Neue Aspekte der kathetergeführten Ablation von Vorhofflimmern mittels Kryoballon Technik

Die Vorhofflimmer-Ablation mittels Kryoballon-Technik ist eine moderne und effektive Alternative zur Radiofrequenz-Technik. Diese Arbeit beschäftigt sich mit dem klinischen Einsatz der Kryoballon-Technik für die Pulmonalvenenisolation bei Patienten mit symptomatischem Vorhofflimmern. Es konnte gezeigt werden, dass diese Technik auch in einem längeren klinischen Follow-up sicher und effektiv ist. Bei einer kontinuierlichen Überwachung des Herzrhythmus mittels Ereignisrekordern oder kardial implantierten elektronischen Geräten wurde diese Effektivität bestätigt. Patienten mit anatomischen Varianten wie eine gemeinsame linke Pulmonalvene können ebenso von einer Ablation mittels Kryoballon-Technik profitieren und wir konnten zeigen, dass diese den Ergebnissen der RF-Technik nicht unterlegen ist. Auch für ältere Patienten ist die Ablation mittels Kryoballon-Technik eine sichere und effektive Therapieoption. Letztlich bestätigten wir die mittlerweile gängige klinische Praxis, dass eine Pulmonalvenenisolation mittels Kryoballon-Technik sicher durchgeführt werden kann, wenn die Patienten mittels DOACs antikoaguliert sind.Atrial fibrillation ablation using cryoballoon technology is a modern and effective alternative to radiofrequency ablation. This work shows data about the clinical use of the cryoballoon technique for pulmonary vein isolation in patients with symptomatic atrial fibrillation. This technique has been shown to be safe and effective even in a long term clinical follow-up. This effectiveness has been confirmed with constant monitoring of the heart rhythm using event recorders or other implantable cardiac devices. Patients with anatomical variants such as a common left pulmonary vein may also benefit from ablation using the cryoballoon technique and we have shown that this is not inferior to radiofrequency ablation. Ablation using the cryoballoon technique is a safe and effective therapy option for older patients. Finally, we confirmed the common clinical practice that pulmonary vein isolation using the cryoballoon technique can be safely performed when patients are anticoagulated using DOACs

Results from a real-time dosimetry study during left atrial ablations performed with ultra-low dose radiation settings

