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Background: Chronic thromboembolic pulmonary hypertension (CTEPH) may lead to typical electrocardiographic changes that can be reversed by balloon pulmonary angioplasty (BPA). The aim of this study was to investigate the significance of rarely used electrocardiogram (ECG) parameters, possible electrocardiographic differences between residual and significantly improved CTEPH and the role of electrocardiographic parameters in low mPAP (mean pulmonary arterial pressure) ranges since the mPAP threshold for the definition of pulmonary hypertension has recently been adjusted (≥25 mmHg to >20 mmHg). Material and Methods: Between March 2014 and October 2020, 140 patients with CTEPH and 10 with CTEPD (chronic thromboembolic pulmonary disease) without pulmonary hypertension (PH) were retrospectively enrolled (12-lead ECG and right heart catheterization before and 6 months after BPA). The ECG parameters of right heart strain validated by studies and clinical experience were evaluated. Special attention was paid to six specific ECG parameters. After BPA, the cohort was divided into subgroups to investigate possible electrocardiographic differences with regard to the haemodynamic result. Results: The present study confirmed that the typical electrocardiographic signs of CTEPH can be found on an ECG, can regress after BPA and partially correlate well with haemodynamic parameters. "R V1, V2 + S I, aVL − S V1" was a parameter of particular note. BPA reduced its frequency (47% vs. 29%) statistically significantly after Bonferroni correction (p < 0.001). Moreover, it showed a good correlation with mPAP and PVR (r-values: 0.372–0.519, p-values: < 0.001). Exceeding its cut-off value before therapy was associated with more severe CTEPH before therapy (higher mPAP, PVR, NT-pro-BNP and troponin and lower TAPSE) and an increased risk of death. Exceeding its cut-off value before and after therapy was associated with more severe CTEPH after therapy (higher RAP, mPAP, PVR, NT-pro-BNP and NYHA class) and an increased risk of death. Men tend to be affected more frequently. After subgrouping, it was observed that a higher median mPAP was associated with a higher right atrial pressure (RAP), a higher pulmonary vascular resistance (PVR) and a lower cardiac output (CO) before and after BPA. In addition, under these conditions, more and more severe electrocardiographic pathologies were detected before and after BPA. Some patients with low mPAP also continued to show mild ECG changes after BPA. In some cases, very few to no pathological ECG changes were detected, and the ECG could present as mostly normal in some patients (5% before BPA and 13% after BPA). Conclusion: "R V1, V2 + S I, aVL − S V1" seems to be able to support the diagnosis of CTEPH, indicate therapeutic improvement and estimate haemodynamics. It also seems capable of predicting a (persistent) severe disease with probably increased need for therapy and increased mortality. Mild PH has been observed to have either no or few mild ECG changes. This might complicate the (early) detection of PH. [ABSTRACT FROM AUTHOR]

