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INTRODUCTION Box isolation of fibrotic areas (BIFA) is a promising ablation approach for atrial fibrillation (AF) patients. However, complete isolation of fibrotic anteroseptal left atrial area, where Bachmann's bundle is blending into the left atrial myocardium, is very specific and complex. METHODS AND RESULTS In 34 AF patients with anteroseptal fibrosis, circumferential BIFA was performed in addition to pulmonary vein isolation. In 8 of 34 patients, complete isolation of the fibrotic area was achieved with BIFA alone. In 26 of 34 patients, a decrease in voltage amplitude with or without conduction delay was observed after box ablation but no complete isolation. Activation mapping and characteristic unipolar potentials revealed earliest activation inside the box from one (73%), two (15%), or three (12%) remaining inputs, in the region of Bachmann's bundle insertion. Focal ablation inside the box (mean radiofrequency impulses: 1.7 ± 0.4, mean radiofrequency time: 70 ± 19 seconds) led to complete isolation of the fibrotic area in 25 of 26 patients. Overall, 97% of anteroseptal boxes were completely isolated with additional focal ablation in the study group compared to 21% in the control group with BIFA alone (33/34 vs. 7/34, P

Introduction One question for the technological advancement of catheter ablation of atrial fibrillation (AF) is whether a creative new concept can combine and even improve the diagnostic mapping options of single-tip and basket catheters with the simplicity of the use of balloon catheters for ablation. Herein, we describe the first in-human experience with a single catheter offering such a complete solution. Methods and results A new catheter (Globe®) with a distal multielectrode array consisting of 16 ribs with 122 gold-plated electrodes was used. Each electrode can ablate, pace, and can measure tissue contact, temperature, current, and intracardiac electrograms. The Globe was deployed and removed without difficulty in all 3 patients. Complete pulmonary vein isolation (PVI) was achieved in all 12 veins. In 10 veins, PVI was achieved with a single placement in front of the respective vein (“single circle isolation”). In one subject, the device was repositioned due to the esophagus location. In the other subject, a single gap was observed after circumferential ablation of the right inferior PV. After precise gap identification, the device was adjusted slightly for improved contact at that region, and reablation resulted in immediate PVI. Conclusions PVI isolation could be performed with the new multielectrode array Globe in all 12 PVs offering the option for easy handling and fast “single-shot” PVI. Several continuously updated mapping types from 122 electrodes even in real time during ablation demonstrate the capability to go beyond PVI for voltage mapping plus substrate modification, and for rotor mapping plus rotor ablation.

Introduction The BIFA concept (box isolation of fibrotic areas) supplementing pulmonary vein isolation (PVI) was implemented in atrial fibrillation (AF) patients with fibrotic atrial cardiomyopathy (FACM) to improve catheter ablation outcomes. Methods and results Ninety-two patients with FACM underwent PVI + BIFA. We investigated patient characteristics (58 persistent/34 paroxysmal, 68 ± 8 years, LA 44 ± 7 mm, CHA2 DS2 -VASc 2.6 ± 1.3, FACM I: 15.2%, II: 53.3%, III: 26.1%, IV: 5.4%), periprocedural data concerning fibrosis extent/distribution, and their impact on outcome. Based on severe fibrosis areas (SFAs) of 13.5 ± 13.9 cm2 detected by voltage mapping, 1.4 ± 0.5 boxes (n = 1-3, 2.2-35.3 cm2 ) were applied in the left atrium. With higher grade FACM, SFAs increased and maximum voltage decreased (I/IV: 6.29/3.18 mV). Anterior (ant.) SFAs were found to be more common and larger than posterior (post.) SFAs (58.3% vs. 42.6%, ant. 8.0 ± 8.0 vs. post. 4.7 ± 6.8 cm2 ). In 40 of 92 (43%) patients, both atrial walls were affected with rare cases of solely post. fibrosis (6 of 92, 6.6%). Women (39 of 92, 42%) showed FACM III+IV more often than men (P = 0.022) and can still present paroxysmal while persistent males are more likely to have FACM I-II. Single and multiple procedure (1.2/patient) success was 69% and 83% after 16 ± 8 months with an unfavorable impact of large SFA size, both-sided fibrosis and reduced maximum voltage, independently of patient characteristics and AF type. Conclusion FACM patients are a challenging AF subgroup for catheter ablation. Women seem to show FACM III+IV more often than men. The distribution of left atrial fibrosis is variable but more pronounced anteriorly. Atrial disease is characterized by SFA size but also maximum voltage reduction, both with implications on ablation outcome. Using BIFA, success rates of patients without fibrosis can be approached but are limited in FACM III+IV.

Atrial fibrosis is the fundamental histopathologic finding in atrial fibrillation (AF) patients and an important predictor of ablation failure beyond pulmonary vein isolation. There is wide variation in the extent and localization of left atrial fibrosis in patients with paroxysmal and nonparoxysmal AF. Box isolation of fibrotic areas is an effective rhythm control concept in patients with paroxysmal AF despite durable pulmonary vein isolation, and this strategy has recently been implemented successfully in initial AF ablation procedures in addition to pulmonary vein isolation for patients with nonparoxysmal AF. In contrast, the time for “empirical” lines or other nonindividualized substrate modifications seems over.

INTRODUCTION The critical question for technological advancement of catheter ablation of atrial fibrillation (AF) is whether a creative new concept can combine and even improve the options of single-tip catheters with the simplicity of the use of balloon catheters. Herein are described the results from the first clinical study of a new multielectrode contact-mapping plus ablation array (Globe) offering such a complete solution. METHODS AND RESULTS The multielectrode Globe array consists of 16 flat ribs with 122 gold-plated electrodes. Each electrode can record electrograms, ablate, pace, and can measure tissue contact and temperature. Single-shot pulmonary vein isolation (PVI) is possible with temperature-guided ablation of up to 24 electrodes simultaneously with automatic, individual power control of every electrode. Sixty patients with symptomatic AF underwent PVI using the Globe. In all sixty patients, acute PVI was achieved in 232 of 234 attempted PVs (99.1%). In 34 patients treated with "single-hot-shot" ablation, PVI was achieved in 136 of 136 PVs (100%). Single-procedure 12-month freedom from AF off antiarrhythmic drugs in the "single-hot-shot" group was 75.5% and freedom from AF/atrial tachycardia 72.3%. In two patients, pericardial tamponade was observed, one after a transseptal puncture, and one during array insertion with an over-advanced sheath. There were no other device-related serious adverse events, including stroke, PV stenosis, esophageal perforation, or phrenic nerve palsy. CONCLUSIONS In this first clinical series, the Globe catheter was found to be an easy-to-use system for single-shot PVI. The continuously updated multielectrode voltage and activation mapping data indicate future options for mapping and ablation beyond PVI.

