Zur Rolle der okkulten koronaren Herzkrankheit bei typischem Vorhofflattern

Patienten, die eine Ablationsbehandlung von typischem Vorhofflattern erhielten und bei denen das Auftreten von Vorhofflattern die Erstmanifestation einer kardialen Erkrankung darstellte, erhielten bei der Abklärung einer kardialen Grunderkrankung auch in der Regel eine bildgebende Koronardiagnostik, sodass von über 80 % dieser Patienten ein Koronarstatus verfügbar war. Dieses Patientenkollektiv wurde mit Patienten verglichen, die im Rahmen einer Ablationsbehandlung von paroxysmalem Vorhofflimmern ebenfalls eine Koronardiagnostik erhielten. In beiden Gruppen durfte keine strukturelle Herzerkrankung vorhanden sein. Es wurden 152 Patienten mit Vorhofflattern mit 141 Patienten mit Vorhofflimmern verglichen. In der Gruppe mit Vorhofflattern finden sich signifikant niedrigere Werte für die LVEF, mehr Patienten mit Herzinsuffizienz, weniger Patienten weiblichen Geschlechts sowie weniger Patienten mit vorbestehender Hyperlipoproteinämie und positiver Familienanamnese. Ebenso fand sich ein geringerer Einsatz von Beta- Blockern, Klasse-I-Antiarrhythmika und NOAKs bei Aufnahme. Die Anzahl klassischer kardiovaskulärer Risikofaktoren pro Patient (arterielle Hypertonie, Hyperlipoproteinämie, Diabetes mellitus, Rauchen, positive Familienanamnese) war normal verteilt und unterschied sich nicht zwischen den Gruppen. In der Vorhofflattergruppe fanden sich signifikant mehr Patienten (n=40; 26 %) mit relevanter KHK (Diameterstenosen >50 %), während in der Vorhofflimmergruppe lediglich 9 Patienten (6 %) mit relevanter KHK gefunden wurden. Signifikante Prädiktoren für das Vorliegen einer klinisch signifikanten KHK (Diamterstenosen >75 % ) waren in beiden Kollektiven Alter, arterielle Hypertonie und das Vorliegen einer extrakardialen vaskulären Erkrankung.In einer logistischen Regressionsanalyse fand sich eine Odds Ratio von über 5 für das Vorliegen einer relevanten KHK bei Vorhofflattern gegenüber Vorhofflimmern. Somit wird geschlussfolgert, dass Vorhofflattern gegenüber Vorhofflimmern als eigenständiger Risikofaktor für das Vorliegen einer koronaren Herzerkrankung anzusehen ist. Die Patienten mit Vorhofflattern und Koronarstenosen >75 % wurden noch weiter untersucht. Gegenüber den anderen Patienten mit Vorhofflattern wies diese Gruppe signifikant höhere Werte für Alter, CHA2DS2-VASc-Score und die Summe der kardiovaskulären Risikofaktoren auf. Die Vorhersagewahrscheinlichkeit in Abhängigkeit vom CHA2DS2-VASc-Score weist einen exponentiellen Anstieg auf, während die Summe der kardiovaskulären Risikofaktoren ab drei Faktoren ein Plateau erreicht. Der CHA2DS2-VASc-Score kann somit zur Risikostratifizierung herangezogen werden. Ein von uns daraufhin entwickelter klinischer Algorithmus schlägt ab einem CHA2DS2-VASc-Score von drei bei asymptomatischen und bisher kardial nicht vorbelasteten Patienten eine weitere Abklärung hinsichtlich KHK vor. Gleiches sollte bei einem Score von zwei und gleichzeitigem Vorliegen einer extrakardialen vaskulären Erkrankung durchgeführt werden. Aufgrund der Limitationen dieser Untersuchung wie der retrospektiven Datenerhebung, Patientenanzahl und ausschließlicher Untersuchung von Patienten mit Ablation, müsste dieser Ansatz in einem prospektiven Modell validiert werden

A worldwide survey on incidence, management, and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: the POTTER-AF study

AIMS Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse. METHODS AND RESULTS This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001]. CONCLUSION Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high

A worldwide survey on incidence, management and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: The POTTER-AF study.