Background: Three-dimensional mapping systems and the use of ultra-low dose radiation protocols have supported minimization of radiation dose during left atrial ablation procedures. By using optimal shielding, scattered radiation reaching the operator can be further reduced. This prospective study was designed to determine the remaining operator radiation exposure during left atrial catheter ablations using real-time dosimetry. Methods: Radiation dose was recorded using real-time digital dosimetry badges outside the lead apron during 201 consecutive left atrial fibrillation ablation procedures. All procedures were performed using the same X‑ray system (Siemens Healthineers Artis dBc; Siemens Healthcare AG, Erlangen, Germany) programmed with ultra-low dose radiation settings including a low frame rate (two frames per second), maximum copper filtration, and an optimized detector dose. To reduce scattered radiation to the operators, table-suspended lead curtains, ceiling-suspended leaded plastic shields, and radiation-absorbing shields on the patient were positioned in an overlapping configuration. Results: The 201 procedures included 139 (69%) pulmonary vein isolations (PVI) (20 cryoballoon ablations, 119 radiofrequency ablations, with 35 cases receiving additional ablation of the cavotricuspid isthmus) and 62 (31%) PVI plus further left atrial substrate ablation. Mean radiation dose measured as dose area product for all procedures was 128.09 ± 187.87 cGy ∙ cm2 with a mean fluoroscopy duration of 9.4 ± 8.7 min. Real-time dosimetry showed very low average operator doses of 0.52 ± 0.10 µSv. A subanalysis of 51 (25%) procedures showed that the radiation burden for the operator was highest during pulmonary vein angiography. Conclusion: The use of ultra-low dose radiation protocols in combination with optimized shielding results in extremely low scattered radiation reaching the operator.Hintergrund: Der Einsatz von dreidimensionalen Mapping-Systemen und von Niedrigdosiseinstellungen der Röntgenanlage führte zu einer Minimierung der Strahlenbelastung bei linksatrialen Ablationen. Optimierte Abschirmung kann die Streustrahlung als Strahlenbelastung des Untersuchers weiter reduzieren. In dieser prospektiven Studie wurde untersucht, welcher Strahlenbelastung der Untersucher unter Anwendung dieser Maßnahmen während linksatrialer Ablationen noch ausgesetzt ist. Methoden: Die Strahlenbelastung wurde mittels Echtzeitdosimetrie an der Außenseite der Bleischürze während 201 konsekutiven linksatrialen Ablationen gemessen. Alle Prozeduren wurden mit demselben Röntgensystem (Siemens Healthineers Artis dBc; Siemens Healthcare AG, Erlangen, Deutschland) und mit strahlensparenden Einstellungen durchgeführt, unter anderem mit einer niedrigen Bildrate von 2 Bildern/s, maximaler Kupferfilterung und angepasster Detektoreingangsdosis. Um Streustrahlung zu reduzieren, wurden die Seitenlamellen, die mobile Acrylscheibe und die strahlenabsorbierenden Schilde auf dem Patienten überlappend angeordnet. Ergebnisse: Die 201 Prozeduren umfassten 139 (69%) Pulmonalvenenisolationen (PVI; 20 Kryoballonablationen, 119 Radiofrequenzablationen, in 35 Fällen mit zusätzlicher Ablation des kavotrikuspidalen Isthmus) und 62 (31%) PVI mit zusätzlicher linksatrialer Substratmodifikation. Die Strahlendosis als Dosis-Flächen-Produkt (DAP) betrug durchschnittlich 128,09± 187,87 cGy ⋅cm2 bei einer Fluoroskopiedauer von imMittel 9,4± 8,7min. Die per Echtzeitdosimetrie erhobene mittlere Strahlendosis des Untersuchers zeigte sich mit 0,52± 0,10 μSv als sehr gering. Eine Subanalyse bei 51 (25 %) Prozeduren zeigte, dass die Strahlendosis des Untersuchers während der Pulmonalvenenangiographie am höchsten war. Schlussfolgerung: Die Kombination von Niedrigdosiseinstellungen und optimierter Abschirmung führt zu einer extremniedrigen Streustrahlung als Strahlenbelastung des Untersuchers

Benefit of a wearable cardioverter defibrillator for detection and therapy of arrhythmias in patients with myocarditis

Aims: Myocarditis may lead to malignant arrhythmias and sudden cardiac death. As of today, there are no reliable predictors to identify individuals at risk for these catastrophic events. The aim of this study was to evaluate if a wearable cardioverter defibrillator (WCD) may detect and treat such arrhythmias adequately in the peracute setting of myocarditis. Methods and results: In this observational, retrospective, single centre study, we reviewed patients presenting to the Charite Hospital from 2009 to 2017, who were provided with a WCD for the diagnosis of myocarditis with reduced ejection fraction (<50%) and/or arrhythmias. Amongst 259 patients receiving a WCD, 59 patients (23%) were diagnosed with myocarditis by histology. The mean age was 46 +/- 14 years, and 11 patients were women (19%). The mean WCD wearing time was 86 +/- 63 days, and the mean daily use was 20 +/- 5 h. During that time, two patients (3%) had episodes of sustained ventricular tachycardia (VT; four total) corresponding to a rate of 28 sustained VT episodes per 100 patient-years. Consequently, one of these patients underwent rhythm stabilization through intravenous amiodarone, while the other patient received an implantable cardioverter defibrillator. Two patients (3.4%) were found to have non-sustained VT. Conclusions: Using a WCD after acute myocarditis led to the detection of sustained VT in 2/59 patients (3%). While a WCD may prevent sudden cardiac death after myocarditis, our data suggest that WCD may have impact on clinical management through monitoring and arrhythmia detection

Hematocrit and the Risk of Recurrent Venous Thrombosis: A Prospective Cohort Study

