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Background: Atrial fibrillation is the most common arrhythmia and has been described as driver of cardiovascular morbidity and risk factor for cardiac device-related complications, as well as in transvenous lead extraction (TLE). Objectives: Aim of this study was to characterize the procedural outcome and risk-factors of patients with atrial fibrillation (AF) undergoing TLE. Methods: We performed a subgroup analysis of all AF patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for all-cause mortality were assessed. Results: A total number of 510 patients with AF were identified with a mean age of 74.0 ± 10.3 years. Systemic infection (38.4%) was the leading cause for TLE, followed by local infection (37.5%) and lead dysfunction (20.4%). Most of the patients (45.9%) presented with pacemaker systems to be extracted. The total number of leads was 1181 with a 2.3 ± 0.96 leads/patient. Clinical procedural success was achieved in 97.1%. Occurrence of major complications was 1.8% with a procedure-related mortality of 1.0%. All-cause mortality was high with 5.9% and septic shock being the most common cause. Systemic device infection (OR: 49.73; 95% CI: 6.56–377.09, p < 0.001), chronic kidney disease (CKD; OR: 2.67; 95% CI: 1.01–7.03, p = 0.048) and a body mass index < 21 kg/m2 (OR: 6.6; 95% CI: 1.68–25.87, p = 0.007) were identified as independent predictors for all-cause mortality. Conclusions: TLE in AF patients is effective and safe, but in patients with systemic infection the mortality due to septic shock is high. Systemic infection, CKD and body mass index

Background and Objectives: Selective pulmonary vein (PV) angiography has been established as the gold standard for PV visualization in cryoballoon (CB)-based pulmonary vein isolation (PVI). We sought to simplify this approach to reduce procedural complexity and radiation exposure. Materials and Methods: Patients with paroxysmal and recently diagnosed persistent AF undergoing CB-based PVI from January 2015 to December 2017 were retrospectively analyzed. Patients underwent either selective PV angiography or conventional left atrial (LA) angiography for PV visualization. Results: A total of 336 patients were analyzed. A total of 87 patients (26%) received PV angiography and 249 (74%) LA angiography. LA angiography required fewer cine-sequences for PV visualization, translating into a significant reduction in procedure duration, fluoroscopy time and dose area product. Additionally, less contrast medium was utilized. PV occlusion by the CB, CB temperature and time to isolation showed no significant differences. The number of CB applications and total application time (LA angiography: 1.4 ± 0.02 vs. PV Angiography: 1.6 ± 0.05; p < 0.0001; LA angiography: 297.9 ± 4.62 vs. PV-Angiography: 348.9 ± 11.03; p < 0.001, respectively) per vein were slightly but significantly higher in the PV angiography group. We observed no difference in late AF recurrence (24.7% LA angiography vs. 21.3% PV angiography; p = 0.2657). Conclusions: A simplified protocol, using LA angiography for PV visualization, entails a reduction in procedure time and radiation exposure while equally maintaining procedural efficiency and safety in both groups.

Catheter-ablation (CA) of consecutive left atrial tachycardias (LAT) can be challenging. Pulsed field ablation (PFA) yields a novel nonthermal CA technology for treatment of atrial fibrillation (AF). There is no data regarding PFA of LAT. This study sought to investigate PFA of consecutive LAT following prior CA of AF.Consecutive patients with LAT underwent ultrahigh-density (UHDx) mapping. Subsequent to identification of the AT mechanism, PFA was performed at the assumed critical sites for LAT maintenance. Continuous ablation lines were performed if required and evaluated with pre- and post-PFA HDx-mapping.Fifteen patients (age 70 ± 10, male 73%) who underwent 3.6 ± 2 prior AF-CA procedures were included. The total mean procedure and fluoroscopy times were 141 ± 43 and 18 ± 10 min, respectively. All 19 of 19 (100%) LAT were successfully ablated with PFA. Two AT located at the right atria required RF-ablation. LAT were identified as localized reentry (n = 1) and macro-reentry LAT (n = 18) and targeted with PFA. All LAT terminated with PFA either to sinus rhythm (9/15) or a secondary AT (6/15 and subsequently to SR); 63% (12/19) terminated with the first PFA-application. All lines (13 roof, 11 anterior, 1 mitral) were blocked. LA-posterior-wall isolation (LAPWI) was successfully achieved when performed (10/10). AF/AT free survival was 80% (12/15) after 153 [88-207] days of follow-up. No procedure-related complications occurred.PFA of consecutive LAT is feasible and safe. Successful creation of ablation lines and LAPWI can be achieved in a short time. PFA may offer the opportunity for effective ablation of atrial arrhythmias beyond AF.

Aims Weight management seems to be beneficial for obese atrial fibrillation (AF) patients; however, randomized data are sparse. Thus, this study aimed to investigate the influence of weight reduction on AF ablation outcomes. Methods and results SORT-AF is an investigator-sponsored, prospective, randomized, multicentre, and clinical trial. Patients with symptomatic AF (paroxysmal or persistent) and body mass index (BMI) 30–40 kg/m2 underwent AF ablation and were randomized to either weight-reduction (group 1) or usual care (group 2), after sleep–apnoea–screening and loop recorder (ILR) implantation. The primary endpoint was defined as AF burden between 3 and 12 months after AF ablation. Overall, 133 patients (60 ± 10 years, 57% persistent AF) were randomized to group 1 (n = 67) and group 2 (n = 66), respectively. Complications after AF-ablation were rare (one stroke and no tamponade). The intervention led to a significant reduction of BMI (34.9 ± 2.6–33.4 ± 3.6) in group 1 compared to a stable BMI in group 2 (P Conclusion The SORT-AF study shows that AF ablation is safe and successful in obese patients using continuous monitoring via ILR. Although the primary endpoint of AF burden after ablation did not differ between the two groups, the effects of weight loss and improvement of exercise activity were beneficial for obese patients with persistent AF demonstrating the relevance of life-style management as an important adjunct to AF ablation in this setting. Trial registration number NCT02064114.

Substrate-based catheter ablation approaches to ventricular tachycardia (VT) focus on low-voltage areas and abnormal electrograms. However, specific electrogram characteristics in sinus rhythm are not clearly defined and can be subject to variable interpretation. We analyzed the potential ablation target size using automatic abnormal electrogram detection and studied findings during substrate mapping in the VT isthmus area.Electrogram characteristics in 61 patients undergoing scar-related VT ablation using ultrahigh-density 3D-mapping with a 64-electrode mini-basket catheter were analyzed retrospectively. Forty-four complete substrate maps with a mean number of 10319 ± 889 points were acquired. Fractionated potentials detected by automated annotation and manual review were present in 43 ± 21% of the entire low-voltage area (1.0 mV), highly fractionated potentials in 7 ± 8%, late potentials in 13 ± 15%, fractionated late potentials in 7 ± 9% and isolated late potentials in 2 ± 4%, respectively. Highly fractionated potentials (10 ± 1 fractionations) were found in all isthmus areas of identified VT during substrate mapping, while isolated late potentials were distant from the critical isthmus area in 29%.The ablation target area varies enormously in size, depending on the definition of abnormal electrograms. Clear linking of abnormal electrograms with critical VT isthmus areas during substrate mapping remains difficult due to a lack of specificity rather than sensitivity. However, highly fractionated, low-voltage electrograms were found to be present in all critical VT isthmus sites.