Background: Silent cerebral microembolic events (SCE) after duty-cycled ablation of atrial fibrillation using PVAC have been detected by cerebral magnet resonance imaging (MRI) in a substantial number of patients. The purpose of this study was to investigate if uninterrupted oral anticoagulation with non-vitamin K antagonists (NOACs) compared with vitamin K antagonists (VKA) affects the incidence of SCE after pulmonary vein isolation (PVI) using PVAC Gold. Methods: Eighty-four consecutive patients (62 ± 15 years, 58% male) undergoing a first PVI were prospectively enrolled. Of these, 42 were on VKA and 42 on uninterrupted NOAC treatment. An activated clotting time (ACT) ≥ 350 s was targeted for ablation. Results: Cerebral MRI the day after PVI revealed acute diffusion-weighted positive lesions in 11/42 (26%) VKA compared with 14/42 (33%) in NOAC patients (p = 0.634). No differences were found for lesion size, number of lesions/patient, and number of lesions indicating cerebral infarction (2.4% for VKA and 4.8% for NOAC patients). Seventy-five percent of NOAC patients with sporadic ACT levels < 300 s during PVI developed SCE compared with 22% of corresponding VKA patients (p = 0.030). VKA and NOAC subgroups with ACT ≥ 350 s had no reduced incidence of SCE compared with ACT 300–350 s. Conclusions: A significant, but comparable, number of patients under uninterrupted anticoagulation with VKA or NOACs still experience SCE after PVAC Gold PVI. NOAC patients with sporadic subtherapeutic ACT levels during PVI are at the highest risk for SCE while permanent ACT levels ≥ 350 s did not further reduce the incidence of SCE in both groups. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) with 2nd-generation cryoballoon (CB) has been shown to be effective in the treatment of paroxysmal atrial fibrillation (AF). We describe pulmonary vein (PV) reconnection at repeat ablation in patients with AF recurrence after CB PVI and analyze the correlation between the time of AF recurrence and the observed PV reconnection patterns. Methods: Sixty-six patients undergoing a redo PVI for recurrent AF were enrolled 9.1 ± 2.6 months after the initial CB PVI procedure. Results: Ninety-two percent had PV reconnections with a mean of 1.97 ± 0.8 reconnected PVs/patient, and 52% of formerly isolated PVs were found reconnected. The highest reconnected rates were observed for left superior PVs (67%). Fifty-three percent of the patients had 2 reconnected PVs, no patient had all PVs reconnected, and 8% were without PV reconnection. There was a significant negative correlation between the time of AF recurrences and the extent of PV reconnections at redo PVI for patients with proven PV reconnection in more than one PV (R = 0.52, p < 0.001), while all patients without PV reconnection had AF recurrences within the first 9 months after PVI. Conclusions: At redo ablation, most patients with recurrence of AF after CB PVI had PV reconnection(s). Patients with PV reconnection(s) showed a negative correlation between the number of reconnected PVs and the time of AF recurrence with more extensive PV reconnections resulting in earlier PV recurrences after the blanking period. Patients without PV reconnection experienced early AF recurrences, indicating non-PV triggers contributing for paroxysmal AF recurrences in these patients. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) using second‐generation cryoballoon (CB2) is considered to be safe and effective in the treatment of atrial fibrillation (AF). Reported radiation exposure during PVI with CB2 is higher if compared with other technologies. We investigated acute and mid‐term effects of a modified fluoroscopy protocol to minimize radiation exposure during CB2 PVI with regard to safety and efficacy. Methods: The study comprised 180 consecutive patients undergoing CB2 PVI. In the first 100 patients, PVI was performed using conventional fluoroscopy settings (group 1), while the following 80 patients (group 2) received PVI with a modified protocol. The protocol consisted of (a) general reduction of fluoroscopy frame rate to 3/s, (b) avoidance of cine runs and selective PV angiograms, and (c) enhanced radiation awareness. Retrospective data analysis was performed in respect to dose area product (DAP), fluoroscopy time, and freedom from AF during a 12‐month follow‐up. Results: Group 2 patients had lower DAP (426 ± 433 vs 3334 ± 2271 cGycm2), fluoroscopy time (13.8 ± 6.3 vs 16.7 ± 5.6 minutes), LA dwell time (49.3 ± 15.5 vs 61.6 ± 16.2 minutes), and procedure time (85.5 ± 22.9 vs 94.9 ± 23.6 minutes); P <.01 for all. One‐year freedom from AF was comparable between both groups (71% group 1 vs 73% group 2, ns). Conclusion: Radiation exposure and procedure time during CB2 PVI can be significantly reduced by using a modified fluoroscopy protocol and increased radiation awareness without compromising acute and 1‐year freedom from AF if performed by experienced operators. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) using phased radiofrequency (RF) energy has been shown to be effective in the treatment of atrial fibrillation (AF).Methods: We characterize and compare pulmonary vein (PV) reconnection at repeat ablation in patients with AF after initially successful PVI using phased RF technology (PVAC) or 2nd generation cryoballoon (CB). Eighty five patients undergoing redo PVI using multielectrode PVAC phased RF catheter and 66 patients after CB PVI were enrolled 9.7 ± 3.4 months after the initial ablation procedure.Results: The percentage of patients with PV reconnection(s) was comparably high between both groups (93% PVAC and 92% CB). However, 75% of all PVs and left common trunks (CTs) isolated with PVAC were reconnected, compared with 52% reconnections after CB PVI (p < 0.001). A mean of 2.79 ± 1.2 PVs and CTs/patient were reconnected after PVAC PVI compared with 1.97 ± 0.8 in CB patients, p < 0.0001. No patients in the CB group had 4 reconnected PVs, while this pattern of reconnection was observed in 33% in the PVAC group (p < 0.0001). The percentage of patients in the PVAC group with ≥3 reconnected PVs was significantly higher compared with CB patients (56 patients (66%) vs. 17 patients (26%), p < 0.0001), while the percentage of patients with no PV reconnection was comparably low in PVAC and CB patients (7 and 8%, respectively). CTs were most frequently reconnected after PVAC PVI (94%) and left superior PVs after CB ablation (67%), respectively.Conclusions: The number of patients with recurrent AF and PV reconnection(s) at redo PVI was comparably high between both groups. However, the extent and distribution of PV reconnections was different in many aspects, indicating more stable atrial lesions after CB PVI compared with PVAC technology. [ABSTRACT FROM AUTHOR]

