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Introduction: Currently, definition of success following atrial fibrillation (AF) ablation is commonly based on the lack of symptoms. The purpose of this study was to evaluate the correlation between symptoms and the underlying rhythm after AF ablation. Methods and Results: Eighty consecutive patients (pts) were treated for paroxysmal episodes of AF by segmental ostial ablation of all pulmonary veins and right atrial isthmus ablation. For 6 months pts transmitted transtelephonic (T-) ECG recordings in combination with comments daily or in the event of symptoms. Eligible comments were classified as: (1) asymptomatic, (2) symptomatic. Analysis was performed at 1-month intervals, defining an acute (first month) and chronic period (second to sixth month) after ablation. Overall 6,835 T-ECGs were analyzed. Of these 5,437 (79.5%) showed sinus rhythm (SR) and 1,398 (20.5%) showed AF. Pts in SR reported symptoms for 593 (10.9%) episodes, whereas 4,844 (89.1%) episodes were asymptomatic. During AF, 646 (46.2%) episodes were associated with symptoms, and 752 (53.8%) episodes remained asymptomatic. Exclusively asymptomatic were 7 (8.8%) pts. In 30 (52.6%) of 57 pts with AF, arrhythmic events were confined to the acute phase. Of the remaining 27 pts 14 (52%) reported an improvement, 12 (44%) the same, and 1 (4%) worsened symptoms after 3 months. A significant change (P < 0.01) toward more asymptomatic episodes from the acute (43.5%) to the chronic (57.5 ± 4.5%) period was evident. Conclusion: Assessment of success after AF ablation cannot be based on the absence of symptoms due to a high prevalence of asymptomatic episodes.

Amiodarone Effect on PV Electrophysiologic Properties. Introduction: Pulmonary veins (PVs) are the predominant location of triggers for atrial fibrillation (AF), but little is known about the electrophysiologic propertiesof PVs. In addition, the influence of amiodarone on the electrophysiologic properties of PVs has not been elucidated. Methods and Results: Fifty-five patients with symptomatic and drug-resistant AF were divided into two groups: group 1 patients (n = 29) without antiarrhythmic drug therapy at the time of electrophysiologic study (EPS), and group 2 patients (n = 26) undergoing continuous long-term treatment with amiodarone. EPS including programmed stimulation of both atria and within the PVs was performed in both groups. In group 1, the effective refractory period (ERP) of all PVs (174 ′ 62 msec) was significantly shorter than the ERP of the left atrium ([LA] 254 ′ 30 msec, P = 0.0001) and right atrium ([RA] 221 ′ 29 msec, P = 0.0001). The same pattern was observed in group 2 (PV: 210 ′ 58 msec; LA: 259 ′ 35 msec, P = 0.0001; RA: 246 ′ 37 msec, P = 0.0255). The ERP of all stimulated PVs was significantly lower in group 1 (174 ′ 62 msec) than in group 2 (210 ′ 58 msec; P = 0.0001). The ERP of the left superior and right superior PVs and RA but not the left inferior PV and LA were significantly increased in patients treated with amiodarone. Decremental conduction properties were observed in all stimulated PVs, and there were no significantly differences between the maximal decrement of both groups. Conclusion: The distinctive electrophysiologic properties of PVs are emphasized by amiodarone therapy. Long-term amiodarone treatment is responsible for heterogeneous alteration of the PV electrophysiology, which may account for the individual antiarrhythmic responses in a subset of patients with paroxysmal AF.

Cooled Versus Large-Tip Catheters for Flutter Ablation. introduction: Open cooled-tip and solid 8-mm-tip catheters have demonstrated safety and effectiveness for radiofrequency current (RFC) ablation of typical atrial flutter (AFL). However, data from prospective and randomized studies in this setting are lacking. Methods and Results: One hundred thirty consecutive patients (104 men; 61 ′ 11 years) with AFL were randomized to undergo RFC catheter ablation either using a solid 8-mm-tip catheter (group A, 65°C, 70 W, 60 s) or an open irrigated-tip catheter (group B, 65°C, 50 W, 60 s, 17 mL/min flow). Endpoint was bidirectional conduction isthmus block. In cases of repeated (two times) transient isthmus block; the catheter was changed (crossed over) to the catheter used in the other randomization arm, but patients remained in the original group following intention-to-treat analysis. The selected endpoint could be achieved in all patients after 12 ′ 6 RFC pulses in group A and 10 ′ 7 RFC pulses in group B (P = 0.11). Procedure times were longer (159 ′ 38 min vs 138 ′ 37 min, P = 0.002) and x-ray exposures higher in group A (fluoroscopy time 25 ′ 17 min vs 21 ′ 10 min, P = 0.08; x-ray dosage 3,133 ′ 2,576 cGy.cm 2 vs 2,326 ′ 1,405 cGy.cm 2 , P = 0.03). Transient isthmus block was observed in 23 group A patients and 12 group B patients (P = 0.03). Onset time of transient isthmus block ranged from 0.5 to 27 minutes. Repeated transient isthmus block occurred in 8 of the 23 patients in group A after 19 ′ 3 RFC applications. After crossover to the cooled-tip catheter, the endpoint was reached another 5 ′ 1 RFC pulses. In group B, all patients could be treated without change of ablation catheter. After a follow-up of 14 ′ 2 months, 2 patients (3%) in group A and 1 patient (1.5%) in group B presented with AFL recurrence. Conclusion: Open cooled-tip catheters are more effective than solid large-tip catheters for AFL ablation. The greater effectiveness is evident in cases showing repeated conduction recovery within the cavotricuspid isthmus. Primary use of open irrigated-tip catheters should be considered for AFL ablation.