Aims S100B, a well-known damage-associated molecular pattern protein is released acutely by central and peripheral nerves and upon concomitant denervation in pulmonary vein isolation (PVI). We aimed to investigate whether the ablation technique used for PVI impacts S100B release in patients with paroxysmal atrial fibrillation (AF). Methods and results The study population consisted of 73 consecutive patients (age: 62.7 ± 10.9 years, 54.8% males) undergoing first-time PVI with either radiofrequency (RF; n = 30) or cryoballoon (CB; n = 43) for paroxysmal AF. S100B determined from venous plasma samples taken immediately before and after PVI increased from 33.5 ± 1.8 to 91.1 ± 5.3 pg/mL (P Conclusion The ablation technique used for PVI has an impact on the release of S100B, a well-established biomarker for neural damage.

Introduction The aim of this study was to investigate electrophysiological findings in patients with arrhythmia recurrence undergoing a repeat ablation procedure using ultra-high-density (UHDx) mapping following an index procedure using either contact-force (CF)-guided radiofrequency current (RFC) pulmonary vein isolation (PVI) or second-generation cryoballoon (CB) PVI for treatment of atrial fibrillation (AF). Methods and results Fifty consecutive patients with recurrence of AF and/or atrial tachycardia (AT) following index CF-RFC PVI (n = 21) or CB PVI (n = 29) were included. A 64-pole mini-basket mapping catheter in combination with an UHDx-mapping system-guided ablation was used. RFC was applied using a catheter tip with three incorporated mini-electrodes. PV reconnection rates were higher after CF-RFC PVI (CF-RFC: 2.5 ± 1.3 PVs vs CB: 1.4 ± 0.9 PVs; P = .0025) and left PVs were more frequently reconnected (CF-RFC: 64% PVs vs CB: 35% PVs; P = .0077). Fractionated signals along the antral index ablation line (FS) were found in 30% of CB-PVI patients (CF-RFC: 9.5% vs CB:30%; P = .098) targeted for ablation. In five cases, FS were a critical part of maintaining consecutive AT. The main AT mechanism found during reablation (n = 45 ATs) was macroreentry (80% [36/45], CF-RFC: 78.9% vs CB: 80.8%; P = 1.0) with a variety of circuits throughout both atria. Conclusion UHDx mapping is sensitive in detecting conduction gaps along the index ablation line. Left PVs are more frequently reconnected after initial CF-RFC PVI. FS are a common finding after CB PVI and can maintain certain forms of ATs. ATs after index PVI are mostly macroreentries with a broad spectrum of entities.

AIMS Catheter contact and local tissue characteristics are relevant information for successful radiofrequency current (RFC)-ablation. Local impedance (LI) has been shown to reflect tissue characteristics and lesion formation during RFC-ablation. Using a novel ablation catheter incorporating three mini-electrodes, we investigated LI in relation to generator impedance (GI) in patients with ventricular tachycardia (VT) and its applicability as an indicator of effective RFC-ablation. METHODS AND RESULTS Baseline impedance, Δimpedance during ablation and drop rate (Δimpedance/time) were analyzed for 625 RFC-applications in 28 patients with recurrent VT undergoing RFC-ablation. LI was lower in scarred (87.0 Ω [79.0-95.0]) compared to healthy myocardium (97.5 Ω ([82.75-111.50]; P = .03) while GI did not differ between scarred and healthy myocardium. ΔLI was higher (18 Ω [9.4-26.0]) for VT-terminating as compared to non-terminating RFC-ablation (ΔLI 13 Ω [8.85-18.0]; P = .03), but did not differ for ΔGI between terminating vs nonterminating RFC-ablation. Correspondingly, LI drop rate was higher for RFC-ablation terminating the VT compared with RFC-ablation not terminating the VT (0.63 Ω/s [0.52-0.76] vs 0.32 Ω [0.20-0.58]; P = .008) while there was no difference for GI drop rate. ΔLI was higher in patients with nonischemic cardiomyopathy vs patients with ischemic cardiomyopathy (16 Ω [11.0-20.0] vs 11.0 Ω [7.85-17.00]; P = .003). CONCLUSION Our findings suggest that LI is a sensitive parameter to guide RFC-ablation in patients with VT. LI indicates differences in tissue characteristics and generally is higher in patients with nonischemic cardiomyopathy. Hence, the etiology of the underlying cardiomyopathy needs to be considered when adopting LI for monitoring catheter ablation of VT.

Ultra-high-density (UHD) mapping can improve scar area detection and fast activation mapping in patients undergoing catheter ablation of ventricular tachycardia (VT). The aim of the present study was to compare the outcome after VT ablation guided by UHD and conventional point-by-point 3D-mapping. The acute and long-term ablation outcome of 61 consecutive patients with UHD mapping (64-electrode mini-basket catheter) was compared to 61 consecutive patients with conventional point-by-point 3D-mapping using a 3.5 mm tip catheter. Patients, whose ablation was guided by UHD mapping had an improved 24-months outcome in comparison to patients with conventional mapping (cumulative incidence estimate of the combination of recurrence or disease-related death of 52.4% (95% confidence interval (CI) [36.9–65.7]; recurrence: n = 25; disease-related death: n = 4) versus 69.6% (95% CI [55.9–79.8]); recurrence: n = 31; disease-related death n = 11). In a cause-specific Cox proportional hazards model, UHD mapping (hazard ratio (HR) 0.623; 95% CI [0.390–0.995]; P = 0.048) and left ventricular ejection fraction > 30% (HR 0.485; 95% CI [0.290–0.813]; P = 0.006) were independently associated with lower rates of recurrence or disease-related death. Other procedural parameters were similar in both groups. In conclusion, UHD mapping during VT ablation was associated with fewer VT recurrences or disease-related deaths during long-term follow-up in comparison to conventional point-by-point mapping. Complication rates and other procedural parameters were similar in both groups.