Background: Conventional catheter ablation of right-sided accessory pathways (RAPs) can be challenging.Objective: To determine if a subvalvular catheter approach for RAPs targeting the ventricular insertion site, as on the left side, can improve catheter stability and tissue contact and thus increase acute and chronic ablation success rates.Methods and Results: We retrospectively compared 22 patients (pts) with conventional catheter ablation of RAPs (group 1) with 9 consecutive pts (group 2) undergoing catheter ablation of a RAP using a subvalvular catheter approach targeting the ventricular site of AP. Ablation failed in 2/22 group 1 vs 0/9 group 2 pts (ns) and recurrences of AP conduction were registered in 4/19 group 1 vs 1/9 group 2 pts (ns) during follow-up. Significant shorter values were found in group 2 pts compared with group 1 for number of RF applications (3.6 ± 1.6 vs 8.2 ± 4.3), AP block time (6.2 ± 2.4 vs 9.2 ± 3.9 min), fluoroscopy time (17.2 ± 6.9 vs 25.6 ± 10.3 min), and procedure time (70.8 ± 23.9 vs 138 ± 44.4 min). There were no procedure related complications.Conclusion: Catheter ablation of RAPs using a subvalvular approach seems as effective and safe compared with conventional ablation but with reduced procedure time and radiation exposure and might be at least considered an alternative after failed conventional catheter ablation of RAPs. [ABSTRACT FROM AUTHOR]

Objective: To determine and compare the incidence of early recurrence of conduction after pulmonary vein isolation (PVI) using two different ablation technologies: phased radiofrequency by a multipolar ablation catheter (PVAC) and cryo‐ablation by a second‐generation cryoballoon (CB). Methods and Results: Two hundred patients (pts) with atrial fibrillation underwent PVI with PVAC (Group 1) or CB (Group 2), with 100 pts in each group. The incidence of PV reconnection (PVR) for each vein was examined in both groups at least 30 minutes after successful PVI. There were no significant clinical differences between both groups. Total procedure‐, fluoroscopy‐, and left atrial (LA) dwell time were significantly shorter in Group 2 pts (P < .0001). Early PVR was recorded in 69/388 (18%) isolated PVs or left common trunks (CTs) in Group 1 compared with 25/386 (7%) in Group 2 (P < .0001). Forty‐three pts in Group1 were found to have PVR compared with 22 pts in Group 2 (P = .0015). Group 1 pts with CTs showed significantly more PVR than pts of Group 2 (P = .047). In both groups, CTs and CT branches were found to reconnect significantly more frequent compared with all other veins. Conclusion: Both PVAC and CB are effective to achieve PVI. Early PVR is observed with the significantly lower frequency with second‐generation CB compared with PVAC, contributing to shorter procedure‐, fluoroscopy, and LA dwell times. CTs and CT branches exhibit the highest incidence of PVR for both devices. [ABSTRACT FROM AUTHOR]

Background. Prolongation of the corrected QT (QTc) interval is well known for many drugs, some of which are an integral part of the therapeutic regimen after lung transplantation (LTX). Therefore, we investigated the QTc interval after LTX in the present study. Patients and Methods. The medical records of patients after LTX were studied for demographic data, indication of LTX, medication, and baseline and follow-up ECGs. The QT interval was corrected for the patient’s heart rate using the different formulae of Bazett, Fridericia, Hodges, and Framingham. Results. Fifty-nine patients were included. The mean age ± SD was 55.6±7.8 years (median 58 years). After LTX, QTc intervals showed no (relevant) changes during follow-up, even though all patients were treated with drugs (in combination) known to bear a risk of prolonged QTc interval and cortisone. The longest QTc intervals were obtained using Bazett’s formula. Conclusion. The QTc interval did not increase under immunosuppressive medication after LTX in our cohort of patients. We speculate that the concurrent use of cortisone may shorten the QT(c) intervals or cancel out drug-induced prolongation of the QTc interval. [ABSTRACT FROM AUTHOR]