In the last years, atrial fibrosis was shown to be an independent predictor of procedural failure in patients with paroxysmal and persistent atrial fibrillation. Ablation strategies have been developed to improve the outcome of catheter ablation by targeting detected areas of fibrosis, based either on endocardial voltage mapping or cardiac magnetic resonance. Box isolation of fibrotic areas (BIFA) is a new and promising patient-tailored ablation strategy for atrial fibrillation patients targeting substantial fibrotic areas by circumferential isolation of left atrial fibrosis. Keywords: Atrial fibrillation, Catheter ablation, Fibrosis, Substrate modification

Substrate Modification BIFA in AF Ablation Background Catheter ablation strategies beyond pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF) are less well defined. Increasing clinical data indicate that atrial fibrosis is a critical common left atrial (LA) substrate in AF patients (pts). Objective We applied a new substrate modification concept according to the individual fibrotic substrate as estimated from electroanatomic voltage mapping (EAVM) in 41 pts undergoing catheter ablation of AF. Results First, EAVM during sinus rhythm was done in redo cases of 10 pts with paroxysmal AF despite durable PVI. Confluent low-voltage areas (LVA) were found in all pts and were targeted with circumferential isolation, so-called box isolation of fibrotic areas (BIFA). This strategy led to stable sinus rhythm in 9/10 pts and was transferred prospectively to first procedures of 31 pts with nonparoxysmal AF. In 13 pts (42%), no LVA (

Catheter ablation of atrial fibrillation (AF) has undergone considerable improvement within the last years. As a result, catheter ablation may even be indicated as a primary therapy in selected patients in experienced centers [(1)][1]. By achieving more proximal plus durable pulmonary vein (PV)

A frequent need for re-ablations and limited overall success rates are still major limitations of catheter ablation procedures for the treatment of atrial fibrillation (AF). These limitations include not only the durability of the pulmonary vein isolation (PVI) lines, but also the pathophysiological understanding of the arrhythmia's substrate. Long-term single procedure success rates in non-paroxysmal AF are disappointingly low for current stepwise ablation approaches adding the placement of linear lines and electrogram-based ablation after circumferential PVI isolation. In the future, substrate modification in AF ablation should move toward individualized patient-tailored ablation procedures. Magnetic resonance imaging could play a major role for noninvasively describing the localization and extent of fibrotic areas. Specific new strategies that could be used include precise localization and ablation of rotors that maintain the arrhythmia using multielectrode mapping during AF and box isolation of fibrotic areas guided by electroanatomic voltage mapping during sinus rhythm.

Aims The rapidly increasing number of patients with implantable cardioverter-defibrillators (ICD) places a large burden on follow-up providers. This study investigated the possibility of longer in-office follow-up intervals in primary prevention ICD patients under remote monitoring with automatic daily data transmissions from the implant memory. Methods and results Conducted in 155 ICD recipients with MADIT II indications, the study compared the burden of scheduled and unscheduled ICD follow-up visits, quality of life (SF-36), and clinical outcomes in patients randomized to either 3- or 12-month follow-up intervals in the period between 3 and 27 months after implantation. Remote monitoring (Biotronik Home Monitoring) was used equally in all patients. In contrast to previous clinical studies, no calendar-based remote data checks were performed between scheduled in-office visits. Compared with the 3-month follow-up interval, the 12-month interval resulted in a minor increase in the number of unscheduled follow-ups (0.64 vs. 0.27 per patient-year; P = 0.03) and in a major reduction in the total number of in-office ICD follow-ups (1.60 vs. 3.85 per patient-year; P < 0.001). No significant difference was found in mortality, hospitalization rate, or hospitalization length during the 2-year observation period, but more patients were lost to follow-up in the 12-month group (10 vs. 3; P = 0.04). The SF-36 scores favoured the 12-month intervals in the domains ‘social functioning’ and ‘mental health’. Conclusion In prophylactic ICD recipients under automatic daily remote monitoring, the extension of the 3-month in-office follow-up interval to 12 months appeared to safely reduce the ICD follow-up burden during 27 months after implantation. ClinicalTrials.gov Identifier NCT00401466 ([http://www.clinicaltrials.gov/ct2/show/[NCT00401466][2]][2]). []: http://www.clinicaltrials.gov/ct2/show/NCT00401466

During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure. In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC). This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools, techniques, and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms, outcomes, and treatment of AF. For this reason, the HRS initiated an effort to rewrite and update this Consensus Statement. Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [SOLAECE]). The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group, convened by these five international societies. The writing group is charged with defining the indications, techniques, and outcomes of AF ablation procedures. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including definitions relevant to this topic. The writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardiacas [SOBRAC]). All the members of the writing group, as well as peer reviewers of the document, have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest. All author and peer reviewer disclosure information is provided in Appendix A and Appendix B. In writing a consensus document, it is recognized that consensus does not mean that there was complete agreement among all the writing group members. Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation. These recommendations were systematically balloted by the 60 writing group members and were approved by a minimum of 80% of these members. The recommendations were also subject to a 1-month public comment period. Each partnering and collaborating organization then officially reviewed, commented on, edited, and endorsed the final document and recommendations. The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state, however, that this document is not a guideline. The indications for catheter and surgical ablation of AF, as well as recommendations for procedure performance, are presented with a Class and Level of Evidence (LOE) to be consistent with what the reader is familiar with seeing in guideline statements. A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended. The writing group reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high-quality evidence from more than one randomized clinical trial, meta-analyses of high-quality randomized clinical trials, or one or more randomized clinical trials corroborated by high-quality registry studies. The writing group ranked available evidence as Level B-R when there was moderate-quality evidence from one or more randomized clinical trials, or meta-analyses of moderate-quality randomized clinical trials. Level B-NR was used to denote moderate-quality evidence from one or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies. This designation was also used to denote moderate-quality evidence from meta-analyses of such studies. Evidence was ranked as Level C-LD when the primary source of the recommendation was randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies of human subjects. Level C-EO was defined as expert opinion based on the clinical experience of the writing group. Despite a large number of authors, the participation of several societies and professional organizations, and the attempts of the group to reflect the current knowledge in the field adequately, this document is not intended as a guideline. Rather, the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF, and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are caring for patients who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF, and those involved in research in the field of AF ablation. This statement is not intended to recommend or promote catheter or surgical ablation of AF. Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient. The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF. A second major objective is to provide recommendations for designing clinical trials and reporting outcomes of clinical trials of AF ablation. It is recognized that this field continues to evolve rapidly. As this document was being prepared, further clinical trials of catheter and surgical ablation of AF were under way.