AIMS A novel measure of local impedance (LI) has been found to predict lesion formation during radiofrequency current (RFC) catheter ablation. The aim of this study was to investigate the utility of this novel approach, while comparing LI to the well-established generator impedance (GI). METHODS AND RESULTS In 25 consecutive patients with a history of atrial fibrillation, catheter ablation was guided by a 3D-mapping system measuring LI in addition to GI via an ablation catheter tip with three incorporated mini-electrodes. Local impedance and GI before and during RFC applications were studied. In total, 381 RFC applications were analysed. The baseline LI was higher in high-voltage areas (>0.5 mV; LI: 110.5 ± 13.7 Ω) when compared with intermediate-voltage sites (0.1-0.5 mV; 90.9 ± 10.1 Ω, P < 0.001), low-voltage areas (

Introduction Tailored catheter ablation of atrial tachycardias (ATs) is increasingly recommended as a potentially easy treatment strategy in the era of high-density mapping (HDM). As follow-up data are sparse, we here report outcomes after HDM-guided ablation of ATs in patients with prior catheter ablation or cardiac surgery. Methods and results In 250 consecutive patients (age 66.5 ± 0.7 years, 58% male) with ATs (98% prior catheter ablation, 13% prior cardiac surgery) an HDM-guided catheter ablation was performed with the support of a 64-electrode mini-basket catheter. A total of 354 ATs (1.4 ± 0.1 ATs per patient; mean cycle length 304 ± 4.3 ms; 64% macroreentry, 27% localized reentry, and 9% focal) with acute termination of 95% were targeted in the index procedure. A similar AT as in the index procedure recurred in five patients (2%) after a median follow-up time of 535 days (interquartile range (IQR) 25th-75th percentile: 217-841). Tailored ablation of reentry ATs with freedom from any arrhythmia was obtained in 53% after a single procedure and in 73% after 1.4 ± 0.4 ablation procedures (range: 1-4). A total of 228 patients (91%) were free from any arrhythmia recurrence after 210 days (IQR: 152-494) when including optimal usual care. Conclusions Tailored catheter ablation of ATs guided by HDM has a high acute success rate. The recurrence rate of the index AT is low. In patients with extensive atrial scaring further ablation procedures need to be considered to achieve freedom from any arrhythmia.

BackgroundPhrenic nerve injury (PNI) remains one of the most frequent complications during cryoballoon-based pulmonary vein isolation (CB-PVI). Since its introduction in 2013, the use of compound motor action potential (CMAP) for the prevention of PNI during CB-PVI is increasing; however, systematic outcome data are sparse.MethodsThe CMAP technique was applied in conjunction with abdominal palpation during pacing manoeuvres (10 mV, 2 ms) from the superior vena cava for 388 consecutive patients undergoing CB-PVI between January 2015 and May 2017 at our tertiary arrhythmia centre. Cryoablation was immediately terminated when CMAP amplitude was reduced by 30%.ResultsReductions in CMAP amplitude were observed in 16 (4%) of 388 patients during isolation of the right veins. Of these, 11 (69%) patients did not manifest a reduction in diaphragmatic excursions. The drop in CMAP amplitude was observed in 10 (63%) patients during ablation of the right superior pulmonary veins (PVs) and in 7 (44%) patients during ablation of the right inferior PVs. Postprocedural persistent PNI was observed in three of four patients for a duration of 6 months, with one of these patients remaining symptomatic at the 24-month follow-up. One of the four patients was lost to long-term follow-up.ConclusionsAll PNIs occurred during right-sided CB-PVI and were preceded by a reduction in CMAP amplitude. Thus, the standardized use of CMAP surveillance during CB-PVI is easily applicable, reliable and compared with other studies, results in a lower number of PNIs.

BACKGROUND Recent evidence indicates that sympathetic/parasympathetic coactivation (CoA) is causally linked to changes in heart rate (HR) dynamics. Whether this is relevant for patients with atrial fibrillation (AF) is unknown. MATERIAL AND METHODS In patients with paroxysmal AF (n=26) and age-matched controls, (n=10) we investigated basal autonomic outflow and HR dynamics during separate sympathetic (cold hand immersion) and parasympathetic activation (O2-inhalation), as well as during CoA (cold face test). In an additional cohort (n=7), HR response was assessed before and after catheter-based pulmonary vein isolation (PVI). Ultra-high-density endocardial mapping was performed in patients (n=6) before and after CoA. RESULTS Sympathetic activation increased (control: 74±3 vs. 77±3 bpm, p=0.0098; AF: 60±2 vs. 64±2 bpm, p=0.0076) and parasympathetic activation decreased HR (control: 71±3 vs. 69±3 bpm, p=0.0547; AF: 60±1 vs. 58±2 bpm, p

Contact force (CF) catheters provide catheter-tissue contact information to improve outcome of pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF). We evaluated different target-CF values for achievement of the additional endpoint of an unexcitable ablation line. A total of 106 patients undergoing PVI were randomized into three groups (G) (G1: target-CF 15 g, G2: target-CF 10 g, G3: CF concealed from operator). The PVI encircling line was divided into predefined sections. Excitable tissue along the PVI-line identified by high output pacing (10 V, 2 ms) was targeted for further ablation. Mean average CF was 17.4 ± 4.7 g (G1) vs. 12.3 ± 6.0 g (G2) vs. 11.1 ± 6.5 g (G 3) (p

AIMS To evaluate the incidence of newly diagnosed intracardiac thrombi (ICT) in respect to the mode of OAC in patients undergoing cardioversion (CV). METHODS AND RESULTS We prospectively assessed transesophageal echocardiography (TEE) and OAC therapy prior to CV in AF patients with ≥48-hour duration scheduled for CV. A total of 60 first-time ICT (4.7%) were diagnosed in 1,286 TEE, with highest rate in patients without OAC (9.6% vs. OAC 4.1%, P = 0.009) and an apparently lower rate in nonvitamin K antagonist anticoagulants (NOAC) therapy compared to vitamin K antagonist (VKA) (2.5% vs. 5.3%, P = 0.02). VKA therapy control 4 weeks prior to CV was overall average (time in therapeutic range 60%) and patients showed more frequently clinical characteristics and TEE parameters associated with risk for ICT. Even among patients with effective OAC therapy (uninterrupted NOAC and VKA therapy with international normalized ratio (INR) ≥2.0 for 3 weeks), ICT occurred in 2.7%, but with no difference between both groups (P = 0.22). There was no difference between different types of NOAC. Independent predictors for ICT were history of embolism, hypertension, BMI, absence of OAC, renal function, reduced atrial appendage flow, and presence of spontaneous echo contrast. CONCLUSION NOAC therapy seems favorable in the overall prevention of ICT, although this is likely to be caused by suboptimal VKA therapy control and differences in the overall health status between VKA and NOAC patients. ICT occurred even with effective OAC therapy suggesting individual TEE-guided cardioversion in patients at risk.