BACKGROUND: Venous thromboembolism (VTE) is a multicausal disease which recurs. Hematocrit is associated with a thrombotic risk. We aimed to investigate if hematocrit is associated with the recurrence risk. METHODS: Patients with a first VTE were followed after anticoagulation. Patients with VTE provoked by a transient risk factor, natural inhibitor deficiency, lupus anticoagulant, homozygous or double heterozygous defects, cancer, or long-term antithrombotic treatment were excluded. The study endpoint was recurrent VTE. RESULTS: 150 (23%) of 653 patients had recurrence. Only high hematocrit was significantly associated with recurrence risk [hazard ratio (HR) for 1% hematocrit increase with the third tertile 1.08; 95% CI 1.01-1.15]. No or only a weak association for hematocrits within the first and second tertile was seen (HR 1.03; 95% CI 0.97-1.09, and 1.07; 95% CI 1.00-1.13). Hematocrit was associated with recurrence risk only among women. After five years, the probability of recurrence was 9.9% (95% CI 3.7%-15.7%), 15.6% (95% CI 9.7%-21.2%) and 25.5% (95% CI 15.1%-34.6%) in women, and was 29.2% (95% CI 21.1%-36.5%), 30.1% (95% CI 24.1%-35.7%) and 30.8% (95% CI 22.0%-38.7%) in men for hematocrits in the first, second and third tertile, respectively. Men had a higher recurrence risk (1.9; 95% CI 1.1-2.7; p = 0.03), which dropped by 23.5% after adjustment for hematocrit. Hematocrit was not a significant mediator of the sex-difference in recurrence risk (p = 0.223). CONCLUSIONS: High hematocrit is associated with the recurrence only in women. The different recurrence risk between men and women is possibly partly explained by hematocrit

Phrenic Nerve Injury During Cryoballoon-Based Pulmonary Vein Isolation: Results of the Worldwide YETI Registry.

BackgroundCryoballoon-based pulmonary vein isolation (PVI) has emerged as an effective treatment for atrial fibrillation. The most frequent complication during cryoballoon-based PVI is phrenic nerve injury (PNI). However, data on PNI are scarce.MethodsThe YETI registry is a retrospective, multicenter, and multinational registry evaluating the incidence, characteristics, prognostic factors for PNI recovery and follow-up data of patients with PNI during cryoballoon-based PVI. Experienced electrophysiological centers were invited to participate. All patients with PNI during CB2 or third (CB3) and fourth-generation cryoballoon (CB4)-based PVI were eligible.ResultsA total of 17 356 patients underwent cryoballoon-based PVI in 33 centers from 10 countries. A total of 731 (4.2%) patients experienced PNI. The mean time to PNI was 127.7±50.4 seconds, and the mean temperature at the time of PNI was -49±8°C. At the end of the procedure, PNI recovered in 394/731 patients (53.9%). Recovery of PNI at 12 months of follow-up was found in 97.0% of patients (682/703, with 28 patients lost to follow-up). A total of 16/703 (2.3%) reported symptomatic PNI. Only 0.06% of the overall population showed symptomatic and permanent PNI. Prognostic factors improving PNI recovery are immediate stop at PNI by double-stop technique and utilization of a bonus-freeze protocol. Age, cryoballoon temperature at PNI, and compound motor action potential amplitude loss >30% were identified as factors decreasing PNI recovery. Based on these parameters, a score was calculated. The YETI score has a numerical value that will directly represent the probability of a specific patient of recovering from PNI within 12 months.ConclusionsThe incidence of PNI during cryoballoon-based PVI was 4.2%. Overall 97% of PNI recovered within 12 months. Symptomatic and permanent PNI is exceedingly rare in patients after cryoballoon-based PVI. The YETI score estimates the prognosis after iatrogenic cryoballoon-derived PNI. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03645577. Graphic Abstract: A graphic abstract is available for this article