Evaluation of the Substrate in Genetic Atrial Arrhythmias Introduction Although atrial arrhythmias may have genetic causes, very few data are available on evaluation of the arrhythmic substrate in genetic atrial diseases in humans. In this study, we evaluate the nature and evolution of the atrial arrhythmic substrate in a genetic atrial cardiomyopathy. Methods and Results Repeated electroanatomic mapping and tomographic evaluations were used to investigate the evolving arrhythmic substrate in 5 patients with isolated arrhythmogenic atrial cardiomyopathy, caused by Natriuretic Peptide Precursor A (NPPA) gene mutation. Atrial fibrosis was assessed using late gadolinium enhancement magnetic resonance imaging (LGE-MRI). The substrate of atrial tachycardia (AT) and atrial fibrillation (AF) was biatrial dilatation with patchy areas of low voltage and atrial wall scarring (in the right atrium: 68.5% ± 6.0% and 22.2% ± 10.2%, respectively). The evolution of the arrhythmic patterns to sinus node disease with atrial standstill (AS) was associated with giant atria with extensive low voltage and atrial scarring areas (in the right atrium: 99.5% ± 0.7% and 57.5% ± 33.2%, respectively). LGE-MRI-proven biatrial fibrosis (Utah stage IV) was associated with AS. Atrial conduction was slow and heterogeneous, with lines of conduction blocks. The progressive extension and spatial distribution of the scarring/fibrosis were strictly associated with the different types of arrhythmias. Conclusion The evolution of the amount and distribution of atrial scarring/fibrosis constitutes the structural substrate for the different types of atrial arrhythmias in a pure genetic model of arrhythmogenic atrial cardiomyopathy.

Catheter ablation of ventricular tachycardia (VT) reduces recurrent VT across multiple clinical settings, from electrical storm to pre-emptive therapy after a first occurrence of VT [(1)][1]. Approaches for ablation include targeting the arrhythmia using electrophysiological approaches (entrainment

During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure. In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC). This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools, techniques, and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms, outcomes, and treatment of AF. For this reason, the HRS initiated an effort to rewrite and update this Consensus Statement. Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [SOLAECE]). The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group, convened by these five international societies. The writing group is charged with defining the indications, techniques, and outcomes of AF ablation procedures. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including definitions relevant to this topic. The writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardiacas [SOBRAC]). All the members of the writing group, as well as peer reviewers of the document, have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest. All author and peer reviewer disclosure information is provided in Appendix A and Appendix B. In writing a consensus document, it is recognized that consensus does not mean that there was complete agreement among all the writing group members. Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation. These recommendations were systematically balloted by the 60 writing group members and were approved by a minimum of 80% of these members. The recommendations were also subject to a 1-month public comment period. Each partnering and collaborating organization then officially reviewed, commented on, edited, and endorsed the final document and recommendations. The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state, however, that this document is not a guideline. The indications for catheter and surgical ablation of AF, as well as recommendations for procedure performance, are presented with a Class and Level of Evidence (LOE) to be consistent with what the reader is familiar with seeing in guideline statements. A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended. The writing group reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high-quality evidence from more than one randomized clinical trial, meta-analyses of high-quality randomized clinical trials, or one or more randomized clinical trials corroborated by high-quality registry studies. The writing group ranked available evidence as Level B-R when there was moderate-quality evidence from one or more randomized clinical trials, or meta-analyses of moderate-quality randomized clinical trials. Level B-NR was used to denote moderate-quality evidence from one or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies. This designation was also used to denote moderate-quality evidence from meta-analyses of such studies. Evidence was ranked as Level C-LD when the primary source of the recommendation was randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies of human subjects. Level C-EO was defined as expert opinion based on the clinical experience of the writing group. Despite a large number of authors, the participation of several societies and professional organizations, and the attempts of the group to reflect the current knowledge in the field adequately, this document is not intended as a guideline. Rather, the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF, and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are caring for patients who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF, and those involved in research in the field of AF ablation. This statement is not intended to recommend or promote catheter or surgical ablation of AF. Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient. The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF. A second major objective is to provide recommendations for designing clinical trials and reporting outcomes of clinical trials of AF ablation. It is recognized that this field continues to evolve rapidly. As this document was being prepared, further clinical trials of catheter and surgical ablation of AF were under way.

Deep Sedation for Catheter Ablation of AF. Introduction: Catheter ablation of atrial fibrillation (AF) is a highly invasive and relatively long-lasting procedure with specific requirements for patient sedation. The feasibility and safety of deep sedation is described in a prospective study of 650 consecutive patients. Methods: Sedation was initiated with an intravenous (iv) bolus of midazolam, and analgesia with an iv fentanyl bolus. After an iv propofol bolus, maintenance of sedation was achieved with continuous iv administration of propofol with a guide dose of 5 mg per kg per hour. Heart rate, invasive arterial blood pressure, and oxygenation were continuously monitored. The administration of sedation and analgesia medication were performed by a nurse under the supervision and instructions of the electrophysiologist. Results: The mean dose of the initial midazolam bolus was 2.4 ± 0.7 mg and of the initial propofol bolus 32 ± 11 mg. The beginning dose of continuous propofol infusion was 352 ± 66 mg/h; titration to the desired effect of deep sedation required adjustment on an average of 3.8 ± 2.6 times leading to a maintenance dose of continuous propofol infusion of 399 ± 99 mg/h. No major sedation-related complications were observed. Endotracheal intubation was necessary in none of the patients. Heart rate, invasive arterial blood pressure, and oxygenation remained stable during sedation. Conclusion: Deep sedation for catheter ablation of AF is feasible and safe. Especially, the goal of keeping the patient in deep sedation while maintaining spontaneous ventilation and cardiovascular hemodynamic stability was accomplished. Endotracheal intubation or consultation of an anesthesiologist was not necessary in any patient. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1339-1343, December 2011)

Catheter ablation of atrial fibrillation (AF) has undergone considerable development within the last 15 years. Originally, the procedure was predominantly reserved for relatively young patients with no significant structural heart disease. Subsequently, more elderly patients and patients with

Idiopathic ventricular arrhythmias occur in patients without structural heart disease. They can arise from a variety of specific areas within both ventricles and in the supravalvular regions of the great arteries. Two main groups need to be differentiated: arrhythmias from the outflow tract (OT) region and idiopathic left ventricular, so-called fascicular, tachycardias (ILVTs). OT tachycardia typically originates in the right ventricular OT, but may also occur in the left ventricular OT, particularly in the sinuses of Valsalva or the anterior epicardium or the great cardiac vein. Activation mapping or pace mapping for the OT regions and mapping of diastolic potentials in ILVTs are the mapping techniques that are typically used. The ablation of idiopathic ventricular arrhythmias is highly successful, associated with only rare complications. Newly recognized entities of idiopathic ventricular tachycardias are those originating in the papillary muscles and in the atrioventricular annular regions.