Background Ablation of scar-related ventricular tachycardia (VT), especially in non-inducible VT or hemodynamically unstable patients, can be challenging. Thus, we evaluated feasibility of an ultra high-density 3D-mapping approach to characterize the ventricular substrate and, if possible, to map VT. Methods and results Twenty-two patients (67±2 years, mean LV-EF 36±3%) with both ischemic and non-ischemic cardiomyopathy and documented VT underwent mapping and catheter ablation using a 64-electrode mini-basket catheter. Substrate characterization included ultra high-density voltage maps, identification of areas of slow conduction and late potentials. Whenever VT was inducible activation mapping was performed. In 13/22 patients the presumed clinical VT (in 16/22 any VT) was inducible. A total of 50 maps were generated (22 substrate maps, 28 during VT), mapping time was 33±4 minutes, number of points was 10937±1923. Low voltage areas were related with the site of origin in all mapped VT. Isochronal maps indicated areas of slow conduction in 14/22 patients, all in border zone scar. In 95% of patients late potentials were found. Mapping time during VT was 9±2 minutes, number of points 6740±1140. Covered cycle length was 82±5% (16 re-entry, 10 focal and 2 undetermined). During 4 months follow-up 90% remained free from VT recurrence. Conclusion Ultra high-density mapping in patients with scar-related VT is feasible, safe and enables detailed insight into tachycardia mechanisms. Critical sites can be identified (1) by precise substrate characterization when VT is not inducible or hemodynamically not tolerated and (2) during short lasting episodes of VT in order to guide catheter ablation. This article is protected by copyright. All rights reserved

Aims During ablation in the vicinity of the coronary arteries establishing a safe distance from the catheter tip to the relevant vessels is mandatory and usually assessed by fluoroscopy alone. The aim of the study was to investigate the feasibility of an image integration module (IIM) for continuous monitoring of the distance of the ablation catheter tip to the main coronary arteries during ablation of ventricular arrhythmias (VA) originating in the sinus of valsalva (SOV) and the left ventricular summit part of which can be reached via the great cardiac vein (GCV). Methods and results Of 129 patients undergoing mapping for outflow tract arrhythmias from June 2014 till October 2015, a total of 39 patients (52.4 ± 18.1 years, 17 female) had a source of origin in the SOV or the left ventricular summit. Radiofrequency (RF) ablation was performed when a distance of at least 5 mm could be demonstrated with IIM. A safe distance in at least one angiographic plane could be demonstrated in all patients with a source of origin in the SOV, whereas this was not possible in 50% of patients with earliest activation in the summit area. However, using the IIM a safe position at an adjacent site within the GCV could be obtained in three of these cases and successful RF ablation performed safely without any complications. Ablation was successful in 100% of patients with an origin in the SOV, whereas VAs originating from the left ventricular summit could be abolished completely in only 60% of cases. Conclusion Image integration combining electroanatomical mapping and fluoroscopy allows assessment of the safety of a potential ablation site by continuous real-time monitoring of the spatial relations of the catheter tip to the coronary vessels prior to RF application. It aids ablation in anatomically complex regions like the SOV or the ventricular summit providing biplane angiograms merged into the three-dimensional electroanatomical map.

Atrial fibrillation (AF), the most common sustained heart rhythm disorder worldwide, is linked to dysfunction of the intrinsic cardiac autonomic nervous system (ICNS). The role of ICNS damage occurring during catheter-based treatment of AF, which is the therapy of choice for many patients, remains controversial. We show here that the neuronal injury marker S100B is expressed in cardiac glia throughout the ICNS and is released specifically upon catheter ablation of AF. Patients with higher S100B release were more likely to be AF free during follow-up. Subsequent in vitro studies revealed that murine intracardiac neurons react to S100B with diminished action potential firing and increased neurite growth. This suggests that release of S100B from cardiac glia upon catheter-based treatment of AF is a hallmark of acute neural damage that contributes to nerve sprouting and can be used to assess ICNS damage.

INTRODUCTION Long-term efficacy and safety are uncertain in patients with cardiac implantable electronic devices (CIED) and transvenous leads (TVL) undergoing radiofrequency catheter ablation of atrial fibrillation (AF). Thus, we assessed the outcome of AF ablation in those patients during long-term follow-up using continuous atrial rhythm monitoring (CARM). METHODS AND RESULTS A total of 190 patients (71.3 ± 10.7 years; 108 (56.8% men) were included in this study. At index procedure 81 (42.6%) patients presented with paroxysmal AF and 109 (57.4%) with persistent AF. The ablation strategy included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines, if appropriate. AF recurrences were assessed by CARM- and CIED-related complications by device follow-up. After a mean follow-up of 55.4 ± 38.1 months, freedom of AF was found in 86 (61.4%) and clinical success defined as an AF burden less than or equal to 1% in 101 (72.1%) patients. Freedom of AF was reported in 74.6% and 51.9% (P = 0.006) and clinical success in 89.8% and 59.3% (P

This study sought to characterize primary left atrial tachycardia (LAT) mechanisms, electrical properties and substrate using high-density mapping.Nonfocal LAT can be found in patients without prior substrate modifying interventions.Of 223 catheter ablation procedures for LAT 15 patients (60% male, age 74 ± 6 years) had nonfocal AT and no history of LA ablation or cardiac surgery.AT (mean cycle length 244 ± 32 ms) were identified as macro-re-entry (12 of 15) or localized re-entry (3 of 15). High-density electroanatomical mapping (EAM, performed in 13 patients) revealed a high proportion of low voltage areas (LVA, 0.45 mV, 41 ± 22%). Anterior LVA regions were predominantly related to the macro-re-entry and directly perpetuating the re-entrant circuit in 8 patients by formation of a conductive channel (width: 14 ± 7 mm, length: 11 ± 3 mm) between the inferior pole of the scar and the mitral valve (MV) annulus with electrophysiological features of diseased tissue. A tailored anterior ablation line successfully terminated AT in 9 patients (6 dominant circuit MV dependent, 3 dominant circuit scar dependent AT), while a lateral isthmus line was performed in 2 patients. Localized re-entries were successfully targeted by local ablation. Acute successful ablation could be achieved in 14 of 15 patients leading to a freedom from any arrhythmias in 9 of 15 patients (60%) after follow-up of 343 ± 203 days.Patients with nonfocal left atrial tachycardia without previous iatrogenic interventions show evidence for advanced atrial myopathy. High-density mapping revealed involvement of the anterior LA and allows for an individualized ablation approach beyond strategies usually applied in consecutive AT.

Since its invention in the late 19(th) century, the Langendorff ex vivo heart perfusion system continues to be a relevant tool for studying a broad spectrum of physiological, biochemical, morphological, and pharmacological parameters in centrally denervated hearts. Here, we describe a setup for the modulation of the intracardiac autonomic nervous system and the assessment of its influence on basic electrophysiology, arrhythmogenesis, and cyclic adenosine monophosphate (cAMP) dynamics. The intracardiac autonomic nervous system is modulated by the mechanical dissection of atrial fat pads-in which murine ganglia are located mainly—or by the usage of global as well as targeted pharmacological interventions. An octapolar electrophysiological catheter is introduced into the right atrium and the right ventricle, and epicardial-placed multi-electrode arrays (MEA) for high-resolution mapping are used to determine cardiac electrophysiology and arrhythmogenesis. Förster resonance energy transfer (FRET) imaging is performed for the real-time monitoring of cAMP levels in different cardiac regions. Neuromorphology is studied by means of antibody-based staining of whole hearts using neuronal markers to guide the identification and modulation of specific targets of the intracardiac autonomic nervous system in the performed studies. The ex vivo Langendorff setup allows for a high number of reproducible experiments in a short time. Nevertheless, the partly open nature of the setup (e.g., during MEA measurements) makes constant temperature control difficult and should be kept to a minimum. This described method makes it possible to analyze and modulate the intracardiac autonomic nervous system in decentralized hearts.