Background. Increased pulmonary vascular resistance in patients with pulmonary hypertension (PH) leads to an increased afterload of right heart and cardiac remodeling which could provide the substrate or trigger for arrhythmias. Supraventricular arrhythmias were associated with clinical deterioration but were not associated with sudden cardiac death (SCD). SCD has been reported to account for approximately 30% of deaths in patients with pulmonary arterial hypertension (PAH). Objective. The role of nonsustained ventricular tachycardia (nsVT) and its prognostic relevance in patients with PH remains unclear. This study evaluated the prognostic relevance of nsVT in patients with PAH and chronic thromboembolic pulmonary hypertension (CTEPH). Methods. Retrospectively, patients with PAH and CTEPH who underwent Holter ECG monitoring and available data of survival were investigated. Results. Seventy-eight (PAH: 55, CTEPH: 23) patients were evaluated. Holter ECG revealed nsVT in 12 patients. Twenty-one patients died during follow-up. In patients with nsVT, tricuspid annular plane systolic excursion was lower (p=0.001), and systolic pulmonary arterial pressure was higher (p=0.163). Mean survival of patients without/with nsVT was 155.2 ± 8.5/146.4 ± 21.4 months (p=0.690). The association between arrhythmias and survival was not confounded by age (p=0.681), gender (p=0.752), 6-MW distance (p=0.196), or arterial hypertension (p=0.238). Conclusions. In patients with PH, nsVT occurs more often than previously reported, and patients with PH group 1 seem to be more at risk. [ABSTRACT FROM AUTHOR]

Aims There are only few descriptions of patients without prior cardiac surgery in whom a large low-voltage zone (LVZ) or scar is the electrophysiological substrate for various atrial tachycardias. We describe the electrophysiological and electroanatomic characteristics of unusual macroreentrant atrial tachycardias (MRATs) in seven patients with spontaneous right atrial (RA) scarring and present long-term follow-up results. Methods and results In 7 of 326 patients with MRAT treated with radiofrequency ablation we detected regions of RA spontaneous LVZ or scarring during conventional mapping of the arrhythmia. They underwent electroanatomic mapping and catheter ablation of the spontaneous and further induced arrhythmias with a long-term follow-up. A total of 17 different atrial tachycardias were observed with typical atrial flutter in four patients. In five patients a LVZ was found in the RA free wall and two patients had a septal scar. Stable circuits were around the scar or LVZ in four patients and through a ‘channel’ within the scar in two. Radiofrequency ablation sites included the cavotricuspid isthmus for typical atrial flutter, between the inferior vena cava and scar, a channel in the scar or the left atrial (LA) mitral isthmus. During follow-up of 34 ± 5 months, four patients were free from atrial tachycardias. Both patients with a septal RA scar developed LA tachycardias, requiring further catheter ablation. One patient presented with a novel type of atypical scar-related RA flutter. Conclusion Mapping and ablation of scar-related RA tachycardias is an effective treatment but does not preclude the development of further tachycardias, some of them arising from the LA during long-term follow-up. [ABSTRACT FROM PUBLISHER]

