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Incessant narrow QRS complex tachycardias may result in severe tachycardia-induced cardiomyopathy even if the heart rate during tachycardia is only moderately elevated. The risk of ventricular deterioration is particularly increased in patients with underlying congenital heart disease. In these patients, drug treatment is often insufficient. Thus, catheter ablation of the arrhythmogenic substrate is required in the majority of patients. After successful ablation, ventricular function may recover completely.

ZusammenfassungAls „Mitral annular Disjunction“ (MAD) bezeichnet man eine pathologische, umschriebene, bindegewebige Dehiszenz zwischen dem kompakten Myokard des linken Ventrikels und dem Mitralklappenanulus. Das Bindegewebe ersetzt anulusnah das Myokard und strahlt in unregelmäßiger Form in die benachbarte Muskulatur des linken Ventrikels ein. Die MAD tritt oft in Verbindung mit einem Mitralklappenprolaps (MVP) auf. Die inhomogene Fibrosierung des klappennahen Myokards sowie eingelagerte und versprengte Purkinje-Fasern bilden ein arrhythmogenes Substrat. Die MAD wird deshalb gehäuft bei Patienten mit ventrikulären Herzrhythmusstörungen bzw. bei plötzlichem Herztod mit und ohne MVP gefunden. Die Diagnose wird mittels Echokardiografie oder kardialer Magnetresonanztomografie bzw. Computertomografie gestellt. Da die prognostische Bedeutung der MAD unklar ist, gibt es bisher keine Therapieempfehlung.

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

In atrioventricular nodal reentrant tachycardia (AVNRT), catheter ablation is considered as first-line therapy. Despite high success rates, some patients present with arrhythmia recurrence or develop other types of arrhythmias over time. To assess the incidence of symptomatic arrhythmias after initially successful AVNRT ablation and to analyze their clinical implications in a real-world cohort. We included 2,795 patients from the German Ablation Registry undergoing first ablation of AVNRT between 01/2007 and 01/2010. In patients alive at long-term follow-up, patient-specific characteristics and long-term follow-up data were compared between patients with (group A) and without (group B) any symptomatic arrhythmia during follow-up. Symptomatic arrhythmias occurred in 17.2% of patients during a mean follow-up of 678 days after AVNRT ablation. The patients with symptomatic arrhythmias were more often female and suffered from structural heart disease. Arrhythmia occurrence was clinically relevant regarding symptoms and patient satisfaction. Serious adverse events including stroke, transient ischemic attack, pacemaker implantation, as well as continued use of antiarrhythmic medication occurred more often in group A. A second ablation procedure was performed in 26% of symptomatic patients to optimize the symptomatic outcome, whereas cardiovascular events or patient satisfaction were not further improved. During long-term follow-up, one out of six patients experienced symptomatic arrhythmias after AVNRT ablation, associated with an increase of serious adverse events. A subset of patients required medical or interventional antiarrhythmic therapy, possibly attributable to the co-existence of other arrhythmias. Screening for arrhythmic and cardiac co-morbidity before and after ablation may support comprehensive therapy planning and outcome.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4–8%) as well as in low-risk patients (STS-Score

Aims Remote monitoring by implantable devices substantially improves management of heart failure (HF) patients by providing diagnostic day-to-day data. The use of thoracic impedance (TI) as a surrogate measure of fluid accumulation is still strongly debated. The multicenter HomeCARE-II study evaluated clinically apparent HF events in the context of remote device diagnostics, focusing on the controversial role of TI. Methods and results We followed 497 patients (66.6 ± 10.1 years, 77% male, QRS 139.8 ± 36.0 ms, ejection fraction 26.8 ± 7.0%) implanted with a CRT-D (67%) or an ICD (33%) for 21.4 ± 8.1 months. An independent event committee confirmed 171 HF events of which 82 were used to develop a TI-based algorithm for the prediction of imminent cardiac decompensation. Highly inter-individual variations in patterns of TI trends were observed. The algorithm resulted in a sensitivity of 41.5% (50.0%) with 0.95 (1.34) false alerts per patient year, and a positive predictive value of 7.9% overall and 27.9% in the HF event group of patients. Averaged ratio statistics showed a significant pre-hospital decrease and a highly significant in-hospital increase in TI after intensified diuresis. Recurrent decompensations turned out to be preceded by a significantly stronger decrease of TI compared to first events with a higher chance for detection (63.6% sensitivity, p Conclusions Overall performance in predicting imminent decompensation by monitoring TI alone is limited due to its high inter-patient variability. TI stand-alone applications should be redirected towards a target population with more advanced symptoms where post-hospital observation aimed to maintain the patient's discharge status might be the most valuable approach. Clinical trial registration ClinicalTrials.gov Identifier NCT00711360 (HomeCARE-II) and NCT01221649 (J-HomeCARE-II).