Background: Increased augmentation index (AIx) is accompanied by an elevated cardiovascular risk. A reduction of AIx is known for long-term continuous positive airway pressure (CPAP) therapy. We hypothesised that acute preload and left ventricular workload effects AIx and subendocardial viability ratio (SEVR) as a marker of coronary flow reserve. Methods: Increased augmentation index and central blood pressure parameters were measured by radial artery tonometry in 17 healthy men (32/ ± 6 years) at rest and during CPAP ventilation at pressures of 5, 10 mbar and after recovery. In a subset of seven individuals, haemodynamic parameters and autonomic function were additionally examined using combined impedance cardiography and continuous noninvasive blood pressure monitoring. Results: Continuous positive airway pressure reduced heart rate corrected (AIx@75) (-2.8 ± 8.1 [rest] to −10.7 ± 11.3 [5 mbar], p < 0.01, to −12.2 ± 10.5% [10 mbar], p < 0.01) and systolic time integral as a marker of left ventricular workload (2115 ± 231 [rest] to 1978 ± 290 [5 mbar], p = 0.02 to 1940 ± 218 [10 mbar], p < 0.01 to 2013 ± 241 mmHg/s per min [recovery], p = 0.03), while central systolic pressure did not change during CPAP. Total Peripheral Resistance Index increased reaching level of significance at 10 mbar CPAP condition (1701 ± 300 [rest] to 1850 ± 301 dyn*s*m2/cm5 [10 mbar], p = 0.04). There was a reversible increase of SEVR under CPAP conditions. Conclusions: Continuous positive airway pressure ventilation acutely reduces AIx, heart rate and left ventricular workload in healthy young men. These effects seem to be mediated by left ventricular filling pressure, workload and reflection wave. Furthermore, we found an increase of subendocardial viability ratio as an indication for a rising coronary flow reserve by CPAP.

Monitoring of cardiovascular function on a beat-to-beat basis is fundamental for protecting patients in different settings including emergency medicine and interventional cardiology, but still faces technical challenges and several limitations. In the present study, we propose a new method for the extraction of cardiovascular performance surrogates from analysis of the photoplethysmographic (PPG) signal alone.We propose using a multi-Gaussian (MG) model consisting of five Gaussian functions to decompose the PPG pulses into its main physiological components. From the analysis of these components, we aim to extract estimators of the left ventricular ejection time, blood pressure and vascular tone changes. Using a multi-derivative analysis of the components related with the systolic ejection, we investigate which are the characteristic points that best define the left ventricular ejection time (LVET). Six LVET estimates were compared with the echocardiographic LVET in a database comprising 68 healthy and cardiovascular diseased volunteers. The best LVET estimate achieved a low absolute error (15.41 ± 13.66 ms), and a high correlation (ρ = 0.78) with the echocardiographic reference.To assess the potential use of the temporal and morphological characteristics of the proposed MG model components as surrogates for blood pressure and vascular tone, six parameters have been investigated: the stiffness index (SI), the T1_d and T1_2 (defined as the time span between the MG model forward and reflected waves), the reflection index (RI), the R1_d and the R1_2 (defined as their amplitude ratio). Their association to reference values of blood pressure and total peripheral resistance was investigated in 43 volunteers exhibiting hemodynamic instability. A good correlation was found between the majority of the extracted and reference parameters, with an exception to R1_2 (amplitude ratio between the main forward wave and the first reflection wave), which correlated low with all the reference parameters. The highest correlation ([Formula: see text] = 0.45) was found between T1_2 and the total peripheral resistance index (TPRI); while in the patients that experienced syncope, the highest agreement ([Formula: see text] = 0.57) was found between SI and systolic blood pressure (SBP) and mean blood pressure (MBP).In conclusion, the presented method for the extraction of surrogates of cardiovascular performance might improve patient monitoring and warrants further investigation.

Introduction The need for transesophageal echocardiography (TEE) before catheter ablation of atrial fibrillation (CA-AF) is still being questioned. The aim of this study is to analyze patients’ (pts) risk factors of left atrial appendage thrombus (LAAT) prior to CA-AF in daily clinical practice, according to oral anticoagulation (OAC) strategies recommended by current guidelines. Methods and results All pts scheduled for CA-AF from 01/2015-12/2016 in our center were included and either treated with NOACs (novel-OAC; paused 24-hours pre-ablation) or continuous vitamin K-antagonists (INR 2.0-3.0). All pts received a preprocedural TEE at the day of ablation. Two groups were defined: 1) pts without LAAT, 2) pts with LAAT. The incidence of LAAT was 0.78% (13/1658 pts). No LAAT was detected in pts with a CHA2DS2-VASc score of ≤ 1 (n = 640 pts) irrespective of the underlying AF type. Independent predictors for LAAT are: higher CHA2DS2-VASc scores (odds ratio (OR) 1.54, 95%-confidence interval (CI): 1.07–2.23, P = 0.0019), a history of non-paroxysmal AF (OR 7.96, 95%-CI: 1.52–146.64, P = 0.049), hypertrophic cardiomyopathy (HCM; OR 9.63, 95%-CI: 1.36–43.05, P = 0.007) and a left ventricular ejection fraction (LVEF) < 30% (OR 8.32, 95%-CI: 1.18–36.29, P = 0.011). The type of OAC was not predictive (P = 0.70). Conclusions The incidence of LAAT in pts scheduled for CA-AF is low. Therefore, periprocedural OAC strategies recommended by current guidelines seem feasible. Preprocedural TEE may be dispensed in pts with a CHA2DS2-VASc score ≤ 1. However, a CHA2DS2-VASc score ≥ 2, reduced LVEF, HCM or history of non-paroxysmal AF are independently associated with an increased risk for LAAT. This article is protected by copyright. All rights reserved