Ventricular tachycardia (VT) late after myocardial infarction is an important contributor to morbidity and mortality. This prospective multicenter study assessed the efficacy and safety of electroanatomical mapping in combination with open-saline irrigated ablation technology for ablation of chronic recurrent mappable and unmappable VT in remote myocardial infarction.In 8 European institutions, 63 patients (89% males) were enrolled in the study. All patients had remote myocardial infarction and presented with a median number of 17 (range 1-380) VTs in the preceding 6 months. Incessant VT was present in 14 patients (22%). Left ventricular ejection fraction measured 30 +/- 13%. A mean of 3 VTs were targeted per patient and 22% of all patients had only unmappable VT. The mean follow-up period was 12 +/- 3 months. A total of 164 VTs were targeted during catheter ablation. Ablation was acutely successful in 51 patients (81%). One patient (1.5%) experienced a major complication with degeneration of VT into ventricular fibrillation necessitating cardiopulmonary resuscitation maneuvers. However, no death occurred acutely or within the first 30 days after catheter ablation. During the follow-up, 19 of the initially successful ablated patients (37%) and 31 of all ablated patients (49%) developed some type of VT recurrence.The results of this multicenter study demonstrate the high acute success rate and a low complication rate of irrigated tip catheter ablation of all clinical relevant VTs in remote myocardial infarction. However, during the follow-up a relevant number of recurrences occurred.

Radiofrequency catheter ablation of typical atrial flutter is one of the most frequent indications for catheter ablation in electrophysiology laboratories today. Clinical utility of electroanatomic mapping systems on treatment results and resource utilization compared with conventional ablation has not been systematically investigated in a prospective multicenter study.In this prospective, randomized multicenter study, the results of catheter ablation to cure typical atrial flutter using conventional ablation strategy were compared with electroanatomically guided mapping and ablation (Carto). Primary endpoints of the study were procedure duration and fluoroscopy exposure time, secondary endpoints were acute success rate, recurrence rate, and resource utilization. A total of 210 patients (169 men, 41 women, mean age 63 +/- 10 years) with documented typical atrial flutter were included in the study. Acute ablation success, that is, demonstration of bidirectional isthmus block, was achieved in 99 of 105 patients (94%) in the electroanatomically guided ablation group and in 102 of 105 patients (97%) in the conventional ablation group (P0.05). Total procedure duration was comparable between both study groups (99 +/- 57 minutes vs 88 +/- 54 minutes, P0.05). Fluoroscopy exposure time was significantly shorter in the electroanatomically guided ablation group (7.7 +/- 7.3 minutes vs 14.8 +/- 11.9 minutes; P0.05). Total recurrence rate of typical atrial flutter at 6 months of follow-up was comparable between the 2 groups (respectively for the CARTO and conventional group 6.6% vs 5.7%, P0.05). The material costs per procedure in the electroanatomically guided and conventional groups (NaviStar DS vs Celsius DS) was 3035 euro (USD 3,870) and 2133 euro (USD 2,720), respectively.This multicenter study documented that cavotricuspid isthmus ablation to cure typical atrial flutter was highly effective and safe, both in the conventional and the electroanatomically guided ablation group. The use of electroanatomical mapping system significantly reduced the fluoroscopy exposure time by almost 50%, however, at the expense of increased cost of the procedure.

Lack of stable access to all desired ablation target sites is one of the limitations for efficacious circumferential left atrial (LA) pulmonary vein (PV) ablation. Targeting that, new catheter navigation technologies have been developed. The aim of this study was to describe atrial fibrillation (AF) mapping and ablation using manually controlled steerable sheath catheter navigation and to compare it against an ablation approach with a nonsteerable sheath.In this case-control-analysis 245 consecutive patients (controls) treated with circumferential left atrial PV ablation were matched with 105 subsequently consecutive patients (cases) ablated with a similar line concept but mapping and ablation performed with a manually controlled steerable sheath. One hundred sixty-six patients were selected to be included into 83 matched patient pairs. Ablation success was measured with serial 7-day Holter electrocardiograms. Patients ablated with the steerable sheath showed an increase in the success rate (freedom from AF) from 56% to 77% (P = 0.009) after a single procedure and 6 months of follow-up. With respect to procedural data no difference could be found for procedure time, fluoroscopy time, irradiation dose, and radiofrequency (RF) burning time. With the steerable sheath mean procedural RF power (33 +/- 9 vs 41 +/- 4 W; P0.0005) and total RF energy delivery (97,498 vs 111,864 J; P0.005) were significantly lower and the rate of complete PV isolation significantly increased from 10% to 52% (P0.0005). The complication rate was the same in both groups. Among different arrhythmia, procedure, and patient characteristics, the lack of early postinterventional arrhythmia recurrences was the only but powerful predictor for long-term ablation success.An AF mapping and ablation approach solely using a manually controlled steerable sheath for catheter navigation improved the outcome of circumferential left atrial PV ablation at similar intervention times and similar complication rates. The 6-month success rate after a single LA intervention increased from 56% to 77%.