Background Cardiogenic shock (CS) in patients (pts) with acute ST elevation myocardial infarction (STEMI) is the strongest predictor of hospital mortality. Radial in contrast to femoral access in STEMI pts might be associated with a lower mortality. However, little is known on radial access in CS pts. Methods We retrospectively analysed all STEMI pts between 2009 and 2015 who sufferend from CS and who were included into the ALKK PCI registry. Pts treated via a radial access were compared to those treated via a femoral access. Results Between 2009 and 2015 23796 STEMI pts were included in the registry. 1763 (7.4%) of pts were in CS. The proportion of radial access was 6.6%: in 2009 4.0% and in 2015 19.6%, p for trend Conclusions Radial access was only used in 6.6% of STEMI pts presenting in CS. However, a significant increase in the use of radial access was observed over time (2009: 4%, 2015 19.6%, p Funding Acknowledgement Type of funding source: None

Background: Hypertension (HTN) constitutes a risk factor for the development of atrial fibrillation (AF), as well as for thromboembolic and bleeding events. We analysed the outcome after catheter ablation of AF in HTN in a cohort from the prospective multicenter German Ablation Registry. Methods: Between 03/2008 and 01/2010, 626 patients undergoing AF-ablation were analysed. Patients diagnosed with HTN (n = 386) were compared with patients without HTN (n = 240) with respect to baseline, procedural and long-term outcome parameters. Results: Patients with HTN were older and more often presented with persistent forms of AF and cardiac comorbidities. Major and moderate in-hospital complications were low. At long-term follow-up, major cardiovascular events were rare in both groups. Rates of AF-recurrence, freedom from antiarrhythmic medication and repeat ablation were not statistically different between groups. Most patients reported improvement of symptoms and satisfaction with the treatment. However, patients with HTN more frequently complained of dyspnea of New York Heart Association (NYHA) class &ge, II and angina. They were more often rehospitalized, particularly when persistent AF had been diagnosed. Conclusion: Catheter ablation of AF is associated with low complication rates and favorable arrhythmia-related results in patients with HTN. Residual clinical symptoms may be due to cardiac comorbidities and require additional attention in this important subgroup of AF-patients.

Background: Since 2008, the German Cardiac Society certified 256 Chest Pain Units (CPUs). Little is known about adherence to recommended performance measures in patients with suspected acute coronary syndrome (ACS) presenting to CPUs. We investigated guideline-adherence regarding critical time intervals and selected performance measures in German Chest Pain Units. Methods: From 2008 to 2014, 23,804 consecutive patients with suspected ACS were prospectively enrolled in the Chest Pain Unit registry of the German Cardiac Society. Results: Median time from symptom onset to first medical contact was 2 h in patients with ST-elevation myocardial infarction (STEMI) and 4 h in patients with unstable angina and non-STEMI (NSTEMI). In patients with STEMI, median time from hospital admission to percutaneous coronary intervention (PCI) was 40 min and median time from first medical contact to PCI was 1 h 35 min. Primary PCI was performed in 94.7% of patients with STEMI, 70.0% of patients with NSTEMI and 37.4% of patients with unstable angina. PCI was performed during the first 24 h in 79.5% of patients with NSTEMI and the first 72 h in 89.0% of patients with unstable angina. Electrocardiograms were performed in 99.5% after a median of 6 min after admission and obtained within 10 min in 71%. Interestingly, 56.1% of patients were found to have non-ACS diagnoses, underlining the importance of access to additional diagnostic modalities including echocardiography, stress testing or computed tomography. Conclusions: Guideline-adherence regarding critical time intervals and primary PCI rates is good in German Chest Pain Units. More than half of patients admitted with suspected ACS had non-ACS diagnoses. Improvements in pre-hospital time delays through public awareness programmes are warranted.

The impact of structural heart disease (SHD) on safety and efficacy of catheter ablation of cavo-tricuspid isthmus-dependent atrial flutter (AFLU) is unclear. In addition, recent data suggest a higher complication rate of AFLU ablation compared to the more complex atrial fibrillation (AF) ablation procedure. Within our prospective multicenter registry, 3526 consecutive patients underwent AFLU ablation at 49 German electrophysiological centers from 2007 to 2010. For the present analysis, the patients were divided into a group with SHD (n = 2164 [61.4%]; median age 69 years; 78.5% male) and a group without SHD (n = 1362 [38.6%]; 65 years; 70.3% male). In our study, SHD mainly encompasses coronary artery disease (52.6%), left ventricular ejection fraction ≤ 50% (47.6%), and hypertensive heart disease (28.0%). The primary ablation success (97%) and the incidence of major (0.2%) or moderate (1.2%) complications did not differ significantly between the two groups (P = 1.0 and 0.87, respectively). Vascular access site complications (0.6%), AV block III° (0.2%), and bleeding (≥ BARC II: 0.2%) were most common. After a median 562 days of follow-up, we observed a 2.92-fold higher one-year mortality (P

Age-Related Complication Rates in AF AblationIntroduction Despite a rising demand for catheter ablation (CA) of atrial fibrillation (AF) in an elderly population, complication and success rates are not fully elucidated. We sought to compare complication rates of CA of AF in patients ≥75 versus