Pulmonary vein isolation (PVI) as a cornerstone for catheter ablation of atrial fibrillation (AF) remains a complex and time-consuming procedure.To assess feasibility, safety, and acute efficacy of a novel irrigated multielectrode ablation catheter guided by an electroanatomic mapping system for PVI in patients with paroxysmal AF.Twenty-five consecutive patients (60 ± 10 years) with paroxysmal AF underwent PVI by using a novel decapolar mapping and ablation catheter (nMARQ catheter, Biosense Webster Inc, Diamond Bar, CA). Ablation was guided by electroanatomic mapping allowing radiofrequency (RF) energy delivery in the antral region of pulmonary veins (PVs) from 10 irrigated electrodes simultaneously. The day after ablation, cardiac magnetic resonance imaging was performed routinely in order to assess for potential acute PV stenosis.Overall, 97 of 97 (100%) targeted PVs could be isolated with a mean of 27 ± 11 RF applications and a mean total burning time of 15 ± 6 minutes per patient. The total procedure time from femoral vein access to catheter withdrawal was 110 ± 31 minutes, including a mean total fluoroscopy time of 23 ± 9 minutes. On average, 6 ± 3 RF impulses with a maximum of 25 W were applied per vein. After a short learning curve, procedure, fluoroscopy, and total burning times decreased to 94 ± 16, 16 ± 3, and 9 ± 2 minutes, respectively (P.05). Entrance and exit blocks could be verified by placing the ablation catheter into 90 of 97 (93%) PVs in 18 of 25 (72%) patients. No procedure-related complications were observed, especially no acute PV stenosis could be detected.The use of a novel irrigated multielectrode ablation system for PVI is feasible and safe, resulting in acute isolation of all targeted PVs with no complications and short procedure times. Sustainability of these initial results has to be confirmed in long-term efficacy and follow-up trials.

Cardiovascular autonomic dysfunction is one of the most overlooked complications in patients with diabetes. We report the case of a 19-year-old woman with a 4-year history of diabetes referred due to palpitations and light-headedness following traumatic stress. Rise of heart rate and blood pressure during tilt table testing indicated hyperadrenergic postural orthstatic tachycardia syndrome (POTS). Elevated blood pressure variability, an indirect parameter of increased sympathetic activity, remained almost stable during orthostatic stress. Short-term treatment with ivabradine in combination with psychosocial support alleviated POTS-related symptoms. Our findings suggest that traumatic stress in patients with type 1 diabetes mellitus might translate into disturbed neural heart rate control due to a central, ephemeral alteration in autonomic balance.

Introduction Comparative data of early recurrence rates of atrial fibrillation (ERAF) following second-generation cryoballoon (CB-G2) and radiofrequency current (RFC) ablation for pulmonary vein isolation (PVI) in paroxysmal AF (PAF) are rare. We randomized PAF patients into either PVI with CB-G2 (group 1) or PVI with a combined RFC-approach applying contact force (CF) with the endpoint of unexcitability (group 2) to investigate ERAF. Methods In group 1 ( n = 30), CB-G2-PVI was performed. After CF-PVI in group 2 ( n = 30), bipolar pacing on the ablation line and additional ablation until unexcitability was conducted. Follow-up included 48 h of in-hospital monitoring followed by 5-day Holter ECGs 1, 2, 3, 6, 12 months postablation to evaluate ERAF. Results Acute PVI was reached in 100% of group 2 and in 99% of group 1. Shorter procedure durations (98.0 ± 21.9 vs. 114.3 ± 18.7 min, P < 0.05) but extended fluoroscopy times (15.4 ± 3.9 vs. 10.0 ± 4.3 min, P < 0.05) were found in the CB-G2 group. Ten non-severe complications occurred (6 vs. 4 in group 1 and 2, P = 0.73). In group 2, five patients suffered from ERAF vs. seven patients in group 1 ( P = 0.67). The time until the occurrence of ERAF was shorter in group 2 (1 day (q1–q3: 1−4.5)) when compared with group 1 (22 (q1–q3: 6−54) days, P = 0.025). Conclusion ERAF rates were equal among groups; however, they occurred earlier in the initial phase after RFC ablation when compared with CB-G2. PVI utilizing cryoablation is associated with shorter procedure durations but extended fluoroscopy time while being similarly secure.

The use of non-vitamin K antagonists (NOACs), uninterrupted (uVKA) and interrupted vitamin K antagonists (iVKA) are common periprocedural oral anticoagulation (OAC) strategies for atrial fibrillation (AF) ablation. Comparative data on complication rates resulting from OAC strategies for solely persistent AF (persAF) undergoing ablation are sparse. Thus, we sought to determine the impact of these OAC strategies on complication rates among patients with persAF undergoing catheter ablation.Consecutive patients undergoing persAF ablation were included. Depending on preprocedural OAC, three groups were defined: (1) NOACs (paused 48 h preablation), (2) uVKA, and (3) iVKA with heparin bridging. A combined complication endpoint (CCE) composed of bleeding and thromboembolic events was analyzed.Between 2011 and 2014, 1440 persAF ablation procedures were performed in 1092 patients. NOACs were given in 441 procedures (31 %; rivaroxaban 57 %, dabigatran 33 %, and apixaban 10 %), uVKA in 488 (34 %), and iVKA in 511 (35 %). Adjusted CCE rates were 5.5 % [95 % confidence interval (CI) (3.1-7.8)] in group 1 (NOACs), 7.5 % [95 % CI (5.0-10.1)] in group 2 (uVKA), and 9.9 % [95 % CI (6.6-13.2)] in group 3. Compared to group 1, the combined complication risk was almost twice as high in group 3 [odd's ratio (OR) 1.9, 95 % CI (1.0-3.7), p = 0.049)]. The major complication rate was low (0.9 %). Bleeding complications, driven by minor groin complications, are more frequent than thromboembolic events (n = 112 vs. 1, p 0.0001).Patients undergoing persAF ablation with iVKA anticoagulation have an increased risk of complications compared to NOACs. Major complications, such as thromboembolic events, are generally rare and are exceeded by minor bleedings.

Electrical cardiac pacing today is the standard therapy for symptomatic bradycardia. Importantly, despite technical advantages, complications associated with conventional transvenous pacing leads and pockets are still challenging in a relevant number of patients. Beyond cosmetic benefits, miniaturized leadless pacemaker may partly overcome these limitations and beneficially influence implantation-related physical restrictions. Initial findings with single-chamber pacemakers for right ventricular pacing, which are completely implanted via a femoral venous vascular access, are promizing. In summary, leadless pacing offers novel perspectives regarding cardiac implantable electronic devices although acute safety and the long-term performance of these systems needs to be determined in more detail.

