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Aims We aimed to assess the long-term effect of a strategy of comprehensive vasodilation versus usual care on health-related quality of life (HRQL) among patients with acute heart failure (AHF). Methods and results Health-related quality of life was prospectively assessed by the generic 3-levelled EQ-5D and the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ) among adult AHF patients enrolled in an international, multicentre, randomised, open-label blinded-end-point trial of a strategy that emphasized early intensive and sustained vasodilation using maximally tolerated doses of established oral and transdermal vasodilators according to systolic blood pressure. Changes in EQ-5D and KCCQ from admission to 180 day follow-up were individually compared between the intensive vasodilatation and the usual care group. Among 666 patients eligible for 180 day follow-up, 284 (43%, median age 79 years, 35% women) and 198 (30%, median age 77 years, 35% women) had completed the EQ-5D and KCCQ at baseline and follow-up, respectively. There was a significant improvement in HRQL as quantified by both, EQ-5D and KCCQ, from hospitalization to 180 day follow-up, with no significant differences in the change of HRQL between both treatment strategies. For instance, 39 (26%) versus 33 (25%) patients had an improvement by at least one level in at least two categories in the EQ-5D. Median increase in KCCQ overall summary score (KCCQ-OSS) was 17.6 (IQR 2.0–42.6) in the intervention group versus 18.5 (IQR 3.9–39.3) in the usual care group (P < 0.001 vs. baseline, P = 0.945 between groups). Conclusions Among patients with AHF, long-term HRQL quantified by EQ-5D and KCCQ improved substantially, with overall no significant differences between a strategy of comprehensive vasodilation versus usual care. [ABSTRACT FROM AUTHOR]

Introduction: The CLOSE protocol combines ablation index (AI) and ≤6 mm interlesion distance using standard power settings for the treatment of atrial fibrillation (AF). The purpose was to compare the safety and efficacy of a conventional CLOSE and a higher power shorter duration (HPSD)‐CLOSE pulmonary vein isolation (PVI) strategy. Methods and Results: All consecutive patients referred for PVI were included after informed consent was obtained from them. Group 1 was treated with a standard CLOSE protocol and group 2 with a HPSD‐CLOSE protocol (45 W anterior and 35 W posterior). Procedural parameters and 6‐month follow‐up were analyzed. In total, 174 patients (group 1: n = 94 [paroxysmal: n = 74]; group 2: n = 80 [paroxysmal: n = 65], similar baseline characteristics) were included. PVI was reached in all, but procedure duration (82 ± 18 minutes vs 100 ± 22 minutes; P < .0001) and radiofrequency (RF) time (23 ± 5 minutes vs 36 ± 11 minutes; P < .0001) was shorter in group 2. First pass isolation was similar in groups 2 and 1 (left veins: 94% vs 90%; P = .42 and right veins: 83% vs 84%; P = .79, respectively). Six‐month off‐ antiarrhythmic drugs freedom of AF/AT was similar in groups 2 and 1 (82% [paroxysmal: 86%] vs 83% [paroxysmal: 88%]; P = .93, respectively). Major complications were similar (group 2: 1% vs group 1: 3%; P = .39). Conclusion: A higher‐power short duration approach can shorten a CLOSE procedure and reduce ablation time without having a negative impact on safety or efficiency. [ABSTRACT FROM AUTHOR]

Background The number of patients with cardiovascular implantable electronic devices (CIEDs) is increasing. The purpose of this study was to compare three methods (sonication, swab cultures, and blood cultures) to detect bacteria in infections of CIEDs. Methods Patients with pocket infection of CIEDs and/or CIED-associated infective endocarditis were prospectively included. Generators and leads were sonicated together. Swab cultures of the generator pocket and blood cultures were performed. Results Between January 2009 and September 2012, 18 patients with a CIED infection were recorded, including two definite and four possible CIED-IEs. In 17 patients, blood cultures were performed and the device was analyzed by sonication. A swab culture from the device pocket was performed in 16 cases. Ten (59%) patients received antibiotic therapy before the device was removed. In 15 of 16 cases (94%), bacteria were detected by sonication, while bacteria were detected in only nine (56%) and seven (41%) cases by swab-and blood cultures, respectively. In four cases (24%), sonication was the only method that detected bacteria. The following bacteria were detected by sonication: methicillin-sensitive Staphylococcus aureus (MSSA; n = 6), coagulase-negative staphylococci (CNS; n = 3), Propionibacterium acnes (n = 2), Staphylococcus lugdunensis ( n = 1), MSSA/ Pseudomonas aeruginosa (n = 1), Bacillus cereus (n = 1), MSSA/ P. acnes (n = 1), and P. acnes/CNS (n = 1). All positive swab cultures and all positive blood cultures but one grew the same bacteria as sonication fluid cultures. Conclusion Sonication can be more sensitive than swab cultures or blood cultures in detecting bacteria in infections of CIEDs. [ABSTRACT FROM AUTHOR]