Background: A remote magnetic navigation system (MNS) is available and has been used with a 4-mm-tip magnetic catheter for radiofrequency (RF) ablation of some supraventricular and ventricular arrhythmias; however, it has not been evaluated for the ablation of cavotricuspid isthmus-dependent right atrial flutter (AFL). The present study evaluates the feasibility and efficiency of this system and the newly available 8-mm-tip magnetic catheter to perform RF ablation in patients with AFL. Methods: Twenty-six consecutive patients (23 men, mean age 64.6 ± 9.6 years) underwent RF ablation using a remote MNS. RF ablation was performed with an 8-mm-tip magnetic catheter (70°C, maximum power 70 W, 90 seconds). The endpoint of ablation was complete bidirectional isthmus block. To assess a possible learning curve, procedural data were compared between the first 14 (group 1) and the rest (group 2) of the patients. Results: The initial rhythm during ablation was AFL in 20 (19 counterclockwise and 1 clockwise) and sinus rhythm in six patients. Due to technical issues, the ablation in the 18th patient could not be done with the MNS, and so we switched to conventional ablation. The remote magnetic navigation and ablation procedure was successful in 24 of the 25 (96%) remaining patients with AFL. In one patient (patient 2), conventional catheter was used to complete the isthmus block after termination of AFL. The procedure, preparation, ablation, and fluoroscopy times (median [range]) were 53 (30–130) minutes, 28 (10–65) minutes, 25 (12–78) minutes, and 7.5 (3.2–20.8) minutes, respectively. Patients in group 2 had shorter procedure (45 [30–70] min vs 80 [57–130] min, P = 0.0001), preparation (25 [10–30] min vs 42 [30–65] min, P = 0.0001), ablation (20 [12–40] min vs 31 [20–78] min, P = 0.002), and fluoroscopy (7.2 [3.2–12.2] min vs 11.0 [5.4–20.8] min, P = 0.014) times. No complication occurred during the procedure. Conclusion: Using a remote MNS and an 8-mm-tip magnetic catheter, ablation of AFL is feasible, safe, and effective. Our data suggest that there is a short learning curve for this procedure.

History While cycling a 38-year-old man suddenly experienced palpitations associated with marked weakness. 90 min later his general practitioner, having diagnosed a ventricular tachycardia (VT) with a rate of 218/min, terminated it by a drug injection. Investigations Electrocardiography (ECG), echocardiography and biventricular cardiac catheterization with right ventricular contrast injection failed to provide any evidence of structural abnormality. However, ergometry and EPS with programmed ventricular stimulation induced VT of identical morphology (left bundle branch bloc [LBBB] with right axis deviation [RAD]). Treatment and course Idiopathic right-ventricular outflow tract tachycardia (IRVT) having been diagnosed, the patient was put on a maintenance dose of 50 mg/d atenolol. After 6 months without symptoms he again experienced several attacks of tachycardia. Resting ECG merely revealed an epsilon potential and negative T waves in V1-V3. Right ventricular contrast injection revealed inferolateral dyskinesia. EPS demonstrated both the known VT and a second, morphologically different one (LBBB with LAD). These findings indicated arrhythmogenic right-ventricular cardiomyopathy (ARCV). A cardioverter/defibrillator was implanted (ICD) and over the subsequent 8 months he had six episodes of VT which were quickly terminated by the ICD. Conclusion At first presentation of right-ventricular outflow tract tachycardia it is often not possible to differentiate between IRVT and arrhythmogenic RV cardiomyopathy. The two being significantly different in prognosis and treatment, follow-up monitoring is essential to establish the definitive diagnosis.

Herausgegeben vom Vorstand der Deutschen Gesellschaftfur Kardiologie – Herz- und Kreislaufforschung e.V.Bearbeitet im Auftrag der Kommission fur Klinische KardiologieM. Borggrefe, M. Bohm, J. Brachmann, H.-R. Figulla, G. Hasenfus,A. Osterspey, K. Rybak, U. Sechtem, S. Silberauserdem H.M. HoffmeisterOnline publiziert: 26. Oktober 2007Prof. Dr. med. Karl-Heinz Kuck (

Aims Earlier ICD therapy included an electrophysiological study (EPS), an extensive defibrillation threshold test (DFT), and a pre-discharge test. Now that ICD-therapy is widely accepted, an EPS is no longer performed in most patients, extensive DFT-tests have been reduced to a minimum of two effective shocks and discharge tests have been discarded in most centres. However, it has never been demonstrated prospectively that this simplification is safe. Methods and results The Quick-Implantable-Defibrillator (Quick-ICD) Trial was a prospective multi-centre trial, which randomized patients, who had survived a cardiac arrest (SCD) or an unstable ventricular tachycardia (VT), to two different clinical strategies:(a) The extensive strategy included an EPS, an extensive DFT-test, and a pre-discharge test; (b) In the simplified approach ( quick strategy ) the ICD was implanted without an EPS and a pre-discharge test. Two effective shocks during implantation at 21 J were sufficient. The primary endpoint of this trial was a cluster of adverse events related to the diagnostic approach and to ICD-therapy. One hundred and ninety patients were included, 97 randomized to the extensive-, 93 to the quick strategy. Mean follow-up was 12 ± 7 months. Twenty-seven patients reached the endpoint in the quick group and 32 in the extensive group. During follow-up, the event-free survival was equal in the two study arms (test for equivalence, P = 0.0044). The initial hospital stay was significantly shorter in the quick population (8.4 ± 4.7 vs. 11.2 ± 7.4 days, P = 0.004) Conclusion It is safe and cost-effective to implant an ICD without an EPS, an extensive DFT-, and a pre-discharge test in carefully selected patients after survived SCD or unstable VTs.

Outflow tract ventricular tachycardias (OT-VTs) re the most common form of idiopathic VTs. In > 80–90% of cases OT-VT originates from the right ventricular outflow tract, however, other origins like the septum, the left ventricular outflow tract, the pulmonary artery, the aortic sinus of Valsalva, the area near the His bundle, and the epicardial surface of the ventricles have been described. OT-VT is a diagnosis by exclusion, i.e., the possible concomitant structural heart disease should be adequately explored and ruled out in all patients presenting with OT-VT. Ablation should be recommended for all patients who present with syncope and who also remain symptomatic despite optimal medical therapy with a well-tolerated drug.

Atrial fibrillation (AF) is commonly associated with overweight and obesity. Both conditions have been identified as major global epidemics associated with increased mortality and morbidity. Overweight populations have higher incidence, prevalence, severity, and progression of AF compared with their normal weight counterparts. Additionally, weight change appears to accompany alteration of arrhythmia profile, raising overweight, and obesity as potential targets for intervention. Recent clinical data confirm hypothesis drawn from epidemiological studies that durable weight reduction strategies facilitate effective management of AF. Stable weight loss decreases AF burden and AF recurrence following treatment. Structural remodelling in response to weight loss suggests that reverse remodelling of the AF substrate mediates improvement of arrhythmia profile. Obesity often co-exists with multiple AF risk factors that improve in response to weight loss, making a consolidated approach of weight loss and AF risk factor management preferable. However, weight loss for AF remains in its infancy, and its broad adoption as a management strategy for AF remains to be defined.