Conventional mapping of complex atrial tachycardias (ATs) can be challenging. Thus, we evaluated feasibility and utility of a novel, ultra high-density 3D mapping approach to characterize and map AT in these cases.Overall, 21 patients (67.4 ± 7.6 years; male: 52.4%, 1.9 ± 1.4 previous ablation procedures) with documented AT referred to our center underwent catheter ablation including ultra high-density mapping using a novel 64-electrode mini-basket catheter and an adjunctive 3D mapping system. A total of 24 AT (20 left atrial, 4 right atrial AT) were analyzed in 19 cases. In 2 patients, map acquisition failed due to scarce local electrograms and unstable AT cycle length, respectively. Underlying mechanisms were focal (n = 3), as well as local (n = 8) and macro (n = 13) reentry tachycardias with a mean cycle length of 311.8 ± 67.7 milliseconds. The analysis of propagation waves, activation and voltage revealed complex activation patterns and allowed for the identification of critical sites of AT initiation or maintenance without the need for further mapping techniques. In all cases critical sites could be verified by successful consecutive ablation. Mean mapping time was 19.4 ± 7.6 minutes, mean number of mapping points was 19,217 ± 10,270. Radiofrequency application until first effect was 165.1 ± 374.2 seconds; total procedure time was 157.6 ± 51.4 minutes, fluoroscopy time 21.7 ± 13.8 minutes, and total radiofrequency duration 1,016 ± 951.9 seconds, respectively. No severe complications occurred.Ultra high-density mapping of complex AT is safe and feasible. Further, it enables detailed insight into AT mechanisms. Critical AT sites can be identified precisely in order to guide successful catheter ablation.

Neurally mediated syncope (NMS) patients suffer from sudden loss of consciousness, which is associated with a high rate of falls and hospitalization. NMS negatively impacts a subject's quality of life and is a growing cost issue in our aging society, as its incidence increases with age. In this paper, we present a solution for prediction of NMS, which is based on the analysis of the electrocardiogram (ECG) and photoplethysmogram (PPG) alone. Several parameters extracted from ECG and PPG, associated with reflectory mechanisms underlying NMS in previous publications, were combined in a single algorithm to detect impending syncope. The proposed algorithm was evaluated in a population of 43 subjects. The feature selection, distance metric selection, and optimal threshold were performed in a subset of 30 patients, while the remaining data from 13 patients were used to test the final solution. Additionally, a leave-one-out cross-validation scheme was also used to evaluate the performance of the proposed algorithm yielding the following results: sensitivity (SE)--95.2%; specificity (SP)--95.4%; positive predictive value (PPV)--90.9%; false-positive rate per hour (FPRh)-0.14 h(-1), and prediction time (aPTime)--116.4 s.

Recently, a new image integration module (IIM, CartoUnivu™ Module) has been introduced to combine and merge fluoroscopy images with 3-dimensional-(3D)-electroanatomical maps (Carto® 3 System) into an accurate 3D view. The aim of the study was to investigate the influence of IIM on the fluoroscopy exposure during pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) in a prospective randomized trial.Between June and November 2014, a total of 60 patients with PAF (73.3% male, 64.0 ± 9.2 years), who underwent PVI with the endpoint of unexcitability of the ablation line, were randomized to either a conventional 3D mapping system (Carto® 3 System) or to an additional IIM on the basis of an assumed reduction of fluoroscopy exposure by the use of IIM. There were no significant differences in baseline characteristics. The median ablation procedure time was identical in both groups (140.7 ± 27.8 minutes vs. 140.8 ± 39.5 minutes; P = 0.851). A significant decrease of mean fluoroscopy time from 11.9 ± 2.1 to 7.4 ± 2.6 minutes (P0.0006) and median fluoroscopy dose from 882.9 to 476.5 cGycm(2) (P0.001) was achieved. The main reduction of radiation could be realized during creation of the 3D-map. No major complications occurred during the procedures. After a median follow-up of 125.7 ± 45.6 days 80% of the patients were free from any atrial arrhythmias.CartoUnivu™ module easily integrates into the workflow of PVI with the endpoint of unexcitability of the ablation line without prolonging the procedure time. It is associated with a marked reduction in fluoroscopic dose when compared to a conventional 3D mapping system.

Neurally mediated syncope (NMS) is a disorder of the autonomic regulation of postural tone, which is characterized by hypotension and/or bradycardia, resulting in cerebral hypo-perfusion and finally in a sudden loss of consciousness. Prediction of an impending NMS requires detection of pulse presence to derive heart rate (HR) as well as to assess the pulse strength (PS) related to systolic blood pressure (SBP) preferably from a single body location only. This paper analyses the basic feasibility of using a single accelerometer positioned above the common carotid artery to assess pulse strength and pulse rate towards NMS prediction. A physical model has been investigated to gain insights into expected signal morphologies and potential feature candidates vs. hemodynamic parameters such as SBP, pulse pressure (PP) and PR relevant for NMS detection. Model results are compared with first measurements obtained in a head-up tilt table test (HUTT) from a patient during impending syncope. We show that an accelerometer positioned at the carotid artery is a potential approach offering a valuable tool in syncope management.

Neurally medicated syncope (NMS) patients suffer from sudden loss of consciousness, which is associated with a high rate of falls and hospitalization. NMS negatively impacts a subject's quality of life and is a growing cost issue for the healthcare systems in particular since mainly elderly are at risk of NMS in our aging societies. In the present paper we present an algorithm for prediction of NMS, which is based on the analysis of the electrocardiogram (ECG) and photoplethysmogram (PPG) signals. Several parameters extracted from ECG and PPG, which have been associated in previous works with reflectory mechanisms underlying NMS, were combined in a single algorithm to detect impending syncope. The proposed algorithm was validated in 43 subjects using a 3-way data split scheme and achieved the following performance: sensitivity (SE) - 100%; specificity (SP) - 92%; positive predictive value (PPV) - 85%; false positive rate per hour (FPRh) - 0.146h(-1) and; average prediction time (aPTime) - 217.58s.

Syncopes are a major public health concern since they can cause severe injuries e.g. by associated falls. We previously demonstrated the feasibility of syncope prediction based on the pulse arrival time (PAT) analysis. Importantly, algorithms for early detection of impending syncope need to be robust against measurement noise, in particular photoplethysmography (PPG) artifacts, causing false detection. We introduce in this work an algorithm concept to deal with artifacts as well as to detect the onset of syncope based on tracking of relative PAT changes only. Our method has been shown useful to improve detection performance for measurements during impending syncope in patients undergoing head-up tilt table testing which might improve syncope prediction.

Nonfluoroscopic catheter ablation has been demonstrated for typical arrhythmias. It is important to note that insufficient contact force may result in an ineffective lesion, whereas excessive contact force may result in complications. Herein, we demonstrate nonfluoroscopic mapping and ablation of a cavotricuspid isthmus–dependent double-loop re-entry tachycardia guided by real-time contact force information. Periprocedural delayed-enhancement magnetic resonance imaging supported the presence of the ablation lesion without any other evidence of a scar substrate for this arrhythmia.