Asymptomatic Cerebral Lesions with Phased RF. Introduction: Left atrial catheter ablation of the pulmonary veins (PVs) is an established option for patients with atrial fibrillation (AF). Asymptomatic cerebral emboli (ACE) detected by diffusion weighted MRI (DW-MRI) following AF ablation has been reported at varying rates. This variability may be linked to procedural variables and demographic risk factors. Animal studies with the multielectrode pulmonary vein ablation catheter (PVAC) have identified potential sources of emboli, including air introduced during PVAC introduction, inadequate anticoagulation, and high current densities when the distal (E1) and proximal (E10) electrodes are in contact. We sought to evaluate the incidence, size, and number of DW-MRI findings with procedural modifications that potentially reduce the embolic load. Methods: Thirty-seven AF patients (59 ± 10 years, 73% male, all with paroxysmal AF, left atrial [LA] diameter 44 ± 7 mm, left ventricular ejection fraction 57 ± 7%) underwent MRI sequences preceding ablation, within 24 hours postablation, and at 4-6 weeks. During the procedure all patients were on uninterrupted phenprocoumon, an attempted activated clotting time (ACT) level >300 seconds, had the PVAC introduced under saline, and antral ablation was started with a 2:1 bipolar/unipolar mode. Files from the ablation unit (GENius v14.4) were retrospectively analyzed to determine the relationship between E1 and E10 in close proximity and DW-MRI findings. Results: Post procedure, 10/37 patients (27%) were positive for new DWI cerebral lesions. Nine of 10 patients had a single lesion, and 1/10 patient had 2 lesions. Average lesion size was 3.1 ± 3.9 mm (2-14 mm). One of 10 (10%) had lesions at MRI follow-up. No neurological symptoms were observed. Eighteen of 37 (49%) of procedures had evidence of E1/E10 interaction. In the subgroup of patients with and without E1 and E10 in close proximity, the DW-MRI rate was 8/18 (44%) and 2/19 (11%), respectively (P = 0.029). Conclusions: The source of positive DW-MRI findings in LA ablation involves several factors. Controlling anticoagulation and careful sheath management helps to reduce the number and size of DW-MRI lesions. With the PVAC catheter, an ablation with the E1 and E10 in close proximity increases the risk of a DW-MRI finding. In the future, electrodes E1 and E10 should be kept apart to help reduce the incidence of acute ACE. (J Cardiovasc Electrophysiol, Vol. 24, pp. 121-128, February 2013) [ABSTRACT FROM AUTHOR]

Purpose: Pulmonary vein isolation (PVI) using phased radiofrequency (RF) energy has been shown to be effective in the treatment of paroxysmal atrial fibrillation (AF). We characterize pulmonary vein (PV) conduction at repeat ablation in patients with AF after an initial successful PVI using phased RF technology and analyze the effects of a primary 2:1 ablation mode. Methods and results: A primary 4:1 bipolar/unipolar mode in group A patients ( n = 22) was compared with a primary 2:1 mode in group B ( n = 22) acutely and during follow-up. Of all PVs, 81 % showed reconnection(s); 52 % of them had reconnected in all PVs. PVI was achieved in all patients without complications. Procedure and fluoroscopy times were shorter in group B (108 ± 15 vs. 126 ± 24 min and 17 ± 5 vs. 23 ± 7 min, respectively). This was attributed to a significant decrease of early PV reconnections within the first 30 min in 17 % of group B patients vs. 45 % of group A patients ( p < 0.001). After 9.5 ± 4 months, recurrence of AF was detected in 5 of 22 patients (22.7 %) in group A vs. 3 of 22 patients (13.6 %) in group B ( p = 0.722). Conclusions: Phased RF energy applied by a 2:1 bipolar/unipolar mode seems safe and effective in redo-PVI procedures, resulting in a mid-term freedom from AF in 86.4%. Significant shorter procedure and fluoroscopy times compared with a primary 4:1 ablation mode during repeat PVI are mainly attributed to a lower incidence of acutely reconnected PVs within the first 30 min. [ABSTRACT FROM AUTHOR]

Background and Aims. The study was a repeated evaluation of the experience of capsule endoscopy (CE) in patients with cardiac pacemaker or implantable cardioverter defibrillator (ICD). Patients and Methods. A standardized questionnaire was sent by the manufactors Given Imaging and Olympus to all centers in Germany, Austria, and Switzerland providing capsule endoscopy service. The questionnaire covers the number of examined patients, monitoring during CE, check of the electric implants before and after CE, occurrence of arrhythmia, quality of CE video, complications, indication of CE, and type of institution. Results. Overall 580 questionnaires were sent to the users. 26/5% (Germany/Austria + Switzerland) of the questionnaires were sent back anonymously to the authors. 114 centers (82 hospitals, 11 surgeries, 21 without specification) replied. In 58 centers (51%), patients with cardiac pacemaker (n = 300) and ICDs (n = 80) underwent uneventful capsule endoscopy. The predominant indication (patients with CP 97%, patients with ICD 100%) was mid gastrointestinal bleeding. Conclusion. The results of our inquiry show that in spite of formal contraindication CE is increasingly applied in bleeding patients with cardiac pacemakers/ICDs and seems to be safe even in a large cohort. [ABSTRACT FROM AUTHOR]