Stratification of patients with atrial fibrillation (AF) according to mechanistic and prognostic criteria may optimize the effectiveness and safety of catheter ablation. In women, AF is associated with more severe symptoms and worse prognosis.We sought to assess sex-related differences in catheter ablation procedures and outcome in a large cohort of patients with AF.A total of 3652 patients (1198 women [33%]; 2454 men [67%]) included in the German Ablation Registry were analyzed. Periprocedural parameters and outcome at 12-month follow-up were compared between male and female patients.Women were older at the time of ablation (women: 63.6 years; men: 59.1 years; P.0001) and exhibited a higher prevalence of paroxysmal AF (women: 72%; men: 61%; P.0001). They were less often affected by cardiovascular disease and reduced left ventricular function. Energy application duration and overall procedure duration were shorter in women. Conversely, the rate of major inhospital complications was increased in female patients (1.9% vs 0.8%; P = .023) and mainly driven by major bleeding events. At follow-up, women experienced higher AF recurrence rates (women: 50%; men: 45%; P = .017) and more often received oral medication for rhythm and rate control. In addition, the rate of pacemaker implantation was higher in the female cohort. Women more frequently reported femoral access site complications (women: 6%; men: 3%; P.001). Overall, male patients were more often free from AF-related symptoms and satisfied with the treatment.Catheter ablation of AF was associated with a distinct sex-related outcome and complication profile that requires consideration in clinical practice.

The aim of this study was to determine the impact of age on procedural and clinical outcomes in patients with cardiogenic shock (CS).The use of early revascularization therapy with percutaneous coronary intervention (PCI) has been shown to improve outcome in patients with acute myocardial infarction (AMI) complicated by CS.Data from consecutive patients with AMI and CS treated with PCI enrolled into the prospective ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte) PCI registry were centrally collected and analyzed. Patients were divided into 4 groups according to their age (65, 65 to 74, 75 to 84, and85 years). Patients' characteristics, procedural features, antithrombotic therapies, and in-hospital complications were compared among the 4 groups.Between 2010 and 2015, a total of 2,323 consecutive patients with AMI and CS were treated by PCI in 51 hospitals. TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 patency after PCI decreased with increasing age from 84% to 78%, while in-hospital mortality increased from 32% to 56%. Bleeding rates were low (2.0% to 2.3%) and not different among age groups. In the multivariate analysis, higher age, TIMI flow grade 3 after PCI, 3-vessel disease, and left main PCI were independent predictors of mortality.PCI in patients with AMI and CS is associated with a high procedural success rate and a low bleeding rate, even in very elderly patients, while mortality increases with increasing age. Because mortality in elderly patients with CS without revascularization therapy is very high, it seems justified to perform PCI in selected patients to reduce mortality.

Digitalis glycosides are employed for rate control of atrial fibrillation. Recent studies suggested potential harmful effects of digitalis monotherapy and combination with antiarrhythmic drugs. The aim of the present study was to assess the prevalence and potential impact of digitalis therapy on outcome in patients undergoing catheter ablation of supraventricular arrhythmias. The German Ablation Registry is a nationwide, prospective registry with a 1-year follow-up investigating 12,566 patients receiving catheter ablations of supraventricular arrhythmias in 52 German centres. The present analysis focussed on pharmacotherapy in 8608 patients undergoing catheter ablation of atrial tachycardia, atrial fibrillation, or atrial flutter. Patients receiving digitalis therapy (n = 417) were older and presented a significantly increased prevalence of comorbidities including coronary artery disease, heart failure, diabetes, and pulmonary disease. One-year mortality was significantly higher in digitalis-treated patients (4.7% vs. 1.3%, p

Objectives: To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs). Methods: A total of 23,997 patients were enrolled. Analyses comprised TTE evaluation rates in relation to clinical presentation, risk profile, left ventricular impairment, final diagnosis and invasive management. Critical times were assessed. Multivariable analyses for independent determinants for the use of TTE were performed. Results: TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times. Conclusions: About two thirds of the patients admitted to certified CPUs received TTE evaluation, with the highest rates being in ACS patients, and thereby providing diagnostic information supporting or refuting further invasive management.

Chest pain is a major reason for admission to an internal emergency department, and smoking is a well-known risk factor for coronary artery disease (CAD) and acute coronary syndrome (ACS). The aim of this analysis is to illustrate the differences between smokers and nonsmokers presenting to German chest pain units (CPU) in regard to patient characteristics, CAD manifestation, treatment strategy, and prognosis. From December 2008 to March 2014, 13,902 patients who had a complete 3‑month follow-up were enrolled in the German CPU registry. The analysis comprised 5796 patients with ACS and documented smoking status. Of all the patients in the CPU registry, 35.2% were smokers. Compared with nonsmokers, they were 13.5 years younger (58.2 vs. 71.7 years, p

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

Atrial fibrillation (AF) is the most common cause of ischemic stroke. Recent data suggest that AF patients after successful ablation have the same risk for thromboembolic events (TE) as patients without AF. Despite current guideline recommendations it is still under debate if oral anticoagulation (OAC) can be safely discontinued after ablation. We analyzed follow-up (FU) after ablation of paroxysmal AF (PAF) in a high- (previous stroke; group 1) and a low-risk group (no previous stroke; group 2) based on data from the German Ablation Registry to reveal real-life prescription behavior. Overall 29 centers in Germany participated by performing AF-ablation. Between April 2008 and April 2011, 83 patients in group 1 and 377 patients in group 2 with a first ablation of PAF were included in the registry. Mean CHA2DS2-VASc-Score was 4.2 ± 1.4 (group 1) vs. 1.6 ± 1.2 (group 2) (p