To evaluate the contraction pattern of the systemic right ventricle (RV) in comparison to healthy controls.31 patients (14 female, mean age 21.5 ± 3.3 years) with congenital corrected (ccTGA) and surgical corrected (D-TGA) TGA and 31 age-matched healthy controls (17 female, mean age 23.1 ± 2.6 years) were included in the study. We compared the contraction pattern of the systemic RV with findings in the right and left ventricle (LV) of healthy controls. Echocardiograms were performed for all patients (19.3 ± 2.5 years after the operation) and all healthy controls. Using a novel computer software (GE Ultrasound, Horton, Norway) that allows automatic frame-by-frame tracking of accoustic markers during the heart cycle longitudinal and circumferential strain and strain rate were defined as parameters of myocardial deformation.In the systemic free RV wall, circumferential strain was greater than longitudinal strain (-25.6 ± 4.2% vs. -15.2 ± 3.9%, P0.001), opposite to the contraction pattern of the subpulmonary free RV wall (-17.7 ± 4.1% vs. -28.3 ± 3.3%, P0.001). Compared with controls, segmental analysis of the free RV wall resulted in lower systolic longitudinal and higher systolic circumferential strain and strain rate values. In the free LV wall, circumferential strain was lower than longitudinal strain (-19.1 ± 2.7% vs. -26.8 ± 4.5%, P0.001) in contrast to the data in the systemic free LV wall (-24.5 ± 3.1% vs. -16.7 ± 3.5%, P0.001).Myocardial deformation parameters were significantly different in systemic and normal RV indicating a dependency of myocardial deformation parameters on right ventricular afterload. The use of myocardial deformation imaging identified a shift from longitudinal to circumferential contraction pattern in the systemic RV in comparison to the LV. This might demonstrate a response to the systemic load creating a myocardial hypertrophy.

Cardiovascular mortality is markedly increased in chronic kidney disease (CKD) and may be explained in part by sympathetic hyperactivity. Impaired hyperoxic chemoreflex sensitivity (CHRS) has been attributed to an increased sympathetic tone. The aim of the present study was to examine whether chemosensor function is altered in patients with CKD.We assessed CHRS in 20 patients with stage 3 CKD [glomerular filtration rate (GFR) 30-59 ml/min/1.73 m(2)], in 15 patients with stage 4 CKD [GFR 15-29 ml/min/1.73 m(2)], as well as in 35 age and gender matched patients without any evidence of CKD. The difference in the R-R intervals divided by the difference in the oxygen pressures before and after deactivation of the chemoreceptors by inhalation of pure oxygen was calculated as the CHRS. A CHRS below 3.0 ms/mmHg was defined as pathological. CHRS was significantly depressed in patients with stage 3 CKD (2.9 ± 0.9 ms/mmHg, P=0.005) and in patients with stage 4 CKD (2.1 ± 0.6 ms/mmHg, P0.001), as compared with patients without CKD (6.7 ± 0.9 ms/mmHg). There was a negative correlation between serum creatinine and CHRS (r=-0.51; P0.001). In patients with CKD, chemosensor deactivation decreased mean arterial pressure from 91 ± 4 mmHg to 87 ± 3 mmHg (P=0.03). Multivariate analysis showed that GFR (P=0.001) was the only independent predictor of a pathological CHRS.Using a relatively non-invasive bedside test we provide evidence for a blunted peripheral chemosensor function in chronic kidney disease. We thereby lay the basis for interventional studies assessing chemosensor function in chronic kidney disease.

AIMS To investigate whether percutaneous left atrial appendage (LAA) closure guided by automated real-time integration of 2D-/3D-transesophageal echocardiography (TEE) and fluoroscopy imaging results in decreased radiation exposure. METHODS AND RESULTS In this open-label single-center study LAA closure (AmplatzerTM Cardiac Plug) was performed in 34 consecutive patients (8 women; 73.1±8.5 years) with (n = 17, EN+) or without (n = 17, EN-) integrated echocardiography/fluoroscopy imaging guidance (EchoNavigator® [EN]; Philips Healthcare). There were no significant differences in baseline characteristics between both groups. Successful LAA closure was documented in all patients. Radiation dose was reduced in the EN+ group about 52% (EN+: 48.5±30.7 vs. EN-: 93.9±64.4 Gy/cm2; p = 0.01). Corresponding to the radiation dose fluoroscopy time was reduced (EN+: 16.7±7 vs. EN-: 24.0±11.4 min; p = 0.035). These advantages were not at the cost of increased procedure time (89.6±28.8 vs. 90.1±30.2 min; p = 0.96) or periprocedural complications. Contrast media amount was comparable between both groups (172.3±92.7 vs. 197.5±127.8 ml; p = 0.53). During short-term follow-up of at least 3 months (mean: 8.1±5.9 months) no device-related events occurred. CONCLUSIONS Automated real-time integration of echocardiography and fluoroscopy can be incorporated into procedural work-flow of percutaneous left atrial appendage closure without prolonging procedure time. This approach results in a relevant reduction of radiation exposure. TRIAL REGISTRATION ClinicalTrials.gov NCT01262508.

Background Left ventricular lead implantation for cardiac resynchronization therapy (CRT) usually requires a pre- or intraprocedural occlusion contrast venography of the coronary sinus (CS) in order to identify tributaries to the lateral wall. As many patients undergo a preprocedural coronary angiogram, we investigated the diagnostic accuracy of venous phase imaging of the CS in patients prior to CRT implantation. The aim of this study was to assess the quality of venous phase coronary sinus angiography. Methods In 24 CRT patients retrograde occlusion venography and venous phase coronary sinus angiography obtained during coronary angiography were compared with respect to image quality, vessel diameters and the ability to identify a coronary sinus side branch suitable for left ventricular lead placement. Results Suitable target vessels for left ventricular lead implantation were identified in all patients irrespective of the method (retrograde occlusion venography or venous phase coronary sinus angiography). There was a high concordance in vessel diameters between venous phase and retrograde angiography. Visibility was superior in retrograde venography. Conclusions In heart failure patients who are scheduled for coronary angiograms venous phase coronary sinus angiography is a time-saving and easy to perform alternative imaging modality. Radiation exposure and the amount of contrast medium needed is reduced as compared to coronary sinus occlusion angiography. The information obtained thereby may be used to plan subsequent CRT implantation without the need for retrograde coronary sinus angiography.

PLoS one 7(11), e48926 (2012). doi:10.1371/journal.pone.0048926, Published by PLoS [u.a.], Lawrence, Kan.

Blood pressure regulation failures cause neurally mediated syncope often resulting in a fall. A warning device might help to make patients aware of an impending critical event or even trigger the patient to perform countermeasures such as lying down or isometric exercises. We previously demonstrated that the Pulse Arrival Time (PAT) methodology is a potential approach to enable early detection of impending faints. The aim of the present study was to evaluate whether PAT can be used as an easy to measure beat-to-beat surrogate for systolic blood pressure (SBP) changes during a passive standing exercise (head-up tilt table testing (HUTT)). A significant PAT increase of more than 10 % was accompanied with a critical SBP decrease in syncope patients. Although PAT is in general not considered as a good measure of absolute blood pressure we found strong correlations (R>0.89, P