results from the TOP40 Heart Failure Registry Berlin

Die Herzinsuffizienz ist eine schwerwiegende Erkrankung mit steigender Inzidenz und Prävalenz. Als Grundlage für eine adäquate Diagnostik und Therapie stehen regelmäßig aktualisierte Leitlinien zur Verfügung. Dennoch zeigen verschiedene Register, dass die Versorgung oft nicht leitliniengerecht erfolgt. Eine aktuelle Publikation beziffert die Anzahl der Patienten, die durch eine leitliniengerechte Therapie zu retten gewesen wäre, in den Vereinigten Staaten von Amerika mit rund 70.000. Medizinische Register werden immer häufiger im Bereich der Qualitätssicherung und Versorgungsforschung bestimmter Zielpopulationen eingesetzt. Ein Register, das die Versorgungsqualität in Kliniken verschiederen Versorgungsstufen verglich, fehlte bislang in Deutschland. Das Berliner TOP40-Herzinsuffzienz-Register untersucht die Versorgungsqualität, sowie das diagnostische und therapeutische Management von Patienten mit systolischer Herzinsuffizienz in universitären und nicht-universitären Kliniken in Berlin. Wie oft erfolgte eine invasive Abklärung der Herzinsuffizienz? Wurden Patienten mit einer leitliniengerechten Herzinsuffizienz-Medikation entlassen? Wie war die Versorgung mittels Device- Therapie in Berlin? Bestanden Unterschiede in den oben genannten Fragestellungen zwischen universitären und nicht-universitären Kliniken? Das TOP40-Herzinsuffizienz-Register ist ein prospektives multizentrisches Kohortenregister, in das 427 Patienten mit systolischer Herzinsuffizienz in Kliniken unterschiedlicher Versorgungsstufen in Berlin eingeschlossen wurden. Einschlusskriterien waren eine systolsiche LV-Funktion von <40%, unabhängig von der Ätiologie und NYHA I-IV. Patienten unter 18 Jahren wurden nicht eingeschlossen. 87% der Patienten wurden invasiv mittels Koronarangiographie bezüglich einer koronaren Herzerkrankung abgeklärt. Insgesamt 19% der Patienten waren mit einem CRT versorgt, sowie 40% mit einem ICD. Es gab jedoch, abhängig von den unterschiedlichen Versorgungsstrukturen sowohl signifikante Unterschiede in der medikamentösen Therapie der Patienten und deutliche Unterschiede im Einsatz der Device-Therapie. In der universitären Klink und in den kardiologischen Schwerpunktkrankenhäusern waren die Patienten signifikant jünger und mobiler als jene in allgemein internistischen Kliniken. Beta-Blocker wurden in allgemein internistischen Kliniken signifikant seltener eingesetzt als in der universitären Klinik und den kardiologischen Schwerpunktkrankenhäusern. Kardiale Glykoside wurden in den kardiologischen Schwerpunktkrankenhäusern und den allgemein internistischen Kliniken häufiger eingesetzt als in der universitären Klinik, wobei in der multivariaten Analyse gezeigt wurde, dass in diesen Kliniken auch mehr Patienten mit Vorhofflimmern behandelt wurden. Diuretika wurden großzügig in allen Kliniken eingesetzt. In der universitären Klinik und in den kardiologischen Schwerpunkt-Krankenhäusern wurde unabhängig vom Alter und von Komorbiditäten signifikant häufiger eine invasisve Diagnostik mittels Koronarangiographie durchgeführt als in den allgemein internistischen Kliniken. In der universitären Klinik und den kardiologischen Schwerpunktkrankenhäusern wurden mehr ICDs und CRTs implantiert als in allgemein internistischen Krankenhäusern unabhängig vom Alter und Begleiterkrankungen. Schlussfolgerung: Aus den Ergebnissen des TOP40-Registers kann man zusammenfassend sagen, dass in Berlin im internationalen Vergleich Patienten mit Herzinsuffizienz medikamentös leitliniengerecht therapiert werden. Es gibt, sowohl in der medikamentösen Therapie, als auch in der invasiven Diagnostik und Device-Therapie signifikante Unterschiede zwischen Kliniken verschiedener Versorgungstufen in Berlin.Heart failure (HF) is a debilitating, fatal syndrome. The economic burden on the health care system is rising. Optimal treatment implementation can prevent patient´s death. No registry data from Germany has yet been published. The aim of the registry was to evaluate potential differences in patient characteristics and health care provision in University Hospital (UH), Hospitals with facilities for interventional cardiology (IC), or Hospitals with general medicine departments (GM). This is a prospective, multicentre pilot-registry of HF patients hospitalized in Berlin from April 2009 and July 2010 with left ventricular ejection fraction (LVEF) ≤40%. The follow up is currently in progress. The TOP40 registry documented significant differences in patient characteristics and in the diagnostic and therapeutic management at university and non-university hospitals. Patients in UH an IC were younger and more mobile. The multimorbidity of patients hospitalized in GM was higher. Beta Blocker were more often prescribed in UH and IC than in GM independent of age or existing comorbidities. Coronary angiography and Device therapy were more often performed in UH and IC than GM. UH seem to initiate device- therapies earlier and more often during routine care. On the other hand IC planned significantly more CRTs than UH and GM