Aims Conventional mapping and catheter ablation of non-sustained focal atrial tachycardia (AT) can be challenging and time consuming. We examined the characteristics and clinical outcomes after catheter ablation of recurrent, sustained AT presenting as non-sustained tachycardia during electrophysiological studies (EPSs), using a non-contact mapping system. Methods and results In 9 of 88 consecutive patients undergoing ablation of sustained right AT, the tachycardia was non-sustained during EPSs, precluding conventional mapping. We used a non-contact system to map and guide the catheter ablation of brief induced episodes of AT. Atrial tachycardia originated in the crista terminalis (CT) in three patients, tricuspid annulus (TA) in four, posterior right atrium (RA) in one, and mid cavo-tricuspid isthmus in one patient. A QS morphology of the earliest virtual unipolar electrogram was systematically found at the site of successful catheter ablation. The breakout sites were near the CT in six, TA in three, posterior RA in one and anterior RA in one patient. In two patients, two separate breakout sites were identified. All AT (i) were focal and (ii) propagated preferentially to the breakout site(s) before depolarizing the atria. A mean of 5 ± 2 applications of radiofrequency energy was delivered without complications. Procedural duration and fluoroscopic exposure with the non-contact mapping system were 44 and 12 min, respectively. Over a follow-up of 16 ± 11 months, eight of nine patients remained asymptomatic, while in one patient a ‘novel’ AT emerged during follow-up. Conclusion Catheter ablation of non-sustained AT, using a non-contact mapping system, was safe and eliminated sustained AT. [ABSTRACT FROM PUBLISHER]

Background and Study Aims. Capsule endoscopy is an established tool for investigation of the small intestine. Because of limited clinical experience in patients with cardiac devices, the Food and Drug Administration and the manufacturer recommended not to use capsule endoscopy in these patients. The vast majority of investigations did not reveal any interference between capsule endoscopy and cardiac devices. Methods. Studies investigating interference between CE and cardiac devices were analysed. For the review we considered studies published in English or German and indexed in Medline, as well as highly relevant abstracts. Results. In vitro and in vivo studies mainly revealed no interference between capsule endoscopy and cardiac devices. Technical data of capsule endoscopy (Given Imaging) reveal that interference with cardiac pacemakers and implantable cardioverter defibrillator is impossible. Telemetry can interfere with CE video. Conclusion. The clinical use of capsule endoscopy (Given Imaging) is unproblematic in patients with cardiac pacemakers. [ABSTRACT FROM AUTHOR]

PV Isolation Using Bipolar/Unipolar RF Energy. Background: Electrical disconnection of the pulmonary veins (PV) plays an important role in the ablation of paroxysmal atrial fibrillation (AF). Antral ablation using a conventional steerable ablation catheter often is technically challenging and time consuming. Methods: Eighty-eight patients (mean age 58 ± 11 years) with symptomatic paroxysmal AF underwent ablation with a circular mapping/ablation decapolar catheter (PVAC). Ablation was performed in the antral region of the PVs with a power-modulated bipolar/unipolar radiofrequency (RF) generator using 8–10 W delivered simultaneously through 2–10 electrodes, as selected by the operator. Seven-day Holter monitor recordings were performed off antiarrhythmic drugs at 3-, 6-, and 12-month follow-up, and patients were requested to visit the hospital in the event of ongoing palpitations. All follow-up patients were divided into 2 groups: Group 1 with a follow-up of less than 1 year and group 2 patients completing a 1-year follow-up. Results: Overall, 338 of 339 targeted PVs (99%) were isolated with the PVAC with a mean of 24 ± 9 RF applications per patient, a mean total procedure time of 125 ± 28 minutes, and a mean fluoroscopy time of 21 ± 13 minutes. Freedom from AF off antiarrhythmic drugs was found in 82 and 79% of group 1 and group 2 patients, respectively. No procedure-related complications were observed. Conclusion: PV isolation by duty-cycled unipolar/bipolar RF ablation can be effectively and safely performed with a circular, decapolar catheter. Twelve-month follow-up data compare favorably with early postablation results, indicating stable effects over time. (J Cardiovasc Electrophysiol, Vol. 21, pp. 399–405, April 2010) [ABSTRACT FROM AUTHOR]