AIMS Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management and outcome are sparse. METHODS AND RESULTS This international multicenter registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553,729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed at 214 centers in 35 countries. In 78 centers 138 patients (0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (p<0.0001)) were diagnosed with an oesophageal fistula. Periprocedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8%, and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) (odds ratio 7.463 (2.414, 23.072) p<0.001). CONCLUSIONS Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high

Catheter ablation of supraventricular tachycardia in patients with and without structural heart disease: insights from the German ablation registry

Aim!#!To compare patient characteristics, safety and efficacy of catheter ablation of supraventricular tachycardia (SVT) in patients with and without structural heart disease (SHD) enrolled in the German ablation registry.!##!Methods and results!#!From January 2007 until January 2010, a total of 12,536 patients (37.2% with known SHD) were enrolled and followed for at least one year. Patients with SHD more often underwent ablation for atrial flutter (45.8% vs. 20.9%, p &amp;lt; 0.001), whereas patients without SHD more often underwent ablation for atrioventricular nodal reentrant tachycardia (30.2% vs. 11.8%, p &amp;lt; 0.001) or atrioventricular reentrant tachycardia (9.1% vs. 1.6%, p &amp;lt; 0.001). Atrial fibrillation catheter ablation procedures were performed in a similar proportion of patients with and without SHD (38.1% vs. 36.9%, p = 0.21). Overall, periprocedural success rate was high in both groups. Death, myocardial infarction or stroke occurred in 0.2% and 0.1% of patients with and without SHD (p = 0.066). Major non-fatal complications prior to discharge were rare and did not differ significantly between patients with and without SHD (0.5% vs. 0.4%, p = 0.34). Kaplan-Meier mortality estimate at 1 year demonstrated a significant mortality increase in patients with SHD (2.6% versus 0.7%; p &amp;lt; 0.001).!##!Conclusion!#!Patients with and without SHD undergoing SVT ablation exhibit similar success rates and low major complication rates, despite disadvantageous baseline characteristics in SHD patients. These data highlight the safety and efficacy of SVT ablation in patients with and without SHD. Nevertheless Kaplan-Meier mortality estimates at 1 year demonstrate a significant mortality increase in patients with SHD, highlighting the importance of treating the underlying condition and reliable anticoagulation if indicated

Impact of Access Site on Periprocedural Bleeding and Cerebral and Coronary Events in High-Bleeding-Risk Percutaneous Coronary Intervention: Findings from the RIVA-PCI Trial

Abstract Introduction The preference for using transradial access (TRA) over transfemoral access (TFA) in patients requiring percutaneous coronary intervention (PCI) is based on evidence suggesting that TRA is associated with less bleeding and fewer vascular complications, shorter hospital stays, improved quality of life, and a potential beneficial effect on mortality. We have limited study data comparing the two access routes in a patient population with atrial fibrillation (AF) undergoing PCI, who have a particular increased risk of bleeding, while AF itself is associated with an increased risk of thromboembolism. Methods Using data from the RIVA-PCI registry, which includes patients with AF undergoing PCI, we analyzed a high-bleeding-risk (HBR) cohort. These patients were predominantly on oral anticoagulants (OAC) for AF, and the PCI was performed via radial or femoral access. Endpoints examined were in-hospital bleeding (BARC 2–5), cerebral events (TIA, hemorrhagic or ischemic stroke) and coronary events (stent thrombosis and myocardial infarction). Results Out of 1636 patients, 854 (52.2%) underwent TFA, while 782 (47.8%) underwent the procedure via TRA, including nine patients with brachial artery puncture. The mean age was 75.5 years. Groups were similar in terms of age, sex distribution, AF type, cardiovascular history, risk factors, and comorbidities, except for a higher incidence of previous bypass surgeries, heart failure, hyperlipidemia, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 60 ml/min in the TFA group. No clinically relevant differences in antithrombotic therapy and combinations were present at the time of PCI. However, upon discharge, transradial PCI patients had a higher rate of triple therapy, while dual therapy was preferred after transfemoral procedures. Radial access was more frequently chosen for non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP) cases (NSTEMI 26.6% vs. 17.0%, p < 0.0001; UAP 21.5% vs. 14.5%, p < 0.001), while femoral access was more common for elective PCI (60.3% vs. 44.1%, p < 0.0001). No differences were observed for ST-segment elevation myocardial infarction (STEMI). Both groups had similar rates of cerebral events (TFA 0.2% vs. TRA 0.3%, p = 0.93), but the TFA group had a higher incidence of bleeding (BARC 2–5) (4.2% vs. 1.5%, p < 0.01), mainly driven by BARC 3 bleeding (1.5% vs. 0.4%, p < 0.05). No significant differences were found for stent thrombosis and myocardial infarction (TFA 0.2% vs. TRA 0.3%, p = 0.93; TFA 0.4% vs. TRA 0.1%, p = 0.36). Conclusions In HBR patients with AF undergoing PCI for acute or chronic coronary syndrome, the use of TRA might be associated with a decrease in in-hospital bleeding, while not increasing the risk of embolic or ischemic events compared to femoral access. Further studies are required to confirm these preliminary findings

A worldwide survey on incidence, management and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation:The POTTER-AF study

AIMS: Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management and outcome are sparse.METHODS AND RESULTS: This international multicenter registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553,729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed at 214 centers in 35 countries. In 78 centers 138 patients (0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (p&lt;0.0001)) were diagnosed with an oesophageal fistula. Periprocedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8%, and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) (odds ratio 7.463 (2.414, 23.072) p&lt;0.001).CONCLUSIONS: Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.</p