Aims Device-based pacing-induced diaphragmatic stimulation (PIDS) may have therapeutic potential for chronic heart failure (HF) patients. We studied the effects of PIDS on cardiac function and functional outcomes. Methods and results In 24 chronic HF patients with CRT, an additional electrode was attached to the left diaphragm. Randomized into two groups, patients received the following PIDS modes for 3 weeks in a different sequence: (i) PIDS off (control group); (ii) PIDS 0 ms mode (PIDS simultaneously with ventricular CRT pulse); or (iii) PIDS optimized mode (PIDS with optimized delay to ventricular CRT pulse). For PIDS optimization, acoustic cardiography was used. Effects of each PIDS mode on dyspnoea, power during exercise testing, and LVEF were assessed. Dyspnoea improved with the PIDS 0 ms mode ( P = 0.057) and the PIDS optimized mode ( P = 0.034) as compared with the control group. Maximal power increased from median 100.5 W in the control group to 104.0 W in the PIDS 0 ms mode ( P = 0.092) and 109.5 W in the PIDS optimized mode ( P = 0.022). Median LVEF was 33.5% in the control group, 33.0% in the PIDS 0 ms mode, and 37.0% in the PIDS optimized mode ( P = 0.763 and P = 0.009 as compared with the control group, respectively). PIDS was asymptomatic in all patients. Conclusion PIDS improves dyspnoea, working capacity, and LVEF in chronic HF patients over a 3 week period in addition to CRT. This pilot study demonstrates proof of principle of an innovative technology which should be confirmed in a larger sample. Trial registration NCT00769678. [ABSTRACT FROM AUTHOR]

Background Multidetector computed tomography (MDCT) may be useful to identify patients with patent foramen ovale (PFO). The aim of this study was to analyze whether a MDCT performed before pulmonary vein isolation reliably detects a PFO that may be used for access to the left atrium. Methods and Results In 79 consecutive patients, who were referred for catheter ablation of symptomatic paroxysmal or persistent atrial fibrillation (AF), the presence of a PFO was explored by MDCT and transesophageal echocardiography (TEE). TEE was considered as the gold standard, and quality of TEE was good in all patients. In 16 patients (20.3%), MDCT could not be used for analysis because of artifacts, mainly because of AF. On TEE, a PFO was found in 15 (23.8%) of the 63 patients with usable MDCT. MDCT detected six PFO of which four were present on TEE. This corresponded to a sensitivity of 26.7%, a specificity of 95.8%, a negative predictive value of 80.7%, and a positive predictive value of 66.7%. The receiver operating characteristics curve of MDCT for the detection of PFO was 0.613 (95% confidence interval 0.493-0.732). Conclusions MDCT may detect a PFO before pulmonary isolation. However, presence of AF may lead to artifacts on MDCT impeding a meaningful analysis. Furthermore, in this study sensitivity and positive predictive value of MDCT were low and therefore MDCT was not a reliable screening tool for detection of PFO. [ABSTRACT FROM AUTHOR]

Background: Sudden cardiac death can be the first clinical presentation of asymptomatic ventricular preexcitation. Recent data about prevalence of preexcitation in the electrocardiograms (ECG) of the general population are scarce. Objective: The aim of the present study was to analyze the prevalence of preexcitation in a contemporary population of young conscripts. Methods: We reanalyzed all consecutive ECGs of Swiss citizens who underwent conscription for the army between March 1, 2004, and July 31,2006. All ECGs with the diagnosis preexcitation were included in the present study. Results: We analyzed ECGs of 41,699 male conscripts. Mean age was 19.2 ± 1.1 years. Preexcitation was found in 53 individuals. The length of the delta wave was 46 ± 10 ms. The most frequent localization of the accessory pathway was the left free wall. Conclusion: The prevalence of preexcitation in young, predominantly male conscripts is 0.13%. This is comparable with previous findings in children. (PACE 2011; 34:949-953) [ABSTRACT FROM AUTHOR]

