hormonal consequences and prognosis of chronic heart failure.

Purpose of reviewChronic heart failure (CHF) is a major public health problem. The failure to provide peripheral tissues with sufficient amounts of oxygen is accompanied by maladaptive responses that include pathophysiological pathways that may lead to an anabolic–catabolic imbalance with the development of cardiac cachexia. This review aims to highlight players of the catabolic–anabolic imbalance, regulators or appetite, and other mediators that are involved in the progression of CHF to cachexia. Recent findingsClinical research has buttressed the view that deficiencies or resistance to growth hormone and testosterone plays an important role in the pathophysiology of CHF. The role of appetite regulation in the development of cardiac cachexia is also subject of recent studies. The resistance of CHF patients to the effects of appetite-stimulating peptide ghrelin may be one of the contributing factors. These circumstances drive muscle, bone, and fat wasting. Plasma levels of the adipokines leptin and adiponectin may have a role in the detection of such wasting processes. SummaryHormonal signaling pathways play an essential role in the development of cardiac cachexia. Recent findings enhance our understanding of the complex interplay between these regulators and may serve as a hub for the development of therapeutic interventions to prevent or potentially even to treat cardiac cachexia.

Role of Iron Deficiency and Anemia in Cardio-Renal Syndromes

Chronic heart failure is a common disorder associated with unacceptably high mortality rates. Chronic renal disease and anemia are two important comorbidities that significantly influence morbidity and mortality in patients with chronic heart failure (CHF). Progress in CHF again may cause worsening of kidney function and anemia. To describe this vicious cycle, the term cardio-renal anemia syndrome has been suggested. Iron deficiency is part of the pathophysiology of anemia in both CHF and chronic kidney disease, which makes it an interesting target for treatment of anemia in cardio-renal anemia syndrome. Recently, studies have highlighted the potential clinical benefits of treating iron deficiency in patients with CHF, even if these patients are nonanemic. This article summarizes studies investigating the influence of iron deficiency with or without anemia in chronic kidney disease and CHF and gives an overview of preparations of intravenous iron currently available.

Variations in the human soluble epoxide hydrolase gene and recurrence of atrial fibrillation after catheter ablation

BACKGROUND Single nucleotide polymorphisms (SNPs) of EPHX2 alter sEH activity and are associated with increased [rs41507953 (K55R)] or reduced [rs751141 (R287Q)] cardiovascular risk via modulation of fibrosis, inflammation or cardiac ion channels. This indicates an effect on development and therapy response of AF. This study tested the hypothesis that variations in the EPHX2 gene encoding human soluble epoxide hydrolase (sEH) are associated with atrial fibrillation (AF) and recurrence of atrial fibrillation after catheter ablation. METHODS AND RESULTS A total of 218 consecutive patients who underwent catheter ablation for drug refractory AF and 268 controls were included. Two SNPs, rs41507953 and rs751141, were genotyped by direct sequencing. In the ablation group, holter recordings 3, 12 and 24 months after ablation were used to detect AF recurrence. No significant association of the SNPs and AF at baseline was detected. In the ablation group, recurrence of AF occurred in 20% of the patients 12 months after ablation and in 35% 24 months after ablation. The presence of the rs751141 polymorphism significantly increased the risk of AF recurrence 12 months (odds ratio [OR]: 3.2, 95% confidence interval [CI]: 1.237 to 8.276, p=0.016) and 24 months (OR: 6.076, 95% CI: 2.244 to 16.451, p<0.0001) after catheter ablation. CONCLUSIONS The presence of rs751141 polymorphism is associated with a significantly increased risk of AF recurrence after catheter ablation. These results point to stratification of catheter ablation by genotype and differential use of sEH-inhibitory drugs in the future.

Management of Chronic Cardiorenal Syndrome

Patients with heart failure (HF) often have renal dysfunction and patients with kidney disease develop congestive HF, therefore the concept of cardiorenal syndromes evolved which can be a chronic or acute cardiorenal syndrome. Both chronic renal and heart disease share comorbidities like anemia which cause symptoms, disease progression and increase the risk of hospital admission and mortality. Even though there are clinical guidelines for managing both dysfunctions separately, patients with severe HF or severe kidney disease have often been excluded from clinical trials of the respective other disorder. We outline here a summary of the current state of the art of the clinical practice to manage patients with chronic cardiorenal syndrome using drug therapy. We will furthermore focus on that management of anemia and iron deficiency in particular as there have been recent advances.