AIMS: The experience of using radiofrequency ablation (RFA) for the treatment of arrhythmias in children and adolescents is still limited. This study aimed to review the most recent results of RF ablation in children and adolescents in a highly experienced centre with access to both conventional techniques and non-fluoroscopic electroanatomic mapping (CARTO). METHODS AND RESULTS: A total of 154 consecutive patients younger than 19 years treated with RFA during the period 2000-04 were included. Numbers (%) or median (quartiles) are reported. Age was 15 (12-17) years, 70 (45%) were males. Five patients (3%) had congenital heart disease. RFA was successful in 147/154 patients (95%). Arrhythmia recurrence occurred in 11 patients (7%). Procedure time was 55 (35-90) min and fluoroscopy time was 8.8 (4-19) min. Number of RF applications was 4 (2-10) and number of RF applications >20 s was 2 (1-7). One patient (0.7%) had complicating high-grade atrioventricular block. CARTO was used in 18 RF ablation procedures (11%) performed in 15 patients. CONCLUSION: RF ablation can be undertaken in children and adolescents with a high success rate, few recurrences and complications, very short procedure times, and acceptable fluoroscopy times. Non-fluoroscopic electroanatomic mapping is helpful in selected patients.

Background Current concepts of catheter ablation for atrial fibrillation (AF) commonly use three-dimensional (3D) reconstructions of the left atrium (LA) for orientation, catheter navigation, and ablation line placement. Objectives The purpose of this study was to compare the 3D electroanatomic reconstruction (Carto) of the LA, pulmonary veins (PVs), and esophagus with the true anatomy displayed on multislice computed tomography (CT). Methods In this prospective study, 100 patients undergoing AF catheter ablation underwent contrast-enhanced spiral CT scan with barium swallow and subsequent multiplanar and 3D reconstructions. Using Carto, circumferential plus linear LA lesions were placed. The esophagus was tagged and integrated into the Carto map. Results Compared with the true anatomy on CT, the electroanatomic reconstruction accurately displayed the true distance between the lower PVs; the distances between left upper PV, left lower PV, right lower PV, and center of the esophagus; the longitudinal diameter of the encircling line around the funnel of the left PVs; and the length of the mitral isthmus line. Only the distances between the upper PVs, the distance between the right upper PV and esophagus, and the diameter of the right encircling line were significantly shorter on the electroanatomic reconstructions. Furthermore, electroanatomic tagging of the esophagus reliably visualized the true anatomic relationship to the LA. On multiple tagging and repeated CT scans, the LA and esophagus showed a stable anatomic relationship, without relevant sideward shifting of the esophagus. Conclusion Electroanatomic reconstruction can display with high accuracy the true 3D anatomy of the LA and PVs in most of the regions of interest for AF catheter ablation. In addition, Carto was able to visualize the true anatomic relationship between the esophagus and LA. Both structures showed a stable anatomic relationship on Carto and CT without relevant sideward shifting of the esophagus.

Antiarrhythmic drugs are used in at least 50% of patients who received an implantable cardioverter defibrillator (ICD). The potential indications for antiarrhythmic drug treatments in patients with an ICD are generally the following: reduction of the number of ventricular tachycardias (VTs) or episodes of ventricular fibrillation and therefore reduction of the number of ICD therapies, most importantly, the number of disabling ICD shocks. Accordingly, the quality of life should be improved and the battery life of the ICD extended. Moreover, antiarrhythmic drugs have the potential to increase the tachycardia cycle length to allow termination of VTs by antitachycardia pacing and reduction of the number of syncopes. In addition, supraventricular arrhythmias can be prevented or their rate controlled. Recently published or reported trials have shown the efficacy of amiodarone, sotalol and azimilide to significantly reduce the number of appropriate and inappropriate ICD shocks in patients with structural heart disease. However, the use of antiarrhythmic drugs may also have adverse effects: an increase in the defibrillation threshold, an excessive increase in the VT cycle length leading to detection failure. In this situation and when antiarrhythmic drugs are ineffective or have to be stopped because of serious side effects, catheter ablation of both monomorphic stable and pleomorphic and/or unstable VTs using modern electroanatomic mapping systems should be considered. The choice of antiarrhythmic drug treatment and the need for catheter ablation in ICD patients with frequent VTs should be individually tailored to specific clinical and electrophysiological features including the frequency, the rate, and the clinical presentation of the ventricular arrhythmia. Although VT mapping and ablation is becoming increasingly practical and efficacious, ablation of VT is mostly done as an adjunctive therapy in patients with structural heart disease and ICD experiencing multiple shocks, because the recurrence and especially the occurrence of "new" VTs after primarily successful ablation with time and disease progression have precluded a widespread use of catheter ablation as primary treatment.

Background— The objective of this study was to assess the incidence and impact of asymptomatic arrhythmia in patients with highly symptomatic atrial fibrillation (AF) who qualified for radiofrequency (RF) catheter ablation. Methods and Results— In this prospective study, 114 patients with at least 3 documented AF episodes together with corresponding symptoms and an ineffective trial of at least 1 antiarrhythmic drug were selected for RF ablation. With the use of CARTO, circumferential lesions around the pulmonary veins and linear lesions at the roof of the left atrium and along the left atrial isthmus were placed. A continuous, 7-day, Holter session was recorded before ablation, right after ablation, and after 3, 6, and 12 months of follow-up. During each 7-day Holter monitoring, the patients recorded quality and duration of any complaints by using a detailed symptom log. More than 70 000 hours of ECG recording were analyzed. In the 7-day Holter records before ablation, 92 of 114 patients (81%) had documented AF episodes. All episodes were symptomatic in 35 patients (38%). In 52 patients (57%), both symptomatic and asymptomatic episodes were recorded, whereas in 5 patients (5%), all documented AF episodes were asymptomatic. After ablation, the percentage of patients with only asymptomatic AF recurrences increased to 37% ( P Conclusions— Even in patients presenting with highly symptomatic AF, asymptomatic episodes may occur and significantly increase after catheter ablation. A symptom-only–based follow-up would substantially overestimate the success rate. Objective measures such as long-term Holter monitoring are needed to identify asymptomatic AF recurrences after ablation.