Cryoballoon isolation of the pulmonary veins (PVI) is an effective and safe method in the treatment of patients with paroxysmal atrial fibrillation (PAF). The circular mapping catheter Achieve® (Medtronic Inc., Minneapolis, USA) can be introduced into the pulmonary vein (PV) through the inner lumen of the balloon catheter, allowing online mapping of the PV electrograms during ablation. We prospectively compared the accuracy of this catheter in both available sizes to a standard circular mapping catheter (SCMC) in order to determine bidirectional PV block. Patients with symptomatic PAF underwent cryoballoon ablation using either the Achieve® 15-mm catheter (group 1, 15 patients) or the Achieve® 20 mm (group 2, 15 patients). PV potentials were recorded using Achieve® before, during, and after ablation, and exit block was obtained by pacing from inside the PV. Accuracy of PV potential detection was controlled by a SCMC before and after ablation. Rate of PV which could be isolated exclusively using the Achieve® as guidewire was 98 % (59/60) in group 1 and 93 % (57/60) in group 2. Online signal recording during ablation was possible in 40 and 60 % of PV (p = 0.037), respectively. Final Achieve® diagnosis was accurate in 55/60 (92 %) of the PVs and 12/15 (80 %) of patients in group 1 and 60/60 (100 %) of PV and 15/15 (100 %) of patients in group 2. Stand-alone mapping using Achieve® 15 mm resulted in a significant lack of diagnostic accuracy. Achieve® 20 mm provided excellent diagnostic accuracy comparable to a SCMC and should be preferentially used.

BACKGROUND: Catheter ablation (CA) for atrial fibrillation (AF) is an effective therapeutic option for the treatment of symptomatic drug-refractory AF. According to current guidelines, the prevention of stroke and embolism is the most important therapeutic goal in AF and the recommendations for anticoagulation (OAC) after successful CA are based upon the CHA2DS2-VASc-Score 3. The aim of this study was to evaluate the use of OAC in patients with a high risk for thromboembolic events 1 year after CA and to identify predictor variables for discontinuation of OAC. METHODS: Between January 2007 and January 2010 13092 patients were enrolled in the study. A total of 52 German electrophysiological centers agreed to participate in this prospective multicenter registry. 41 centers included patients undergoing CA for AF. Analysis included patients who were discharged with OAC after CA and had a CHA2DS2-VASc-Score ≥ 2. A centralized 1 year follow-up (FU) was conducted via telephone. RESULTS: 1300 patients fulfilled the inclusion criteria. One year after CA 51.8 % of these patients were on OAC. Factors significantly associated with discontinuation of OAC included no AF recurrence in FU (adjusted odds ratio (OR): 2.14, [95 % confidence interval (CI): 1.73-2.66], P < 0.001) and paroxysmal AF (OR: 1.53 [95 % CI: 1.29-1.81], P < 0.001). Factors associated with continuation of OAK were patient age (OR per 10 years: 0.79 [95 % CI: 0.68-0.91], P = 0.002), valvular heart disease (OR: 0.67 [95 % CI: 0.48-0.92], P = 0.013), an implanted pacemaker, defibrillator or a cardiac resynchronization therapy system (OR: 0.55 [95 % CI: 0.41-0.74], P < 0.001) and neurological events in hospital or during FU (OR: 0.40 [95 % CI: 0.18-0.88], P < 0.022). CONCLUSION: Almost half of the patients with an indication for OAC are not adequately anticoagulated one year after CA for AF. Paroxysmal AF or freedom from AF is significantly associated with discontinuation of OAC.

Acute Complication Rate in AF Ablation Introduction Catheter ablation (CA) has emerged as a widespread therapeutic option in the treatment of atrial fibrillation (AF). Currently, no safety data with regard to the impact of the underlying structural heart diseases (SHD) are available. We sought to assess the risk for acute and long-term complications during CA of AF in relation to underlying SHD. Methods and Results We included 6,211 patients in a prospective registry undergoing CA of AF in 41 nationwide centers. All patients were divided into 4 groups according to the underlying heart disease: No SHD (69.4%), hypertensive heart disease (HHD) (12.0%), coronary artery disease (CAD) (15.1%), and cardiomyopathy (CM) (3.6%). In univariate analysis, patients with HHD had an overall complication rate of 7.28%, whereas patients without an SHD had a significantly lower rate of 6.01% (P < 0.01). Multivariate analysis revealed that HHD (adjusted odds ratio [OR]: 1.97 [95% confidence interval (CI): 1.02–3.83], P = 0.0442) and age (years; OR: 1.04 [95% CI: 1.01–1.07], P = 0.0155) were independent predictors of severe, nonfatal complications and death. Other SHD including CAD (OR: 1.48 (0.73–3.00), P = 0.2797) and CM (OR: 2.37 [0.70–7.99], P = 0.1630) failed to reach statistical significance. Male sex was protective (OR: 0.47 [95% CI: 0.27–0.81], P = 0.0062). Conclusion In general, CA of AF has a low number of severe complications. In our prospective registry HHD emerged as an independent predictor of severe, nonfatal complications during AF ablation but other SHD including CAD and CM did not. The influence of HHD on the complication rate should be considered in patient selection.