The authors investigated acoustic cardiography, the digital analysis of electrocardiogram (ECG) and heart sounds, to detect phrenic nerve stimulation (PNS) and assess its hemodynamic significance. They studied 42 patients and induced 46 instances of PNS induced through cardiac pacing at various locations in the heart. These 46 instances of PNS were either independently documented using fluoroscopy or were symptomatic. The authors collected acoustic cardiography data including the electromechanical activation time (interval from Q onset to the first heart sound [S1]) as a percentage of the RR interval (%EMAT) to assess systolic function. Acoustic cardiography provided evidence of PNS when it occurred. They also found significant %EMAT prolongation when right ventricular pacing was associated with PNS (Δ%EMAT=2.7, P=.012), but none beyond the normal range with right ventricular pacing in the absence of PNS. Documented PNS occurred in 33 episodes (60%) in patients with noticeable symptoms. Stimulation amplitudes could be found that generated asymptomatic PNS for all of the five participants explicitly tested for it. PNS can be asymptomatic. PNS due to right ventricular pacing is associated with impaired left ventricular systolic function. Acoustic cardiography is an effective method of detecting and assessing the hemodynamic significance of pacemaker-related PNS. Congest Heart Fail. 2010;16:147–152. © 2010 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Introduction: Electrocardiographic criteria for left ventricular hypertrophy (LVH) have been limited by low sensitivity at acceptable levels of specificity. A number of studies have demonstrated that body mass index (BMI) is associated with decreased sensitivity of ECG LVH classification in hypertensive patients. The objective of this study is to investigate the correlation relationship between LVH voltage criteria and BMI in Swiss conscripts. Methods: A database of 41,806 young Swiss people, who underwent compulsory conscription for the Swiss Army, was compiled. Along with other medical data, an ECG was taken. Statistical analyses, such as linear regression and calculation of correlation coefficient, were carried out between LVH voltage criteria and BMI. Results: The mean age in the studied population was 19.2 ± 1.1 years with a median age of 19 years (range from 17 to 38 years). We found an overweight prevalence of 25.1%. The results showed that body habitus had significant association with Sokolow-Lyon voltages. A mean decrease of 13%, 5%, 19%, 14%, and 12% for the five studied Sokolow-Lyon indexes were found between normal range subjects (18.5 ≤ BMI < 25) and obese subjects (25≤ BMI). Conclusions: Our study confirms the hypothesis that people with higher BMI, a growing section of the population, have lower ECG amplitudes. Therefore, the Sokolow-Lyon voltage criteria may underestimate the presence of LVH for subjects with higher BMI, which is not the case for the Cornell voltage. Our analysis suggests that computerized electrocardiography for the diagnosis of left ventricular hypertrophy based on Sokolow-Lyon voltages should incorporate the BMI factor. [ABSTRACT FROM AUTHOR]

The intention of this study was to evaluate the short-term effect of right ventricular (RV) pacing on cardiorespiratory function in patients with a biventricular pacemaker. A group of 26 patients with a biventricular pacemaker was enrolled in this cross-over, single-blind study. All patients underwent spiroergometry and electrocardiography in RV and biventricular pacing mode. Peak work capacity (102±32 W and 107±34 W for RV and biventricular pacing mode, respectively; P<.01) and peak oxygen consumption (21.4±6.7 mL/min/kg and 22.6±7.0 mL/min/kg for RV and biventricular pacing mode, respectively; P<.01) were significantly lower in the RV pacing mode. Heart rate at rest was significantly higher with active RV pacing. Short-term RV pacing in patients with a biventricular pacemaker resulted in a higher heart rate at rest, a lower peak work capacity, and a lower peak oxygen consumption compared with that in the biventricular pacing mode. [ABSTRACT FROM AUTHOR]