Studies analyzing the diagnostic value of 12-lead electrocardiographic criteria differentiating slow-fast atrioventricular nodal reentrant tachycardia (AVNRT) from atrioventricular reentrant tachycardia (AVRT) due to concealed accessory pathway have shown inconsistent results. In 97 patients (50 with AVNRT, 47 with AVRT) 12-lead electrocardiograms (ECGs) were recorded during sinus rhythm and tachycardia (QRS120 ms). The ECGs were blinded for diagnosis and patient and analyzed independently by 2 electrophysiologists. The studied criteria differentiating AVNRT from AVRT included pseudo-r'/S, the presence of a retrograde P wave, RP interval, ST-segment depression/=2 mm with the number and location of the affected leads, QRS amplitude, and cycle length alternans.

In more than 95% of patients with atrioventricular nodal reentrant tachycardia (AVNRT), curative treatment can be achieved with selective ablation of the slow pathway in the right-sided septum. We report a patient with typical AVNRT who had failed attempts to perform conventional right septal ablation of the slow as well as of the fast pathway and finally underwent successful ablation of the fast pathway on the left side of the interatrial septum using a transseptal approach.

Introduction 17 years ago the first radiofrequency catheter ablation of an accessory pathway (AP) was performed. The aim of this study was to describe the contemporary success rates and procedure related complication rates of radiofrequency (RF) ablation of accessory pathways (APs). In addition, the present study describes the anatomical distribution of APs according to the new nomenclature introduced by NASPE and ESC in 1999. Methods The analysis included all patients, who underwent RF ablation of an AP in the Heart Center Leipzig between January 2000 and December 2003. Results Over a 4 year period 336 APs were ablated in 323 patients. 201 APs (60%) presented with antegrade and retrograde conduction and showed preexcitation on ECG. For the remaining 135 APs (40%), only retrograde conduction over the AP was documented. According to the new nomenclature APs were classified as left-sided, right sided, septal and paraseptal APs. 188 APs (56%) were located on the left, 41 (12%) on the right, 64 (19%) in the paraseptal space and 31 APs (9%) presented with a septal or parahisian localization, respectively. Because of atypical course and/or characteristics 12 APs (4%) could not be classified. Ablation of all pathways were successful in 315 patients (98%). In 289 patients (89%) success was achieved within a single ablation session. The left-sided pathways had a re-intervention rate of 5%, which was significantly lower compared to the remaining localizations. The highest re-intervention rate was observed in the septal APs (23%). Complications were observed in less than 2% of all treated patients. Conclusions 17 years after the first RF catheter ablation of an AP this therapy is established as a highly effective procedure. The success rate has improved to 98% and the complication rate has been minimized to less than 2%. The most frequent localization of APs is left posterior. Left sided APs also presented with the lowest re-intervention rate. The introduction of the new nomenclature in 1999 by NASPE and ESC has simplified the description of the exact anatomical localization of an AP.

Objectives: The aim of this study was to analyze different anatomic mapping approaches for successful ablation of outflow tract tachycardia with R/S transition in lead V3.Background: Idiopathic ven...

Objectives The aim of the study was to determine the incidence of atrial flutter and other arrhythmia recurrences (other than atrial fibrillation [AF]) during long-term follow-up after left atrial substrate modification by percutaneous radiofrequency (RF) ablation of AF. Background RF ablation is an effective treatment for patients with AF. However, late recurrent arrhythmias may complicate the patient's course. Methods One hundred fifty consecutive patients with paroxysmal or persistent AF were included in this prospective study. The incidence of arrhythmia recurrences after AF ablation was analyzed during long-term follow-up using repetitive 7-day ECG recording. Results In 28 of 150 patients (18.7%), stable regular arrhythmias other than AF were detected during follow-up. Left atrial flutter observed in 10 patients (6.7%) was treated by recompletion of the ablation lines in all 10 patients. Left atrial flutter was associated with recurrence of AF in all 10 patients. Nine of 10 patients (90%) were free from atrial flutter and 6 of 10 patients were free from AF after the second intervention. Typical right atrial flutter occurred in 10 patients (6.7%) and was treated successfully by percutaneous RF ablation without recurrence in all patients. Additionally, atrial flutter was documented during follow-up in 7 patients (4.7%); however, invasive electrophysiologic evaluation was not performed due to various reasons. Conclusions Left atrial flutter is a relevant complication after RF catheter ablation of AF and was always associated with AF recurrence in our study population. Prevention of left atrial flutter can be achieved by induction of ablation lines as continuous and transmural as possible. However, left atrial flutter that does occur late after ablation is amenable to interventional treatment with good prospects of success.

Das Ziel einer elektrophysiologischen Untersuchung (EPU) ist die Analyse der Mechanismen von brady- und tachykarden Rhythmusstörungen im Hinblick auf die Festlegung der weiteren Therapie (medikamentös, Hochfrequenz-Katheterablation, Schrittmacher-, ICD-Implantation). Dabei werden diagnostische Elektrodenkatheter perkutan über die Vena femoralis in den rechten Vorhof, an das His-Bündel, in den Koronarsinus und/oder den rechten Ventrikel geführt. Über diese Elektrodenkatheter werden intrakardiale Elektrogramme abgeleitet und das Herz nach vorgegeben Protokoll stimuliert. Dabei werden die elektrischen Leitungseigenschaften des Herzens analysiert. Mittels der Stimulation können die klinischen Tachykardien meist reproduziert werden. Im ersten Teil dieser Übersichtsarbeit wird der genaue Ablauf einer EPU beschrieben. Im zweiten Teil werden die Indikationen für diese Untersuchung besprochen.

INTRODUCTION Intraoperative radiofrequency (RF) 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 RF 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 RF 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 RF ablation. In 2 patients (1.6%), ectopic right atrial tachycardias occurred and were treated with percutaneous RF ablation. CONCLUSION Late after intraoperative RF 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 RF ablation due to noncontinuous or nontransmural linear lesions may lead to stable left atrial macroreentrant tachycardias, requiring new interventional therapy.