The aim of this analysis was to compare troponin-positive patients presenting to a chest pain unit (CPU) and undergoing coronary angiography with or without subsequent revascularization. Leading diagnosis, disease distribution, and short-term outcomes were evaluated. Chest pain units are increasingly implemented to promptly clarify acute chest pain of uncertain origin, including patients with suspected acute coronary syndrome (ACS). A total of 11,753 patients were prospectively enrolled into the German CPU-Registry of the German Cardiac Society between December 2008 and April 2011. All patients with elevated troponin undergoing a coronary angiography were selected. Three months after discharge a follow-up was performed. A total of 2,218 patients were included. 1,613 troponin-positive patients (72.7 %) underwent a coronary angiography with subsequent PCI or CABG and had an ACS in 96.0 %. In contrast, 605 patients (27.3 %) underwent a coronary angiography without revascularization and had an ACS in 79.8 %. The most frequent non-coronary diagnoses in non-revascularized patients were acute arrhythmias (13.4 %), pericarditis/myocarditis (4.5 %), decompensated congestive heart failure (3.7 %), Takotsubo cardiomyopathy (2.7 %), hypertensive crisis (2.4 %), and pulmonary embolism (0.3 %). During the 3-month follow-up, patients without revascularization had a higher mortality (12.1 vs. 4.5 %, p

Catheter ablation of paroxysmal atrial fibrillation (PAF) has been suggested as first-line treatment for selected patients (pts). However, patient characteristics, procedural data, and complication rate in the group of young patients remain undetermined. The German Ablation Registry has been designed as a multi-center prospective registry. AF ablation data were collected from 51 German centers between March 2007 to September 2012 and 2 groups were defined (group A: ≤45 years, group B: >45 years). Data were analyzed according to patient characteristics, procedural data, and complications. To calculate differences between both groups CHI2 or Mann–Whitney–Wilcoxon tests was utilized. A total of 7243 patients undergoing AF ablation were included (group A: 593, 8.2 %; group B: 6650, 91.8 %). Male gender and PAF were significantly more often present in group A. Patient characteristic revealed decreased co-morbidities in the young. In both groups circumferential pulmonary vein isolation represented the procedural cornerstone, whereas substrate modification was significantly more often performed in group B. Procedure-, and fluoroscopy-time was similar but there was a shorter hospital stay and a favorable complication profile in the young. After 12 months AF recurrence and use of antiarrhythmic drugs were less common in group A. The young AF ablation patient has typically paroxysmal AF and less comorbidities. In this group, catheter ablation of AF is associated with a lower major complication rate, shorter hospitalization, and a favorable clinical outcome.

Catheter Ablation of Stable Ventricular TachycardiaBackground In the Ventricular Tachycardia Ablation in Coronary Heart Disease (VTACH) study, an intention-to-treat approach was used and may have diminished the observed degree of treatment effect. We present a subanalysis of the VTACH study by treatment actually received. Methods and Results The VTACH study was a prospective, open, randomized controlled trial, undertaken in 16 European centers, comparing defibrillator implantation with and without ventricular tachycardia (VT) ablation in patients with stable VT, previous myocardial infarction, and reduced left-ventricular ejection fraction. Of the 52 patients in the ablation group, 7 (13%) did not receive VT ablation and 19% of patients assigned to implantable cardioverter defibrillator (ICD) only treatment group crossed over and had an ablation. The primary endpoint (first recurrence of any documented VT or ventricular fibrillation [VF]) was reached after a median of 19.5 months in the ablation group and 5.9 months in the ICD only group (P = 0.01). Overall, 685 VT/VF events occurred per year of follow-up in 22 patients of the ablation group and 4,986 events in 43 patients of the control group (P = 0.024). In the ICD only group, median numbers of VT/VF episodes were 25 (IQR 5.8–45.3) and 1.5 (IQR 0–24.8) per patient and year before and after crossover (n = 12), respectively. Conclusion On-treatment analysis of the VTACH study emphasizes the effectiveness of VT ablation in patients receiving ICD treatment because of monomorphic VT post myocardial infarction. VT ablation clearly prolonged time to recurrence of VT/VF episodes and markedly decreased VT/VF burden.

Aims To analyse outcomes of supraventricular tachycardia (SVT) ablations performed within a prospective German Ablation Quality Registry. Methods and results Data from 12 566 patients who underwent catheter ablation of SVT between January 2007 and January 2010 to treat atrial fibrillation (AFIB, 37.2% of procedures), atrial flutter (AFL, 29.9%), atrioventricular nodal re-entrant tachycardia (AVNRT, 23.2%), atrioventricular re-entrant tachycardia (6.3%), and focal atrial tachycardia (AT, 3.4%) were prospectively collected. Patients were followed for at least 1 year. The periprocedural success rate was 96.3%, ranging from 84.3% (focal AT) to 98.9% (AVNRT). Kaplan–Meier mortality estimate at 1 year was 1.4% overall, and as high as 2.6% in the AFL group and 2.8% in the focal AT group. Recurrence of ablated or another symptomatic SVT was observed in 3783 (32.6%) of patients, ranging from 17.2% (AVNRT) to 45.6% (AFIB). Repeat ablation was performed in 12.0% of patients. After 1 year, 74.1% of survivors perceived ablation therapy as successful, 15.7% as partly successful, and 9.6% as unsuccessful. Even in those patients with arrhythmia recurrence, 76.0% perceived ablation as successful or partly successful and 89.6% would still undergo repeat ablation in the same institution. Conclusion Ablation therapy for SVT is a safe procedure bringing symptomatic improvement and satisfaction to three quarters of patients after 1 year. Even in patients with arrhythmia recurrence, a high satisfaction level and adherence to the ablating institution could be documented. Strikingly high mortality and stroke rates in follow-up were observed in AFL patients, who apparently need consistent long-term anticoagulation and more medical attention.

