Topics in Atrial Fibrillation Management

Atrial fibrillation (AF) is the most frequently encountered arrhythmia in clinical practice. Physicians of almost all specialities have to deal with this arrhythmia and its consequences. The incidence of AF rises proportional with age. 75 % of patients with AF are older than 75 years. AF is not a benign disease. It can result in symptomatic palpitations, symptoms of pump failure, and above all an increase in the incidence of thrombo-embolic events like stroke. In the Framingham study it was shown that AF also independently increases mortality. In patients with heart failure the presence of AF further increases the risk of death. For a long time the only therapy available to the treating physician was digoxin. Today the therapeutic options are too numerous to cover in one thesis, however, they options are mentioned briefly in chapter one

Imaging of a coronary artery bypass graft during coronary sinus venography

Retrograde coronary sinus perfusion to maintain viability during cardiac surgery means that a connection via the capillary system to the coronary arteries, and potentially bypass grafts, may be possible. Coronary sinus (CS) venography prior to resynchronisation therapy in this patient with previous bypass grafting was associated with visualisation of these grafts

Comparison of monophasic and biphasic shocks for transthoracic cardioversion of atrial fibrillation

OBJECTIVE: To compare the efficacy of cardioversion in patients with atrial fibrillation between monophasic damped sine waveform and rectilinear biphasic waveform shocks at a high initial energy level and with a conventional paddle position. DESIGN: Prospective randomised study. PATIENTS AND SETTING: 227 patients admitted for cardioversion of atrial fibrillation to a tertiary referral centre. RESULTS: 70

Psychological Indices as Predictors for Phantom Shocks in Implantable Cardioverter Defibrillator Recipients

Background\ud A phantom shock—the sensation of an implantable cardioverter defibrillator (ICD) discharge in the absence of an actual discharge—is a phenomenon that can occur in ICD patients. Little is known about the influence of psychological factors on the incidence of phantom shocks. We evaluated psychological correlates of phantom shocks 2 years post-ICD implant in a cohort of Dutch ICD recipients.\ud \ud Methods\ud Consecutive patients (N = 300; 87.5% men; mean age = 62.3) willing to participate in a prospective study (Twente ICD Cohort Study) on psychological factors in ICD recipients received an ICD between September 2007 and February 2010. At baseline, patients complete the 36-item Short Form Health Survey, Hospital Anxiety and Depression Scale, and the Type D Scale. Lifetime presence of anxiety and depression was assessed with the MINI structural interview.\ud \ud Results\ud During a follow-up of 24 months, 16 patients (5.4%) experienced a phantom shock. Median time to (first) phantom shock was 13 weeks (range 0–48 weeks). In univariable analysis, no significant relationships were found between clinical or psychological indices and the occurrence of phantom shocks, nor was there an association between phantom shocks and type D personality, symptoms of anxiety, or a history of anxiety and depression.\ud \ud Conclusions\ud Neither symptoms of anxiety and depression nor psychiatric history were associated with the occurrence of phantom shocks. Further studies using more explorative, qualitative research techniques are warranted to examine the correlates of phantom shocks

Association of Psychiatric History and Type D Personality with Symptoms of Anxiety, Depression, and Health Status Prior to ICD Implantation

BACKGROUND: Personality factors and psychiatric history may help explain individual differences in risk of psychological morbidity and poor health outcomes in patients with an implantable cardioverter defibrillator (ICD). PURPOSE: We examined associations between previous anxiety and depressive disorder, type D personality, anxiety or depressive symptoms, and health status in ICD patients prior to ICD implantation. METHOD: Patients (N = 278; 83 % men; mean age = 62.2 years ±11) receiving a first ICD from September 2007 through April 2010 at the Medisch Spectrum Twente, The Netherlands completed validated questionnaires before implantation assessing type D personality (14-item Type D Scale), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale), and health status (36-item Short Form Health Survey). History of anxiety or depressive disorder was assessed with the Mini International Neuropsychiatric Interview structural interview. RESULTS: Previous anxiety or depressive disorder was prevalent in 8 and 19 % of patients, respectively. Type D personality was present in 21 %, depressive symptoms in 15 %, and anxiety in 24 %. In adjusted analyses, type D personality was a dominant correlate of previous depressive disorder (odds ratio (OR) 6.2, p < 0.001) and previous anxiety disorder (OR 3.9, p = 0.004). Type D personality (OR 4.0, p < 0.001), age (OR 1.03, p = 0.043), and gender (OR 2.5, p = 0.013) were associated with anxiety symptoms at baseline. Type D personality (OR 5.9. p < 0.001) was also associated with increased depressive symptoms at baseline. Heart failure and type D personality were related to poorer health status. CONCLUSION: In ICD patients, prior to ICD implantation, a previous anxiety or depressive disorder, type D personality, and anxiety and depressive symptoms were associated with poorer health status. Type D personality was also independently associated with increased anxiety and depression symptoms

Predicting Early Mortality Among Implantable Defibrillator Patients Treated With Cardiac Resynchronization Therapy

Background: The beneficial effects of a cardiac resynchronization defibrillator (CRT-D) in patients with heart failure, low left ventricular ejection fraction (LVEF), and wide QRS have clearly been established. Nevertheless, mortality r