In den letzen 20 Jahren haben verfeinerte elektrophysiologische Mappingtechniken zu einem besseren Verständnis der pathophysiologischen Grundlagen von Vorhofflattern und Vorhofflimmern geführt, was wiederum zur Entwicklung von kathetertechnischen Behandlungsverfahren mittels Hochfrequenzstromablation geführt hat. Bei rezidivierendem symptomatischem oder hämodynamisch relevantem typischem Vorhofflattern hat sich diese Behandlungsform als kurative Therapie der ersten Wahl im klinischen Alltag durchgesetzt. Auch bei Vorhofflimmern stellt die primäre Katheterablation eine neue, potentiell kurative Behandlungsoption dar. Dieses in klinischer Erprobung befindliche Verfahren muss sich jedoch aufgrund der zur Zeit noch nicht bekannten Langzeitergebnisse im Rahmen von kontrollierten Studien zuerst etablieren, bevor es bei Patienten mit Vorhofflimmern zu einem generellen Einsatz empfohlen werden kann. Bei Patienten mit Vorhofflimmern, die medikamentös nicht ausreichend behandelbar sind und die für die neuen Behandlungsverfahren mittels direkter Katheterablation nicht in Betracht kommen, kann als ultima ratio nach einer Schrittmacherimplantation der AV-Knoten zur Erzeugung eines kompletten AV-Blocks abladiert werden.

The electroanatomic mapping system Carto((R)) with its combination of anatomic and electrophysiologic information has substantially improved our understanding of arrhythmia mechanisms and substrates in patients with ventricular tachycardia (VT) and structural heart disease. Identification of the individual arrhythmogenic substrate and successful ablation guided by the combination of sinus rhythm voltage mapping and conventional electrophysiologic techniques like pace and activation/entrainment mapping are best described for patients with recurrent VT in remote myocardial infarction. In about 75-90% of the patients, the target VT can be ablated with acute success and the patients remain free of any VT recurrence in up to 75%. First results of electroanatomically guided ablation in patients with arrhythmogenic right ventricular dysplasia are promising. Data on ablation of VT in other structural heart diseases are very limited, since the arrhythmogenic substrate is very diffuse, e. g., in dilated cardiomyopathy, or there are only small patient numbers, e. g., for cardiac sarcoidosis or monomorphic VT after repair of congenital heart disease. In this article, the current status of electroanatomically guided endocardial mapping and ablation of VT in patients with structural heart disease is described.

ObjectivesWe postulated a change of angiotensin II receptor subtype expression in patients with lone atrial fibrillation (AF) and AF with underlying mitral valve disease (MVD) both compared with sinus rhythm (SR).BackgroundAtrial fibrillation is a progressive disease associated with electrical and structural remodeling. Angiotensin II (ANGII) is involved in the process of myocardial remodeling. Actions of ANGII are mediated by ANGII receptor subtypes 1 and 2 (AT1and AT2).MethodsLeft atrial (LA) and right atrial (RA) tissue samples were obtained from patients with AF or SR with or without underlying MVD. The AT1and AT2protein levels were measured by quantitative Western blotting techniques.ResultsThe AT1protein level in the LA was significantly increased in patients with AF (all forms) compared with SR (p < 0.05), whereas AT2expression was not significantly altered. Comparison of the subgroups revealed a similar increase of AT1in both paroxysmal AF and chronic AF with or without MVD. Additionally, investigations of ANGII receptor subtypes in the RA did not exhibit any significant changes either in AT1or in AT2in patients with AF versus SR. Underlying MVD did not significantly affect AT2receptor subtype expression in LA.ConclusionsAtrial fibrillation is associated with an up-regulation of AT1in LA, but not in RA, and did not appear to influence the AT2expression in the atrium. Because we found an enhanced expression of AT1in the LA, we conclude that AT1might be involved in the pathogenesis of AF in the LA.

Patienten mit alleinigem therapierefraktarem chronischen oder paroxysmalen Vorhofflimmern, oder mit begleitenden kardialen Erkrankungen, wie Herzklappendegenerationen, konnen mit verschiedenen Techniken chirurgisch behandelt werden. Mit der unipolare Hochfrequenzenergie, der Kryoapplikation und der Mikrowellenenergie ist eine erfolgreiche Behandlung des Vorhofflimmerns im Bereich des linken Vorhofes moglich. Die postoperative Mortalitat und Morbiditat ist vergleichbar mit anderen kardiochirurgischen Eingriffen. Der operative Eingriff ist weniger aufwendig als die MAZE-Operation und kann in einer minimalinvasiven Technik, auch in Zusammenhang mit Mitralklappeneingriffen, durchgefuhrt werden. Alternative Techniken, wie die neue Kryotechnologien, die Laserapplikation und die bipolare Hochfrequenzenergie werden im Rahmen von Studien auf ihre Effektivitat und Sicherheit gepruft.

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)

Die Entwicklung sicherer, kurativer Therapieverfahren zur Behandlung von Vorhofflimmern verbleibt eine der grosen Herausforderungen fur die nachsten Jahre in der invasiven Elektrophysiologie. Unser pathophysiologisches Verstandnis der Rhythmusstorung wurde durch primar chrirugische Therapieansatze wie die MAZE-Prozedure und intraoperative Mappingstudien masgeblich mitentwickelt. Trotz der hohen Effektivitat konnte sich die MAZE-Operation aufgrund der Komplexitat des Eingriffs in der Breite nicht durchsetzen. Ende der 90er Jahre hauften sich die Hinweise fur die pradominate Rolle linksatrialer Rotor-Reentry-Kreislaufe zur Aufrechterhaltung von Vorhofflimmern. Unter anderem basierend auf der Annahme, dass die Pulmonalvenenostien als anatomisches Substrat fur die Aufrechterhaltung von linksatrialen Anker-Reentry fungieren, wurden moderne chirurgische Therapiekonzepte zur kurativen Behandlung von Vorhofflimmern entwickelt. Das groste Patientenkollektiv wurde mit dem IRAAF-Konzept (Intraoperative Radiofrequency Ablation of Atrial Fibrillation) behandelt. Durch die intraoperative Induktion kontinuierlicher linksatrialer Lasionslinien mittels Hochfrequenzstrom konnte ein neues Therapiekonzept mit hohen Erfolgsraten etabliert werden. Da die Methode auch bei minimal invasivem chirurgischem Vorgehen anwendbar ist, konnten auch Patienten mit alleinigem Vorhofflimmern mittels intraoperativer Ablation behandelt werden. Die Erfolgsraten lagen bei diesen Patienten uber 95%. Aufgrund seltener aber schwerwiegender Komplikationen (vorwiegend intraoperative Verletzungen des Osophagus) musste die intraoperative Anwendung von Hochfrequenzstom jedoch wieder gestoppt werden. Andere und potentiell sicherere Energiequellen (Kryoenergie) sind zurzeit in der experimentellen und klinischen Prufung, um die Fortfuhrung dieses auserst effektiven Therapiekonzeptes auch als sog. Primarindikation in Zukunft wieder moglich zu machen.