Chest pain units (CPUs) are increasingly established in emergency cardiology services. With improved visibility of CPUs in the population, patients may refer themselves directly to these units, obviating emergency medical services (EMS). Little is known about characteristics and outcomes of self-referred patients, as compared with those referred by EMS. Therefore, we described self-referral patients enrolled in the CPU-registry of the German Cardiac Society and compared them with those referred by EMS.From 2008 until 2010, the prospective CPU-registry enrolled 11,581 consecutive patients. Of those 3789 (32.7%) were self-referrals (SRs), while 7792 (67.3%) were referred by EMS. SR-patients were significantly younger (63.6 vs. 70.1 years), had less prior myocardial infarction or coronary artery bypass surgery, but more previous percutaneous coronary interventions (PCIs). Acute coronary syndromes were diagnosed less frequently in the SR-patients (30.3 vs. 46.9%; p0.0001). SR-patients showed ST-segment changes in their initial ECG in 19.6% of cases. EMS-patients underwent more coronary angiographies (60.0 vs. 47.5%; p0.0001), while SR-patients underwent more stress tests (11.3 vs. 7.8%; p0.001). PCI was performed in 32.6% of the EMS- and in 24.0% of the SR-group (p0.0001).These data demonstrate that patients who contact a CPU as a self-referral are younger, less severely ill and have more non-coronary problems than those calling an emergency medical service. Nevertheless, 30% of self-referral patients had an acute coronary syndrome.

Riata® and Riata ST® implantable cardioverter defibrillator (ICD) leads (St. Jude Medical, Sylmar, CA) show an increased incidence of insulation defects, particularly "inside-out" lead fracture where inner, separately insulated cables penetrate through the surrounding silicone of the lead body. The exact incidence of Riata® lead problems is not clear and seems to range between 2-4% per year in the first 5 years after implantation according to new registry data. We recommend beyond a detailed information the following care of patients with Riata® and Riata ST® leads: 1) Activation of automatic ICD alerts, 2) remote monitoring with automatic daily alerts whenever possible, 3) monthly ICD controls in patients at high risk (pacemaker dependency, history of ventricular tachyarrhythmias) and high or moderate lead-related risk (8F, 7F single coil), 3-monthly controls in moderate patient and lead-related risk, 3 to 6-monthly controls in low patient and lead-related risk (no bradycardia, no history of ventricular tachyarrhythmia). Every ICD control should include meticulous analysis of oversensing artifacts in stored electrograms (EGMs) of sustained and non-sustained ventricular tachyarrhythmias and registration of EGMs during provocation testing (pectoral muscle activity, arm movements). If electrical abnormalities are observed, reoperation with addition of a new ICD lead is recommended; lead extraction only if indicated according to current guidelines. Fluoroscopy should only be performed if electrical abnormalities are found by an experienced electrophysiologist and a high frame rate and resolution. Management of fluoroscopic abnormalities in the absence of electrical abnormalities is not clear. Therefore, routine fluoroscopy of patients with Riata® leads without electrical abnormalities is not recommended.

Catheter ablation (CA) is considered the treatment of choice for patients with atrioventricular nodal reentrant tachycardia (AVNRT). However, there is a tendency to avoid CA in the elderly because of a presumed increased risk of periprocedural atrioventricular (AV) nodal block.The purpose of this prospective registry was to assess age-related differences in the efficacy and safety of CA within a large population with AVNRT.A total of 3,234 consecutive patients from 48 German trial centers who underwent CA of AVNRT between March 2007 and May 2010 were enrolled in this study. The cohort was divided into three age groups:50 years (group 1, n = 1,268 [39.2%]; median age = 40 [30.0-45.0] years, 74.1% women), 50-75 years old (group 2, n = 1,707 [52.8%]; 63.0 [58.0-69.0] years, 63.0% women), and75 years old (group 3, n = 259 [8.0%]; 79.0 [77.0-82.0] years, 50.6% women).CA was performed with radiofrequency current (RFC) in 97.7% and cryoablation technology in 2.3% of all cases. No differences were observed among the three groups with regard to primary CA success rate (98.7% vs. 98.8 % vs. 98.5%; P = .92) and overall procedure duration (75.0 minutes [50.0-105.0]; P = .93). Hemodynamically stable pericardial effusion occurred in five group 2 (0.3%) and two group 3 (0.8%) patients but in none of the group 1 (P.05) patients. Complete AV block requiring permanent pacemaker implantation occurred in two patients in group 1 (0.2%) and six patients in group 2 (0.4%) but none in group 3 (P = 0.41). During a median follow-up period of 511.5 days (396.0-771.0), AVNRT recurrence occurred in 5.7% of all patients. Patients75 years (group 3) had a significantly longer hospital stay (3.0 days [2.0-5.0]) compared with group 1 (2.0 days [1.0-2.0]) or group 2 (2.0 days [1.0-3.0]) patients (P.0001).CA of AVNRT is highly effective and safe and does not pose an increased risk for complete AV block in patients over 75 years of age, despite a higher prevalence of structural heart disease. Antiarrhythmic drug therapy is often ineffective in this age group; thus, CA for AVNRT should be considered the preferred treatment even in elderly patients.