Background: Physicians who are caring for patients with implantable cardioverter-defibrillators (ICDs) are regularly confronted with questions concerning daily activities. This study evaluates the habits of ICD patients with respect to sports activities, stays at high-altitude, and driving patterns. Methods: A survey was performed in 387 patients with ICDs who were followed at two hospitals in Switzerland. The special-designed questionnaire addressed lifestyle practices concerning sports activity, high-altitude visits, and driving motor vehicles. Results: Fifty-nine percent of ICD patients participated in some kind of sports activity; an ICD shock was experienced in 14% of these patients. Fifty-six percent of the patients reported a stay at high altitudes at least 2,000 m above the sea level; 11% of them stayed regularly above 2,500 m; 4% of these patients experienced an ICD shock during high altitude stay. Seventy-nine percent of the patients drove a motor vehicle; 2% of them experienced an ICD shock during driving, but none of them reported loss of consciousness or a traffic accident. Conclusion: It is accepted that ICD patients disqualify for competitive sports. However, the patients may be encouraged to continue leisure-time physical activities at low-to-moderate intensity. Staying at high altitudes and driving motor vehicles are very rarely associated with ICD shocks. Therefore, these activities that are likely to contribute to a better quality of life should not be discouraged in most ICD recipients in the absence of other medical reasons. [ABSTRACT FROM AUTHOR]

Background: Left ventricular noncompaction (LVNC) is a rare, congenital cardiomyopathy and can be associated with heart failure, embolic events, arrhythmias, and sudden cardiac death. Implantation of implantable cardioverter-defibrillators in these patients is a treatment option, but data on long-term follow-up are limited. The aim of the study was to analyze the clinical outcome of patients with LVNC who were treated with an implantable cardioverter-defibrillator (ICD). Methods: We conducted a retrospective study on 12 patients (mean age: 45 ± 13 years, range 20–60) with LVNC, who underwent ICD implantation for secondary (n = 8) and primary (n = 4) prevention. Results: During a median follow-up of 36 months, five patients (42%) presented with appropriate ICD therapy: in four of the eight patients (50%) in whom the ICD was implanted as a secondary prevention and in one of the four patients (25%) for whom the ICD was implanted for primary prevention. In eight patients (66%) supraventricular tachyarrhythmias were documented. Improvement of left ventricular function could be observed in one of two patients with a biventricular ICD. Conclusions: Potentially life-threatening ventricular tachyarrhythmias may occur in patients with LVNC. ICD therapy may be effective for primary and secondary prevention in these patients. Due to the high prevalence of supraventricular tachyarrhythmias devices with reliable detection enhancements should be considered. [ABSTRACT FROM AUTHOR]

Background: Trials on implantable cardioverter-defibrillators (ICD) for patients after acute myocardial infarction (AMI) have highlighted the need for risk assessment of arrhythmic events (AE). The aim of this study was to evaluate risk predictors based on a novel approach of interpreting signal-averaged electrocardiogram (SAECG) and ejection fraction (EF). Methods: SAECG, interpreted with a new index, and EF were prospectively evaluated to predict AE in 144 patients with AMI. Results: During the mean follow-up period of 4.1 years, 19 AE occurred. The new SAECG index showed a sensitivity of 84%, a specificity of 62%, a positive predictive value (PPV) of 25%, and a negative predictive value (NPV) of 96%. A combination of a normal new SAECG index and an EF >35% resulted in a sensitivity of 100%, a specificity of 47%, a PPV of 22%, and a NPV of 100%; this corresponded to an AE incidence rate of 0%. When both tests were abnormal, the AE incidence rate was 21.3%. Conclusions: This is the first contemporary study reporting predictive values based on a combination of SAECG and EF. If confirmed in an appropriately designed and powered trial, this novel approach might be used to identify both patients at very low risk for AE not requiring further risk assessment and patients at high risk in whom ICD implantation can be considered without further risk assessment. [ABSTRACT FROM AUTHOR]

Background: The results of multiple implantable cardioverter-defibrillator (ICD) studies have demonstrated a survival benefit in specific high-risk populations, leading to the expansion of ICD implantation rates worldwide. Because the ICD reduces the incidence of sudden cardiac death, patients with these devices more often die of nonarrhythmic causes. For those with a malignancy, little is known about their preferences for disabling ICD therapy. Methods: The objective of the present study was to evaluate whether patients with an ICD and a malignant tumor desire deactivation of their ICD in order to have a death without ICD interventions, which are life-prolonging, bothersome, and prevent a peaceful death. All deceased patients having had an ICD implanted at our institution were retrospectively analyzed with respect to whether the option of disabling ICD therapy had been discussed and whether the ICD had been deactivated. Results: Two hundred and seventy-two patients received an ICD at our institution between January 1, 1994, and January 31, 2007. Thirty-six of the patients have died, and of these eight had a malignant tumor. In six of these eight patients (75%) the option of disabling their ICD therapy was discussed extensively; none wished to abandon the possibility of terminating a malignant arrhythmia by the ICD. Conclusions: With the use of ICDs, patients with heart failure are more frequently protected from arrhythmic death, and consequently treating physicians are increasingly confronted with ICD patients presenting with a malignant tumor or other noncardiac terminal disease. In these situations, dialogue between the treating physician and the patient about the possibility of withdrawing ICD therapy is important to terminal care. The physician must be aware that the patient's attitude may contrast with his/her own, and that the patient may be resolute in maintaining ICD protection from arrhythmic death. [ABSTRACT FROM AUTHOR]