The present study sought to investigate the electrophysiological properties of isolated pulmonary veins following successful radiofrequency (RF) catheter ablation in patients with paroxysmal atrial fibrillation (PAF). Overall, 71 pulmonary veins in 37 consecutive patients (age:56 ± 9 years) with recurrent PAF were targeted for RF ablation at the ostial region in order to achieve a complete functional block. Following disconnection, the incidence of dissociated pulmonary vein (PV) activity and its response to orciprenalin were studied. RF ablation abolished conduction in 67 (94%) of 71 potentially arrhythmogenic PVs after a mean of10.7 ± 6.4 RFapplications for each PV. After ablation, spontaneous dissociated automatic activity (9 to 52 beats/min, median 27) was found in 6 out of 67 isolated PVs (left superior:n = 1, left inferior:n = 1, right superior:n = 2, common left PV:n = 2). Slight acceleration (13 to 68 beats/min, median 29) of dissociated PV activity was observed during infusion of orciprenalin. Following isolation, initiation of sustained or nonsustained local fibrillation was recorded in only two cases of the common left sided PV with preceding automatic activity. In one patient PV fibrillation occurred during orciprenalin infusion following a repetitive response to a dissociated automatic rhythm with increasing duration as well as destabilization. In the other patient, PV fibrillation occurred immediately after the occurrence of PV automaticity. Slow dissociated automatic rhythms are detectable within 9% of disconnected PVs. The unique anatomic substrate of common left PVs seem to favor the occurrence of local fibrillation following isolation. The initiation pattern of fibrillation within the isolated PV has pathophysiological implications and underlines the contribution of multiple factors to the onset and sustenance of PAF. (PACE 2003; 26:1363–1370)

Automatic threshold tracking (Autocapture) controls the amplitude of the pacing pulse and adjusts it to the actual pacing threshold. The algorithm is based on the proper detection of the evoked response (ER) amplitude after the pacing pulse. For this reason an intraoperative evaluation of ER and polarization is recommended. The aims of the study were to evaluate the ER signal and polarization and the performance of automatic threshold tracking without any intraoperative testing of the ER signal. In addition, the ER amplitude was correlated with the pacing threshold, pacing impedance, spontaneous R wave amplitude, and with the clinical data. The study included 60 patients who received the VVIR pacemaker Regency connected to the Membrane E 1450/1452 pacing lead (St. Jude-Pacesetter). At implantation, a pacing threshold < 0.7 V at 0.5 ms was achieved in all patients. ER and polarization were assessed for the first time at hospital predischarge testing. Follow-up measurements were conducted at month 1, 3, and 6. The ER amplitude at hospital discharge was 8.4 +/- 4.2 mV and increased to 9.4 +/- 4.8 mV at the 6-month follow-up. The pacemaker recommended not to program automatic threshold tracking on in one patient permanently and in three patients intermittently. The ER amplitudes were not differently distributed in men compared with women or in right-sided compared to left-sided implants. The correlation between age and the evoked response was r = 0.15. The correlation between ER amplitude and pacing threshold was r = -0.08, with pacing impedance r = 0.02, and with R wave amplitude r = 0.44. In conclusion, despite no operative evaluation of the ER amplitude being performed, the mean ER amplitude was about 9 mV at 6-month follow-up. Automatic threshold tracking could be programmed on in 93% of the patients throughout the time. Neither the clinical data nor the conventional electrical parameters help to predict patients who will have low ER amplitude or to optimize the ER signal at implantation.

AVNRT in the Elderly. Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common regular supraventricular tachycardia in the general population as well as in elderly patients. The purpose of thestudy was to investigate the success and complication rate particularly regarding the induction of an atrioventricular (AV) block by radiofrequency (RF) ablation in elderly patients with and without a preexisting AV block. Methods and Results: Between February 1998 and July 2004, all patients with symptomatic AVNRT referred for slow-pathway ablation in our institution were included and divided into two groups: group 1 patients younger than 75 years (n = 508) and group 2 patients >75 years (n = 70). A preexisting prolonged PR interval was present in 17 (3.3%) patients of group 1 and in 26 (37%, P < 0.0001) patients of group 2. Following successful slow-pathway ablation (follow-up time group 1: 37 ′ 22, group 2: 37 ′ 24 months) no induction of an AV block was observed in group 2 but in four patients of group 1 (0.79%) a complete heart block was induced requiring a pacemaker implantation. In group 1, 15 (2.95%) patients with a recurrence of AVNRT were readmitted for a repeat ablation procedure. No recurrences occurred in group 2. Conclusion: Despite a higher incidence of preexisting prolonged PR intervals slow-pathway ablation in elderly patients is both effective and safe and should be considered as the first line therapy also in this patient population.

Pulmonary vein (PV) isolation for the treatment of atrial fibrillation is limited by procedure related complications, such as PV stenosis and occlusions. We report about a PV isolation using a circumferential cryoablation catheter which applies the ablation energy simultaneously at the entire circumference by cooling down to a minimal temperature of −80°C. (PACE 2004; 27:1024–1025)