Ein 67-jahriger Patient mit langjahrig bekannter arterieller Hypertonie berichtet seit ca. 6 Monaten uber anfallsweise auftretende Episoden mit schnellem, unregelmasigem Pulsschlag, einhergehend mit deutlicher Minderung der korperlichen Leistungsfahigkeit sowie Dyspnoe- und Angina-pectoris- Symptomatik. Der Patient ist ansonsten sportlich aktiv (Tennisspieler) und auserhalb der Tachykardieepisoden korperlich gut belastbar. Die Episoden wurden in letzter Zeit an Haufigkeit und Dauer zunehmen, zuletzt etwa einmal pro Woche mit einer Dauer bis zu 16 h auftreten. Das Ruhe-EKG des Patienten zeigt einen normofrequenten Sinusrhythmus, einen Linkslagetyp bei ansonsten unauffalliger Erregungsausbreitung und -ruckbildung. Echokardiographisch zeigen sich ein gering dilatierter linker Vorhof (43 mm) sowie eine leichtgradige Linksherzhypertrophie (Septumdicke 13 mm) mit diastolischer Compliancestorung und normaler systolischer Funktion, vereinbar mit einer hypertensiven Herzkrankheit. In der Ergometrie ist der Patient bis 175 W ohne Ischamiezeichen belastbar. Im 24-h-Langzeit-EKG findet sich neben multiplen supraventrikularen Extrasystolen und kurzen atrialen Salven eine ca. 2 h anhaltende Episode mit Tachyarrhythmia ab soluta bei Vorhofflimmern mit Herzfrequenzen bis 180/min. Therapeutisch wird neben der bereits bestehenden Therapie mit einem β-Blocker (Bisoprolol 5 mg/d) und einem ACE-Hemmer (Ramipril 5 mg/d) eine antiarrhythmische Therapie mit Flecainid initial 2 × 50 mg/d mit Dosissteigerung bei guter Vertraglichkeit auf 2 × 100 mg/d eingeleitet. Unter dieser Therapie kam es bislang zu keinen weiteren symptomatischen Vorhofflimmerepisoden mehr. Im Langzeit-EKG lassen sich jedoch weiterhin kurz anhaltende, asymptomatische Vorhofflimmerphasen nachweisen. Bei einem CHADS2-Score von 1 (arterielle Hypertonie) erhalt der Patient zur Thromboembolieprophylaxe Acetylsalicylsaure (ASS) 100 mg/d.

Regelmasige Tachykardien mit breitem Kammerkomplex konnen im klinischen Alltag eine diagnostische Herausforderung sein. Differenzialdiagnostisch muss an folgende Arrhythmiegruppen gedacht werden: 1. Kammertachykardien (VT); 2. supraventrikulare Tachykardien (SVT) mit Schenkelblock; 3. supraventrikulare Tachykardien (SVT) mit antegrad akzessorischer Leitung und 4. eine ventrikulare Stimulation. Aufgrund der Konsequenzen fur die Akut- und Dauertherapie ist eine schnelle und zuverlassige Differenzierung anhand des EKG wichtig. Es existieren zahlreiche EKG-Kriterien die eine mehr oder weniger zuverlassige Unterscheidung v. a. von VT und SVT mit Schenkelblock ermoglichen. Die SVT mit akzessorischer Leitung ist sehr selten. Die ventrikulare Stimulation kann durch Stimulationsartefakte abgegrenzt werden. Im Einzelnen finden v. a. folgende Parameter Anwendung: 1. QRS-Breite >140 ms bei RSB oder >160 ms bei LSB; 2. Fusionsschlage; 3. uberdrehter Rechtslagetyp bei RSB-Morphologie (Nordwestachse); 4. VA-Dissoziation; 5. fehlender RS-Komplex bzw. RS-Intervall >100 ms in V1–V6; 6. positive oder negative Konkordanz in V1–V6; 7. Fehlende initiale r-Zacke oder fehlende S-Zacke in V1 bei Tachykardie mit RSB-Morphologie; 8. Fehlende R-Zacke oder R 60 ms) oder plumpe R-Zacke (R >30 ms) in V1 bei Tachykardie mit LSB-Morphologie; 10. Nachweis einer pathologischen Q-Zacke (besonders in V6 bei Tachykardie mit LSB-Morphologie). Der positive Nachweis eines der genannten Parameter spricht jeweils fur eine VT. Allerdings variiert die Sensitivitat und Spezifitat der einzelnen Parameter stark. Aus diesem Grund wurden mehrere Diagnosealgorithmen vorgeschlagen, die im Wesentlichen auf der konsekutiven Anwendung der oben genannten Kriterien beruhen. Hierdurch lasst sich die Spezifitat und Sensitivitat fur die korrekte Diagnose einer VT oder einer SVT mit Schenkelblock auf jeweils uber 95% erhohen.