Subcutaneous implantable cardioverter-defibrillators: long-term results of the EFFORTLESS study

AIMS: To report 5-year outcomes of EFFORTLESS registry patients with early generation subcutaneous implantable cardioverter-defibrillator (S-ICD) devices. METHODS AND RESULTS: Kaplan-Meier, trend and multivariable analyses were performed for mortality and late (years 2-5) complications, appropriate shock (AS) and inappropriate shock (IAS) rates. Nine hundred and eighty-four of 994 enrolled patients with diverse diagnoses (28% female, 48 ± 17 years, body mass index 27 ± 6 kg/m2, ejection fraction 43 ± 18%) underwent S-ICD implantation. Median follow-up was 5.1 years (interquartile range 4.7-5.5 years). All-cause mortality was 9.3% (95% confidence interval 7.2-11.3%) at 5 years; 703 patients remained in follow-up on study completion, 171 withdrew including 87 (8.8%) with device explanted, and 65 (6.6%) lost to follow-up. Of the explants, only 20 (2.0%) patients needed a transvenous device for pacing indications. First and final shock efficacy for discrete ventricular arrhythmias was consistent at 90% and 98%, respectively, with storm episode final shock efficacy at 95.2%. Time to therapy remained unaltered. Overall 1- and 5-year complication rates were 8.9% and 15.2%, respectively. Early complications did not predict later complications. There were no structural lead failures. Inappropriate shock rates at 1 and 5 years were 8.7% and 16.9%, respectively. Self-terminating inappropriately sensed episodes predicted late IAS. Predictors of late AS included self-terminating appropriately sensed episodes and earlier AS. CONCLUSION: In this diverse S-ICD registry population, spontaneous shock efficacy was consistently high over 5 years. Very few patients underwent S-ICD replacement with a transvenous device for pacing indications. Treated and self-terminating arrhythmic episodes predict future shock events, which should encourage more personalized device optimization. KEY QUESTION: Is subcutaneous implantable cardioverter-defibrillator (S-ICD) shock efficacy maintained over time? KEY FINDING: Subcutaneous implantable cardioverter-defibrillator shock efficacy remains high for discrete and storm episodes. For discrete episodes first and final shock efficacy do not change over time or by rhythm type. TAKE-HOME MESSAGE: The EFFORTLESS study 5-year results provide the longest follow up of a large patient cohort implanted with the S-ICD. For 984 patients with a median follow-up of 5.1 years, the S-ICD maintains a high level of shock efficacy of 98%

Ablation lesions in Koch's triangle assessed by three-dimensional myocardial contrast echocardiography

BACKGROUND: Myocardial contrast echocardiography (MCE) allows visualization of radiofrequency (RF) ablation lesions in the left ventricle in an animal model. Aim: To test whether MCE allows visualization of RF and cryo ablation lesions in the human right atrium using three-dimensional echocardiography. METHODS: 18 patients underwent catheter ablation of a supraventricular tachycardia and were included in this prospective single-blind study. Twelve patients were ablated inside Koch's triangle and 6, who served as controls, outside this area. Three-dimensional echocardiography of Koch's triangle was performed before and after the ablation procedure in all patients, using respiration and ECG gated pullback of a 9 MHz ICE transducer, with and without continuous intravenous echocontrast infusion (SonoVue, Bracco). Two independent observers analyzed the data off-line. RESULTS: MCE identified ablation lesions as a low contrast area within the normal atrial myocardial tissue. Craters on the endocardial surface were seen in 10 (83%) patients after ablation. Lesions were identified in 11 out of 12 patients (92%). None of the control patients were recognized as having been ablated. The confidence score of the independent echo reviewer tended to be higher when the number of applications increased. CONCLUSIONS: 1. MCE allows direct visualization of ablation lesions in the human atrial myocardium. 2. Both RF and cryo energy lesions can be identified using MCE

The learning curve associated with the introduction of the subcutaneous implantable defibrillator

Aims: The subcutaneous implantable cardioverter defibrillator (S-ICD) was introduced to overcome complications related to transvenous leads. Adoption of the S-ICD requires implanters to learn a new implantation technique. The aim of this study was to assess the learning curve for S-ICD implanters with respect to implant-related complications, procedure time, and inappropriate shocks (IASs). Methods and results: In a pooled cohort from two clinical S-ICD databases, the IDE Trial and the EFFORTLESS Registry, complications, IASs at 180 days follow-up and implant procedure duration were assessed. Patients were grouped in quartiles based on experience of the implanter and Kaplan-Meier estimates of complication and IAS rates were calculated. A total of 882 patients implanted in 61 centres by 107 implanters with a median of 4 implants (IQR 1,8) were analysed. There were a total of 59 patients with complications and 48 patients with IAS. The complication rate decreased significantly from 9.8% in Quartile 1 (least experience) to 5.4% in Quartile 4 (most experience) (P = 0.02) and non-significantly for IAS from 7.9 to 4.8% (P = 0.10). Multivariable analysis demonstrated a hazard ratio of 0.78 (P = 0.045) for complications and 1.01 (P = 0.958) for IAS. Dual-zone programming increased with experience of the individual implanter (P 13 implants). Conclusion: There is a short and significant learning curve associated with physicians adopting the S-ICD. Performance stab