Introduction An increasing number of patients undergo left atrial ablation procedures, since several approaches have proven efficacy in the treatment of atrial fibrillation. Although transseptal catheterization was generally shown be a safe technique, it harbors the principal risk of cardiac injury. Therefore, there is a need for a safe and effective tool to enable transseptal puncture in difficult cases as well. Methods and Results In 158 consecutive patients, a transseptal puncture was intended for mapping and ablation of left atrial tachycardias. In seven patients of this series transseptal puncture using different sheaths and needle designs, the operators failed to cross the interatrial septum as a result of severe tenting. Three patients were known to have a septal aneurysm; a redo procedure was performed in two patients. In the remaining patients, there was no obvious explanation for the difficulty in crossing the interatrial septum conventionally. In all seven patients, a 120-cm-long nitinol guidewire ("needle wire") with a 0.014-inch diameter was used to cross the atrial septum with the following idea: after tenting the fossa ovalis with the transseptal dilator and the Brockenbrough needle positioned just inside the tip, effortless advancement of the needle wire perforates the membranous fossa. Unsupported by the needle and dilator, the tip of the wire immediately assumes a "J" shape, rendering it incapable of further tissue penetration after its entry into the left atrium. In all seven patients, the needle wire could be placed into a left pulmonary vein. In five patients, a single attempt was sufficient to reach the left atrium with the wire, two patients needed two and three attempts, respectively. No complications occurred. Conclusions Additional use of a needle wire to perform transseptal puncture in a subset of patients at higher risk for complications appears safe and effective. [ABSTRACT FROM AUTHOR]

Background The electrical disconnection of the pulmonary veins (PV) plays an important role in the ablation strategy of paroxysmal atrial fibrillation (PAF). Circumferential antral ablation with a conventional ablation technique using a steerable ablation catheter is sometimes difficult to perform and does not always result in isolation of the targeted PV. Methods Patients with symptomatic PAF were treated with a novel circular mapping/ablation catheter (PVAC). Ablation was performed in the antral region of the PV with a power-modulated bipolar/unipolar RF generator using 8-10 W until isolation of the vein was achieved. Seven-day Holter monitor recordings were performed off antiarrhythmic drugs at 3 and 6 months after the initial procedure. A subgroup of patients had received an implantable recorder before ablation, and the device was interrogated at the same time. The primary objective of this study is acute isolation of the targeted PV, and the second objective is clinical efficacy with a short-term follow-up. Results In 73 patients, 290 PV could be reached with the PVAC. Antral ablation was performed in 244 PV showing PV potentials. Acutely, 243 PV (99%) were isolated with the PVAC after 21±7 energy applications per patient with a mean fluoroscopy time of 20±11 min. Total procedure time was 122±27 min. No complications were observed. Follow-up at 3 and 6 months showed freedom from AF in 61 of 73 (84%) patients and 38 of 45 patients (85%), respectively, off antiarrhythmic drugs. Conclusions PV isolation by duty-cycled unipolar/bipolar RF ablation can be effectively and safely performed with a circular, decapolar catheter. Clinical results at 3 and 6 months after ablation are encouraging with the need for longer follow-up intervals. [ABSTRACT FROM AUTHOR]

Background Ventricular ectopy (VE) originating in the right ventricular outflow tract (RVOT) is a common arrhythmia. Mechanisms triggering or eliminating VE from RVOT are not entirely understood. Methods and Results A patient with frequent, symptomatic VE underwent an electrophysiologic study: VE origin was mapped by NavX 3D navigation (St. Jude Medical, Inc., St. Paul, MN, USA). Incidental pressure applied manually to the sternum reproducibly eliminated VE for the time of exposure. Radiofrequency-ablation was successfully performed in the posterior RVOT. Conclusion The mechanism resulting in VE suppression remains speculative, since a mechanical alteration of the substrate for VE in the posterior RVOT by sternal pressure seems unlikely. 'Mechano-electrical feedback' might have been the mechanism operative in this case. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to an article about capsule endoscopy is safe in patients with cardiac pacemakers and implantable cardioverter defibrillators.