Malfunction of a dual chamber system pacemaker due to a current leak in the output circuitry leading to a rapid decline in battery longevity is described. Serial pulse amplitude alterations in defined device configurations enabled location of the defect in the 2.5-V output voltage level; the current leak disappeared in the 5-V output voltage level, and recurred in the 7.5-V output voltage level which combines both 2.5-V and 5-V output circuitries. Reprogramming of pulse amplitudes rectified device malfunction. Circuitry reprogramming of pacemakers with faulty unexplained high battery current can circumvent early replacement in management of device malfunction. [ABSTRACT FROM AUTHOR]

Background: Multiple clinical trials have shown that a properly functioning implantable cardioverter-defibrillator (ICD) is capable of interrupting sudden death caused by ventricular tachyarrhythmias. However, ICDs are complex medical devices, and they do not always perform as expected or they may fail completely. Exposure of ICD recipients to professional or media reports that their specific device type is potentially malfunctioning could negatively influence their psychological status. Methods: This study aimed to evaluate and quantify psychological distress in patients implanted with an ICD-recall device. Thirty patients implanted with ICD-recall devices (ICD-recall group) and 25 patients with unaffected ICD devices (ICD-control group) were interviewed using the Brief Symptom Inventory (a psychological self-report symptom scale). Results: Mean values of all primary psychiatric distress symptom dimensions and global indices were within the normal range for both the ICD-recall and the ICD-control group. New York Heart Association (NYHA) class was a predictor of higher distress symptoms in all categories, independently of the ICD group. NYHA II group patients tended toward higher stress levels than the NYHA I group, but only somatization was significantly different. An upward, but not significant, trend in 7 of the 12 scales was associated with symptomatic shock experience. Conclusion: This study demonstrates that psychological distress was not significantly increased in patients recently informed about a potential malfunction of their device. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to compare transtelephonic ECG every 2 days and serial 7-day Holter as two methods of follow-up after atrial fibrillation (AF) catheter ablation for the judgment of ablation success. Patients with highly symptomatic AF are increasingly treated with catheter ablation. Several methods of follow-up have been described, and judgment on ablation success often relies on patients' symptoms. However, the optimal follow-up strategy objectively detecting most of the AF recurrences is yet unclear. Methods: Thirty patients with highly symptomatic AF were selected for circumferential pulmonary vein ablation. During follow-up, a transtelephonic ECG was transmitted once every 2 days for half a year. Additionally, a 7-day Holter was recorded preablation, after ablation, after 3 and 6 months, respectively. With both, procedures symptoms and actual rhythm were correlated thoroughly. Results: A total of 2,600 transtelephonic ECGs were collected with 216 of them showing AF. 25% of those episodes were asymptomatic. On a Kaplan-Meier analysis 45% of the patients with paroxysmal AF were still in continuous SR after 6 months. Simulating a follow-up based on symptomatic recurrences only, that number would have increased to 70%. Using serial 7-day ECG, 113 Holter with over 18,900 hours of ECG recording were acquired. After 6 months the percentage of patients classified as free from AF was 50%. Of the patients with recurrences, 30–40% were completely asymptomatic. The percentage of asymptomatic AF episodes stepwise increased from 11% prior ablation to 53% 6 months after. Conclusions: The success rate in terms of freedom from AF was 70% on a symptom-only-based follow-up; using serial 7-day Holter it decreased to 50% and on transtelephonic monitoring to 45%, respectively. Transtelephonic ECG and serial 7-day Holter were equally effective to objectively determine long-term success and to detect asymptomatic patients. [ABSTRACT FROM AUTHOR]