Enhanced suicidal erythrocyte death in acute cardiac failure.

A common complication of acute cardiac failure (AHF) is anaemia, which negatively influences the clinical outcome. Causes of anaemia include enhanced eryptosis, a suicidal erythrocyte death characterized by cell shrinkage and cell membrane scrambling with phosphatidylserine translocation. Signalling triggering eryptosis include oxidative stress, increase of cytosolic Ca2+‐activity ([Ca2+]i) and ceramide. The present study explored whether AHF is associated with accelerated eryptosis.

Treatment of Nonagenarians With Atrial Fibrillation: Insights From the Berlin Atrial Fibrillation (BAF) Registry

OBJECTIVES The objective of this study was to determine course and treatment of atrial fibrillation (AF) in nonagenarians. Incidence of AF increases with age. Due to the demographic change in the industrialized world, an increase of AF in the group of elderly and very elderly is expected in the next decades. However, only few data exist on the clinical relevance of AF in patients aged 89 years or older. DESIGN Observational, mono-centric registry. SETTING University hospital. PARTICIPANTS Of the 11,888 patients included in the Berlin Atrial Fibrillation (BAF) Registry, 279 patients aged 89 years or older were identified. All patients presented to our hospital with AF between January 2001 and December 2014. MEASUREMENTS AF type, symptoms, comorbidities, CHA2DS2-VASc and HAS-BLED, treatment strategy, and anticoagulant treatment were assessed at baseline. A composite of stroke/transient ischemic attack (TIA), thromboembolic events, major bleeding, and death was the primary endpoint. Stroke/TIA, thromboembolic events and major bleeding, presence of AF, new onset of heart failure and change of NYHA class, and bradyarrhythmia necessitating pacemaker implantation were secondary endpoints. RESULTS Patients (age 92 ± 2.7 years, range 89-108) presented in EHRA class I in 38.4% of the cases, class II in 49.5%, class III in 10%, and class IV in 2%. Rhythm control was attempted in 37 (13.3%) of the patients. Baseline CHA2DS2-VASc and HAS-BLED were 5.0 ± 1.3 and 3.1 ± 0.9, respectively. Oral anticoagulation (OAC) was initiated in 74 (26.5 %) of the patients. Of all patients, 33 (11.8%) patients died in hospital. Of the remaining patients, 104 were followed over 13.8 ± 17.5 months with 3.5 ± 2.3 visits during follow-up. Rhythm control was attempted in 10 patients (9.6%). OAC was initiated in 37 patients (35.6 %). Fifty-nine (56.7%) patients reached the primary composite endpoint. Stroke/TIA (34.6%) and heart failure (49%) were common. Subgroup analysis revealed no significant differences in any of the endpoints between patients undergoing rhythm versus rate control and between patients under OAC compared with patients without OAC. INR at follow-up and TTR were 1.76 ± 1.0 and 29.5% ± 37.8% in patients receiving VKA. CONCLUSION In this real-world cohort of very elderly patients with AF, a rhythm control strategy and OAC treatment were chosen only in a minority of the cases. If OAC was initiated, most received VKAs with a poor TTR during follow-up. A high incidence of stroke/TIA was observed in patients with and without OAC. Further data are needed to define optimal treatment of AF in this particular patient group.

Treatment with Iron of Patients with Heart Failure With and Without Anemia

Iron deficiency is a common cause of anemia in otherwise healthy individuals and plays an important role in the development of anemia within the heart failure patient population. Iron-deficient heart failure patients experience worse symptoms and are less exercise tolerant than those without iron deficiency. These symptoms may occur even before clinical anemia is evident. This article reviews studies of the benefits of the use of intravenous iron to treat iron deficiency in anemic and nonanemic heart failure patients and an overview of the physiology and pathophysiology of iron metabolism in chronic heart failure.

Performance of the New BioMonitor 2-AF Insertable Cardiac Monitoring System: Can Better be Worse?: NEW BIOMONITOR 2-AF PERFORMANCE

Implantable loop recorders (ILR) are valuable tools for the investigation of patients with suspected arrhythmias. The BioMonitor 2‐AF is a novel insertable ILR with enhanced atrial fibrillation (AF) detection algorithm and remote monitoring capability.