Velocity characteristics of atrial fibrillation sources determined by electrographic flow mapping before and after catheter ablation

Background: Electrographic-Flow-(EGF)-Mapping is a novel method to identify Atrial Fibrillation (AF) drivers. Sources of excitation during AF can be characterized and monitored. Objective: The aim of this study was to evaluate the correlation between velocity of EGF around a respective AF source and its spatial variability (SV) and stability (SST). Methods: 25 patients with AF were included in this study (persistent: n = 24, long-standing persistent: n = 1; mean age 70 +/- 8.3 years, male: n = 17). Focal impulse and Rotor-Mapping (FIRM) was performed in addition to pulmonary vein isolation. One-minute epochs of unipolar electrograms recorded via a 64-pole basket catheter in both atria were re-analyzed with EGF-Mapping. SST was calculated as the percentage of time in which a source was detected. Results: AF sources identified with EGF-Mapping show a wide range of SV during 1 min covering between 0.12% and 38% of the recorded basket-catheter surface. The 12 atria where the sources showed highest temporal stability (TS; between 34% and 97% of 1 min recorded) and those 12 with the lowest TS (between 11 and 20%) differed significantly in their velocities (17.8 el/s vs 12.2 el/s; p < 0.01). In 11 atria ablation caused an average decrease of TS by 47% and of velocity by 27% while SV more than doubled. Conclusion: Less stable AF-sources with high spatial variability showed reduced excitation propagation velocity while stable AF sources displayed a high average velocity in their vicinity. Importantly, catheter ablation reduced stability of sources and velocity suggesting a role of these parameters in guidance of ablation. Condensed abstract: Electrographic Flow(EGF)-Mapping is a novel method to identify Atrial Fibrillation (AF) drivers based on modeling of an electrical potential surface and subsequent flow analysis. Sources of excitation during AF can be characterized and monitored. The aim of this study was to evaluate the correlation between velocity of EGF around a respective AF source and its spatial variability and stability. Less stable AF sources with high spatial variability showed reduced excitation propagation velocity while very stable AF sources displayed a high average velocity in their vicinity. Catheter ablation reduced stability of sources and velocity. Crown Copyright (C) 2019 Published by Elsevier B.V. All rights reserved

Patient characteristics.

<p>Plus-minus values are means ± standard deviation.</p

Cumulative recurrence rates (as estimated from the Cox regression model) in women and men according to tertile mean values of hematocrit, adjusted for location of first venous thromboembolism, body mass index, age, factor V Leiden, and smoking status.

<p>Cumulative recurrence rates (as estimated from the Cox regression model) in women and men according to tertile mean values of hematocrit, adjusted for location of first venous thromboembolism, body mass index, age, factor V Leiden, and smoking status.</p

Five-year cumulative recurrence risk as estimated from the Cox regression model in women (left) and men (right) at various hematocrits, adjusted for location of first venous thromboembolism, body mass index, age, factor V Leiden, and smoking status.

<p>The gray-shaded area corresponds to the 95% confidence intervals. The histograms at the bottom show the frequency distribution (n = number of patients) of hematocrit in women and men.</p