Verena Tscholl

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.

Heart rate following short‐term beta‐blocker titration predicts all‐cause mortality in elderly chronic heart failure patients: insights from the CIBIS‐ELD trial

Beta‐blockers (BBs) improve outcomes in heart failure. Results from the Cardiac Insufficiency Bisoprolol Study in Elderly (CIBIS‐ELD) trial previously demonstrated the feasibility of heart rate, not maximum dose, as a treatment goal. In this pre‐specified analysis, we investigated the prognostic value of achieved heart rate after BB optimization on long‐term mortality.

Should procalcitonin be measured routinely in acute decompensated heart failure

AIM To elucidate the prognostic role of procalcitonin (PCT) in patients with acute decompensated heart failure (ADHF) without clinical signs of infection at admission. MATERIALS & METHODS Serial measurements of PCT and NT-proBNP were performed in 168 patients, aged 68 ± 10 years with ADHF followed by 3-month outcome evaluation. RESULTS Cox regression analysis demonstrated significant predictive value of baseline PCT for all-cause death/hospitalization (area under the curve: 0.67; p = 0.013) at 90th day. The patients with persistently elevated PCT or with an increase during the first 72 h of hospitalization had the worst prognosis (p = 0.0002). CONCLUSION Baseline and serial in-hospital measurements of PCT have significant prognostic properties for 3-month all-cause mortality/hospitalization in patients with ADHF without clinical signs of infection at admission.

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.

N-terminal pro-B-type natriuretic peptide and long-term mortality in non-ischaemic cardiomyopathy

ZusammenfassungZIEL: N-Terminales Pro-B-Typ Natriuretisches Peptid (NT-proBNP) ist ein starker Prädiktor für Sterblichkeit bei Patienten mit akuter und chronischer Herzinsuffizienz bedingt durch eine ischämische Herzerkrankung. Hingegen ist die prognostische Aussagekraft bei Patienten mit nicht-ischämischer Herzerkrankung weit weniger etabliert. Wir haben daher den Zusammenhang von NT-proBNP Serumspiegeln und Langzeit-Sterblichkeit von Patienten mit nicht-ischämischer Kardiomyopathie untersucht. METHODEN: Bei 156 Patienten, die sich mit einer invasiv gesicherten nicht-ischämischen Herzinsuffizienz in unserer Klinik vorstellten, wurden die NT-proBNP Serumspiegel bestimmt. Die Gesamtsterblichkeitsrate wurde im Rahmen eines mittleren Beobachtungszeitraums von 8.9 Jahren erhoben. ERGEBNISSE: Unter Verwendung eines proportionalen Cox Risiko Models konnte in multivariaten Analysen NT-proBNP und der linksventrikuläre diastolische Durchmesser als Prädiktoren für kardial bedingte Sterblichkeit mit einer geschätzten Hazard Ratio von 2.76 (95 % KI: 1.53, 4.98) und 1.06 (95 % KI: 1.02, 1.10) beobachtet werden. SCHLUSSFOLGERUNG: In dieser bisher längsten Nachbeobachtung eignete sich NT-proBNP auch bei Patienten mit nicht-ischämischer Kardiomyopathie als Risikoprädiktor für Sterblichkeit und war einer Beurteilung nach der New York Heart Association Klasse und der linksventrikulären Ejektionsfraktion überlegen.SummaryAIM: The inactive N-terminal fragment of B-type natriuretic peptide is a strong predictor of mortality among patients with acute and chronic heart failure secondary to ischaemic heart disease. Its prognostic utility in patients with non-ischaemic heart disease is not well established. We therefore assessed the relationship of N-terminal proBNP levels and long-term mortality in patients with non-ischaemic cardiomyopathy. METHODS: N-terminal proBNP was measured in serum samples of 156 patients who presented to a single academic centre with worsening heart failure secondary to non-ischaemic cardiomyopathy. The rate of death from all causes was determined after a mean follow-up of 8.9 years. RESULTS: Multivariate analyses, using Cox proportional hazards models, established NT-proBNP and left ventricular diastolic diameter as predictors for cardiac mortality with estimated hazard ratios of 2.76 (95% confidence interval: 1.53, 4.98) and 1.06 (95% confidence interval: 1.02, 1.10), respectively. CONCLUSION: This to date longest-term analysis of N-terminal proBNP and mortality in patients with proven non-ischaemic cardiomyopathy confirms this cardiac-specific biomarker as powerful, independent risk predictor. It is a superior prognostic determinant to New York Heart Association functional class and left ventricular ejection fraction.

What is the real recurrence rate after cryoballoon-based pulmonary vein isolation? Lessons from rhythm follow-up based on implanted cardiac devices with continuous atrial monitoring

BACKGROUND Second-generation cryoballoon (CB2)-based pulmonary vein isolation (PVI) has demonstrated encouraging clinical results for the treatment of paroxysmal atrial fibrillation (AF) and persistent AF. However, rhythm follow-up after PVI is mainly based on Holter electrocardiography of limited duration. OBJECTIVE The purpose of this study was to assess the real AF burden following CB2-based PVI in patients with implanted cardiac devices. METHODS A total of 670 consecutive patients underwent CB2-based PVI at 3 electrophysiology centers. In 66 patients (9.9%), an implantable cardiac device with continuous monitor function was independently implanted before the procedure (device group). This patient cohort was compared to propensity score-matched patients without cardiac devices (n = 66; control group). RESULTS A total of 254 of 258 PVs (98.4%0 in the device group were successfully isolated using only CB2. Postprocedural device interrogation found no device or lead malfunction related to the procedure. Periprocedural complications were registered in 7 of 66 patients (11%) in the device group and in 6 of 66 patients (9%) in the control group (P = .770). Phrenic nerve palsy occurred in 6 of 66 patients (9%) in the device group) and in 2 of 66 patients (3%) in the control group) (P = .274). Clinical success in terms of freedom from AF recurrence after a 1-year follow-up period was 63.8% (95% confidence interval 53-77) in the device group and 77.3% (95% confidence interval 68-88) in the control group (P = .038). In the device group, AF/AT burden decreased from 41.8% ± 35.0% before the procedure to 10.2% ± 22.4% after 1 year (P <.0001). CONCLUSION CB2-PVI seems safe and feasible in patients with an implanted cardiac device. A significantly higher AF/AT burden was seen in patients with an implanted cardiac device compared to a control group.

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, …