Topography of the Esophagus in Atrial Fibrillation Ablation. Introduction:The close anatomic relationship of the posterior wall of the left atrium (LA) and the thermosensitive esophagus creates a potential hazard in catheter ablation procedures.Methods and Results:In 30 patients (pts) with atrial fibrillation (AF) undergoing catheter ablation, we prospectively studied the course and contact of the esophagus in relation to LA and the topographic proximity to ablation lines encircling the right-sided and left-sided pulmonary veins (PV) as well as to the posterior line connecting the encircling lines using the electromagnetic mapping system for reconstruction of LA and for tagging of the esophagus. This new technique of anatomic tagging of the esophagus was validated against the CT scan as a standard imaging procedure. The esophageal course was highly variable, extending from courses in direct vicinity to the left- or right-sided PV as well as in the midportion of the posterior LA. In order to avoid energy application in direct proximity to the esophagus, adjustments of the left and right PV encircling lines were necessary in 14/30 pts (47%) and 3/30 (10%). In 30 pts (100%), the mid- to inferior areas of the posterior LA revealed contact with the esophagus. Therefore, posterior and inferior linear ablation lines were abandoned and shifted to superior in 29 pts (97%).Conclusions:Anatomic tagging of esophagus revealed a highly variable proximity to different areas of the posterior LA suggesting individual adjustment of encircling and linear ablation lines in AF ablation procedures to avoid the life threatening complication of esophagus perforation.(J Cardiovasc Electrophysiol, Vol. 16, pp. 1-5, April 2005) [ABSTRACT FROM AUTHOR]

Arrhythmias After Ablation of Atrial Fibrillation. Introduction: Intraoperative radiofrequency (RE) ablation is an effective treatment of atrial fibrillation (AF). However, secondary arrhythmias late after ablation may complicate the patient's course. We report on the incidence, mechanisms, and treatment of gap-related atrial flutter and other secondary arrhythmias during long-term follow-up. Methods and Results: In 129 patients who underwent intraoperative RE ablation with placement of left atrial linear lesions using minimally invasive surgical techniques, secondary arrhythmias were analyzed during long-term follow-up (20 ± 6 months). Transient atrial arrhythmias during the first 3 postoperative months were excluded. In 8 (6.2%) of 129 patients, sustained stable secondary arrhythmias were documented. Left atrial, gap-related atrial flutter was observed in 4 patients (3.1%). The flutter was treated by percutaneous RE ablation in 3 patients (2.3%) and with drugs in 1 patient (0.8%). In 2 patients (1.6%), right atrial isthmus-dependent atrial flutter occurred and was treated successfully by percutaneous RE ablation. In 2 patients (1.6%), ectopic right atrial tachycardias occurred and were treated with percutaneous RE ablation. Conclusion: Late after intraoperative RE ablation of atrial fibrillation, three types of stable secondary arrhythmias were observed in 6% of patients: left atrial gap-related atrial flutter, right atrial isthmus- dependent atrial flutter, and ectopic atrial tachycardia. Gaps after intraoperative RE ablation due to non- continuous or nontransmural linear lesions may lead to stable left atrial macroreentrant tachycardias, requiring new interventional therapy. [ABSTRACT FROM AUTHOR]

Substrate Description and Ablation of VT. Introduction: The aim of this study was to describe the arrhythmogenic substrate in postinfarction patients with ventricular tachycardia (VT) guiding the placement of individual strategic linear lesions transecting all potential isthmuses using target area maps with limited mapping points to allow short procedure times. Methods and Results: In 28 patients with pleomorphic, unstable, and/or incessant VT, electroanatomic voltage mapping was performed in conjunction with limited sinus rhythm mapping, pace mapping, and activation mapping. Radiofrequency (RF) energy was applied directly within the low-voltage areas of the chronically infarcted areas or in the border zone. Ablation lines typically were perpendicular to the course of the presumed central common pathways. The maps consisted of 63 ± 30 mapping points. An average lesion line length of 46 ± 21 mm was placed with 17 ± 7 RF pulses. Twenty-two (79%) of the 28 patients were rendered completely noninducible at the end of the procedure. Procedure time measured 134 ± 41 minutes . No major complications were observed. Six (27%) of 22 patients who were rendered completely noninducible experienced VT recurrence during follow-up versus 4 (67%) of 6 patients who were still inducible after ablation (P = 0.06) . Conclusion: Individually tailored substrate description guiding the placement of linear lesion lines transecting potential isthmuses rendered 80% of the patients completely noninducible. The construction of regional target area maps allowed short procedure times, with a resulting low incidence of complications in these critically ill patients. (J Cardiovasc Electrophysiol, Vol. 14, pp. 675-681, July 2003). [ABSTRACT FROM AUTHOR]

A response by Richard Kobza, Paul Erne and Firat Duru to a letter to the editor about their article about cardioverter-defibrillator (ICD) therapy is presented.

