Survivorship - lebenslange Begleitung von Krebspatienten

Survivorship - lebenslange Begleitung von Krebspatiente

High-density mapping of spontaneous pulmonary vein activity initiating atrial fibrillation in humans

Introduction: High-density three-dimensional (3D) mapping of the pulmonary vein (PV)-left atrial (LA) junction was performed to characterize spontaneous PV activity in humans. Methods and Results: The activation patterns of ectopic beats and of the initial 2 seconds of atrial fibrillation (AF) from the PVs were analyzed using a 64-poles basket catheter. A focal mechanism was defined as a discrete site of early and centrifugal activation. Continuous activity was considered as an activation covering ≥80% of the tachycardia beat-to-beat cycle length within the mapping field. In 35 patients, 123 spontaneous focal ectopic beats that did not induce AF and 95 that did induce AF were mapped. The mean coupling interval of ectopic discharges not inducing AF was 281 ± 70 msec versus 236 ± 90 msec for ectopies initiating AF (P ≤ 0.01). The first ectopic activity of all 218 arrhythmogenic events showed exclusively a focal mechanism. During the 95 episodes of AF initiation, one or two ectopic beats from the PVs initiated AF in the LA in 39%, a stable focal tachycardia was recorded in 14%, continuous activity with important changes in cycle length (35 ± 15 msec) suggestive of decremental or fibrillatory conduction was found in 18%, and in 29% the activation pattern could not be classified. No stable and sustained reentrant circuit could be identified by our mapping tool in the PV-LA junction. Conclusions: Arrhythmogenic activity from PVs in humans is predominantly due to discrete focal activity.Thomas Arentz , Laurent Haegeli , Prashanthan Sanders , Reinhold Weber , Franz Josef Neumann , Dietrich Kalusche , Michel Haïssaguerr

Necessity for surgical revision of defibrillator leads implanted long-term : causes and management

BACKGROUND: Defibrillator lead malfunction is a potential long-term complication in patients with an implantable cardioverter-defibrillator (ICD). The aim of this study was to determine the incidence and causes of lead malfunction necessitating surgical revision and to evaluate 2 approaches to treat lead malfunction. METHODS AND RESULTS: We included 1317 consecutive patients with an ICD implanted at 3 European centers between 1993 and 2004. The types and causes of lead malfunction were recorded. If the integrity of the high-voltage part of the lead could be ascertained, an additional pace/sense lead was implanted. Otherwise, the patients received a new ICD lead. Of the 1317 patients, 38 experienced lead malfunction requiring surgical revision and 315 died during a median follow-up of 6.4 years. At 5 years, the cumulative incidence was 2.5% (95% confidence interval, 1.5 to 3.6). Lead malfunction resulted in inappropriate ICD therapies in 76% of the cases. Implantation of a pace/sense lead was feasible in 63%. Both lead revision strategies were similar with regard to lead malfunction recurrence (P=0.8). However, the cumulative incidence of recurrence was high (20% at 5 years; 95% confidence interval, 1.7 to 37.7). CONCLUSIONS: ICD lead malfunction necessitating surgical revision becomes a clinically relevant problem in 2.5% of ICD recipients within 5 years. In selected cases, simple implantation of an additional pace/sense lead is feasible. Regardless of the chosen approach, the incidence of recurrent ICD lead-related problems after lead revision is 8-fold higher in this population

Heart Rhythm

BACKGROUND: Experimental data suggest that use of cryoablation in pulmonary vein isolation (PVI) is associated with less cell damage and less thrombus formation compared to radiofrequency (RF) energy. OBJECTIVE: The purpose of this study was to test the hypothesis that cryoablation significantly reduces markers of cell damage, platelet activation, and inflammation in patients undergoing PVI for treatment of atrial fibrillation (AF). METHODS: Sixty patients with symptomatic drug-resistant AF (age 56 +/- 9 years, 48 males, 38 with paroxysmal AF) were randomly assigned to undergo PVI using either an open irrigated-tip RF catheter or a cryoballoon. Markers of cell damage (high-sensitive troponin T [hs-TnT], microparticles), platelet activation (platelet reactivity by aggregometry, expression of platelet surface proteins P-selectin and activated glycoprotein [GP] IIb/IIIa), and inflammatory response (high-sensitive C-reactive protein [hs-CRP]) were determined before and up to 48 hours after the procedure. RESULTS: PVI resulted in a significant rise in hs-TnT, microparticles, markers of platelet activation, and hs-CRP over time, with distinct temporal patterns for each parameter. However, after Bonferroni correction for repeated measurements, no significant differences were noted in these parameters between patients treated with cryoablation or RF energy. Procedural time was significantly shorter in patients treated with cryoballoon (177 +/- 30 minutes vs 200 +/- 46 minutes, P = .03), with no differences in fluoroscopic time, periprocedural complications, or success rate. CONCLUSION: Cryoablation and RF energy result in a comparable rise of markers of cell damage, platelet activation and inflammatory response. The data do not support the concept of an improved safety profile for cryoablation in PVI