Pulmonary vein anatomy addressed by computed tomography and relation to success of second-generation cyroballoon ablation in paroxysmal atrial fibrillation

BACKGROUND: Cryoballoon isolation is considered a safe and effective treatment for atrial fibrillation (AF). However, recurrence of AF after first cryoballoon ablation occurs in ~30% of patients. Pre-procedurally identifying patients at risk of AF recurrence could be beneficial. HYPOTHESIS: Our aim was to determine how pulmonary vein (PV) anatomy influences the recurrence of AF using the second-generation cryoballoon in patients with paroxysmal AF. METHODS: We included 88 consecutive patients with paroxysmal AF undergoing PVI procedure with a second-generation 28-mm cryoballoon. All patients were evaluated at 3, 6 and 12 months using a 12-lead ECG and 24-hour Holter monitoring. Pulmonary vein (PV) anatomy was assessed by creating three dimensional models using computed tomography (CT) segmentations of the left atrium. RESULTS: Fifty-one patients (61%) had left PVs with a shared carina, 35 patients (42%) had a shared right carina. Nine patients (11%) were classified having a right middle PV. In total 17 (20.2%) of patients had a left common PV. At 12 months, 14 patients (17%) had experienced AF recurrence. Neither PV ovality, variant anatomy, the presence of shared carina nor a common left pulmonary vein was a predictor for AF recurrence. CONCLUSIONS: No specific characteristics of PV dimensions nor morphology were associated with AF recurrence after cryoballoon ablation in patients with paroxysmal AF. This article is protected by copyright. All rights reserved

The effect of electrical neurostimulation on collateral perfusion during acute coronary occlusion

<p>Abstract</p> <p>Background</p> <p>Electrical neurostimulation can be used to treat patients with refractory angina, it reduces angina and ischemia. Previous data have suggested that electrical neurostimulation may alleviate myocardial ischaemia through increased collateral perfusion. We investigated the effect of electrical neurostimulation on functional collateral perfusion, assessed by distal coronary pressure measurement during acute coronary occlusion. We sought to study the effect of electrical neurostimulation on collateral perfusion.</p> <p>Methods</p> <p>Sixty patients with stable angina and significant coronary artery disease planned for elective percutaneous coronary intervention were split in two groups. In all patients two balloon inflations of 60 seconds were performed, the first for balloon dilatation of the lesion (first episode), the second for stent delivery (second episode). The Pw/Pa ratio (wedge pressure/aortic pressure) was measured during both ischaemic episodes. Group 1 received 5 minutes of active neurostimulation before plus 1 minute during the first episode, group 2 received 5 minutes of active neurostimulation before plus 1 minute during the second episode.</p> <p>Results</p> <p>In group 1 the Pw/Pa ratio decreased by 10 ± 22% from 0.20 ± 0.09 to 0.19 ± 0.09 (p = 0.004) when electrical neurostimulation was deactivated. In group 2 the Pw/Pa ratio increased by 9 ± 15% from 0.22 ± 0.09 to 0.24 ± 0.10 (p = 0.001) when electrical neurostimulation was activated.</p> <p>Conclusion</p> <p>Electrical neurostimulation induces a significant improvement in the Pw/Pa ratio during acute coronary occlusion.</p

Advanced clinical approaches in complex cardiovascular disease : invasive options at the crossroad of ischemia, heart failure, and arrhythmias

In this thesis an overall assessment of a variety of advanced diagnostic and treatment approaches (PET, VEGF gene and laser treatment, NOGA, ablation therapy and PCI after immediate graft failure) in subjects with complex cardiovascular disease is made during daily clinical practice. It is argued that such an evaluation is facilitated by creating a knowledge platform based on the three major interrelated entities in cardiovascular disease: ischemia, heart failure and arrhythmia. The main driving force to elaborate on this topic is to provide more insight into the added-value of the aforementioned cardiovascular modalities or clinical approaches for main stream patients. Zie: Summary and future perspectives

Value and limitations of electromechanical endocardial mapping in the assessment of global and regional left ventricular function and transmural extent of infarction:a comparison with cardiovascular magnetic resonance

Aims: To determine the relation between electromechanical endocardial mapping (EEM) and cardiac magnetic resonance (CMR) derived functional and viability parameters in patients with a large myocardial infarction. Methods and results: Forty-two patients with a large ST-elevation myocardial infarction underwent both EEM and CMR four months after primary percutaneous coronary intervention. EEM was performed to assess linear local shortening (LLS), unipolar voltage (UV) and bipolar voltage (BV). CMR cine imaging was performed to determine left ventricular global volumes, ejection fraction and regional function. Late gadolinium enhancement was used to assess size and transmural extent of infarction. Average LLS, UV and BV differed significantly between normal and dysfunctional segments (9.8 vs. 7.3, 11.8 vs. 9.7 and 3.3 vs. 2.8 for LLS, UV and BV respectively; p Conclusions: EEM may be helpful in determining both the regional function and the transmural extent of infarction in patients with a large myocardial infarction. However, correlation with CMR parameters was moderate and exact cut-off values for EEM parameters could not be established. Further development of this potentially very useful modality is needed before it can be advocated for exact border-zone endocardial injection

Operator dependence of outcome after primary percutaneous coronary intervention

Aims: Primary percutaneous coronary intervention (PCI) is a widely practised therapeutic procedure to treat ST-elevation myocardial infarction (STEM l). However, a significant proportion of patients undergoing primary PCI suffers from adverse events, such as incomplete myocardial reperfusion. It is currently unknown to which degree these adverse events are operator related. Methods and results: We investigated inter-operator variation using objective safety and efficacy endpoints during primary PCI for STEM I. All PCIs were performed by six experienced interventional cardiologists as part of a randomised single centre trial. The primary endpoint of this study was optimal myocardial reperfusion (myocardial blush grade 3 [MBG]). All 1,071 patients enrolled in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) were included in this analysis. In the six operator groups, the rate of the primary endpoint MBG 3 ranged between 29.2% and 55.5%. The variable for operators remained significantly associated with MBG 3 after adjustment for baseline and procedural differences. There were no statistical differences observed with regard to safety endpoints. Conclusions: This study illustrates the observation that even in a controlled setting significant inter-operator variation may exist in the efficacy of primary PCI. This study supports the routine collection of high-quality datasets to evaluate and improve individual operator competence and skills