This case study illustrates that acoustic cardiography—a simple non-invasive test—can be applied in any diagnostic setting as well as during biventricular pacemaker implantation to ensure that the pacemaker settings are not leading to phrenic nerve stimulation. [ABSTRACT FROM AUTHOR]

Background Atrial fibrillation (AF) is a major risk factor for mortality. The prevalence, clinical correlates, and prognostic impact of AF in Takotsubo syndrome (TTS) have not yet been investigated in a large patient cohort. This study aimed to investigate the prevalence, clinical correlates, and prognostic impact of AF in patients with TTS. Methods and Results Patients with TTS were enrolled from the International Takotsubo Registry, which is a multinational network with 26 participating centers in Europe and the United States. Patients were dichotomized according to the presence or absence of AF at the time of admission. Of 1584 patients with TTS, 112 (7.1%) had AF. The mean age was higher ( P <0.001), and there were fewer women ( P =0.046) in the AF than in the non-AF group. Left ventricular ejection fraction was significantly lower ( P =0.001), and cardiogenic shock was more often observed ( P <0.001) in the AF group. Both in-hospital ( P <0.001) and long-term mortality ( P <0.001) were higher in the AF group. Multivariable Cox regression analysis revealed that AF was independently associated with higher long-term mortality (hazard ratio, 2.31; 95% CI, 1.50-3.55; P <0.001). Among patients with AF on admission, 42% had no known history of AF before the acute TTS event, and such patients had comparable in-hospital and long-term outcomes compared with those with a history of AF. Conclusions In patients presenting with TTS, AF on admission is significantly associated with increased in-hospital and long-term mortality rates. Whether antiarrhythmics and/or cardioversion are beneficial in TTS with AF should thus be tested in a future trial. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01947621.

Background Left ventricular (LV) recovery in takotsubo syndrome (TTS) occurs over a wide-ranging interval, varying from hours to weeks. We sought to investigate the clinical predictors and prognostic impact of recovery time for TTS patients. Methods and Results TTS patients from the International Takotsubo Registry were included in this study. Cut-off for early LV recovery was determined to be 10 days after the acute event. Multivariable logistic regression was used to assess factors associated with the absence of early recovery. In-hospital outcomes and 1-year mortality were compared for patients with versus without early recovery. We analyzed 406 patients with comprehensive and serial imaging data regarding time to recovery. Of these, 191 (47.0%) had early LV recovery and 215 (53.0%) demonstrated late LV improvement. Patients without early recovery were more often male (12.6% versus 5.2%; P =0.011) and presented more frequently with typical TTS (76.3% versus 67.0%, P =0.040). Cardiac and inflammatory markers were higher in patients without early recovery than in those with early recovery. Patients without early recovery showed unfavorable 1-year outcome compared with patients with early recovery ( P =0.003). On multiple logistic regression, male sex, LV ejection fraction <45%, and acute neurologic disorders were associated with the absence of early recovery. Conclusions TTS patients without early LV recovery have different clinical characteristics and less favorable 1-year outcome compared with patients with early recovery. The factors associated with the absence of early recovery included male sex, reduced LV ejection fraction, and acute neurologic events. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short- and long-term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short- and long-term mortality. A subanalysis was performed comparing long-term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long-term mortality was higher in patients with malignancy (P<0.001), while short-term outcome was comparable (P=0.17). In a subanalysis, long-term mortality was comparable between TTS patients with malignancies and ACS patients with malignancies (P=0.13). Malignancy emerged as an independent predictor of long-term mortality. Conclusions A substantial number of TTS patients show an association with malignancy. History of malignancy might increase the risk for TTS, and therefore, appropriate screening for malignancy should be considered in these patients. Clinical Trial Registration URL: http://www.clinicaltrial.gov. Unique identifier: NCT01947621.