Medikamente freisetzende Stents („drug-eluting stents“ [DES]) zeichnen sich im Vergleich zu unbeschichteten Metallstents durch eine niedrigere Restenoserate aus. Seit 2002 sind sie in Deutschland zugelassen. Die folgende Analyse zeigt die Verwendung von DES im klinischen Alltag sowie Determinanten des Einsatzes in den Jahren 2003 und 2005 in Deutschland. Das ALKK-Register (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte) erfasst konsekutiv klinische und prozedurale Parameter interventionell behandelter Patienten mittels standardisierter Fragebogen, welche zur Datenzentrale des KL-Neuhaus Datenzentrums (Ludwigshafen) weitergeleitet werden. Die folgende Analyse umfasst die Daten von 40 434 Koronarinterventionen (PCIs), welche in den Jahren 2003 und 2005 an 32 Kliniken durchgefuhrt wurden. Insgesamt wurden 2003 18 564 PCIs und 2005 21 870 PCIs erfasst. Der Anteil von DES lag 2003 bei 4,3% und stieg bis 2005 auf 19,1% an. Die Hauptindikation fur die Implantation eines DES war die stabile Angina pectoris (2003: 68,4%, 2005: 55,3%); DES wurden vor allem bei Patienten mit bekannter PCI eingesetzt (2003: 42,5%, 2005: 48,1%) . Der Anteil von DES bei komplexen Prozeduren war besonders hoch bei Interventionen am ungeschutzten Hauptstamm (DES 2003: 15,6%, 2005: 35,9%), einer Ostiumstenose (DES 2003: 6,4%, 2005: 32,7%), bei In-Stent-Stenose (DES 2003: 9,5%, 2005: 40,6%) und Interventionen an mehr als einem Versorgungsgebiet (DES 2003: 7,6%, 2005: 29,3%). DES wurden vorwiegend bei stabiler Angina pectoris eingesetzt, allerdings mit zunehmendem Anteil auch bei komplexen Koronarlasionen im Off-Label-Bereich.

Objectives The purpose of this study was to investigate the efficacy safety of the novel cryoballoon device (Arctic Front, Cryocath, Quebec, Canada). Background Antral pulmonary vein (PV) ablation with radiofrequency energy is widely used as a strategy for catheter ablation of paroxysmal atrial fibrillation (PAF). A novel double lumen cryoballoon catheter was designed for circumferential pulmonary vein isolation (PVI) with the cryoablation technique. Methods We consecutively enrolled 346 patients with symptomatic, drug refractory paroxysmal (n = 293) or persistent (n = 53) atrial fibrillation (AF). In all patients, PVI of all targeted PVs was the therapeutic aim. The primary end points of this nonrandomized study were: 1) acute isolation rate of targeted PV; and 2) first electrocardiogram-documented recurrence of AF. The secondary end point was occurrence of PV stenosis or atrio-esophageal fistula. Results The 1,360 of 1,403 PVs (97%) were targeted with balloons or balloons in combination with the use of Freezor Max (Cryocath). We found that ablation with the cryoballoon resulted in maintenance of sinus rhythm in 74% of patients with PAF and 42% of patients with persistent AF. No PV narrowing occurred. The most frequent complication was right phrenic nerve palsy observed during cryoballoon ablation at the right superior PV. Conclusions Pulmonary vein isolation with a new cryoballoon technique is feasible. Sinus rhythm can be maintained in the majority of patients with PAF by circumferential PVI using a cryoballoon ablation system. Cryoablation was less effective in patients with persistent AF than in patients with PAF.

BACKGROUND AND OBJECTIVE Epidemiological studies have demonstrated a circadian distribution of sudden cardiac death (SD) and acute myocardial infarction (AMI), with a maximum frequency of events during the morning hours. Recently an analysis of computer recordings of implanted cardioverter/defibrillators has confirmed these findings with respect to SD. The majority of these studies concerned patients with coronary heart disease. In a prospective study we evaluated the circadian and weekly distribution of malignant ventricular tachyarrhythmias (VTA) in patients with a nonischaemic cardiac disease, namely dilated cardiomyopathy (CMP), and those with coronary heart disease (CHD). PATIENTS AND METHODS Over a mean period of 25 +/- 9 months computer-stored data and cardiac electrograms recorded from the implanted cardioverter/defibrillators (ICD) were analysed in 28 patients with CHD and 11 with DCMP. The circadian and weekly distribution of VTA was obtained, using customary arrhythmia classification and the stored and timed events. RESULTS Patients with CHD had a maximal frequency of VTA or ventricular fibrillation (VF) during the morning, with a peak between 9 and 10 o/c, while those with DCMP were at a higher risk of VTA or VF in the later afternoon and early evening. Regarding the frequency of events during the week, a significantly higher incidence of VTA was recorded on Saturdays in those with CHD, but on Mondays and Wednesdays in those with DCMP. INTERPRETATION The circadian and weekly distribution of VTA differs significantly between patients with CHD and those with DCMP. A possible reason for this difference may be different trigger mechanisms in the two types of cardiac disease, since transient ischaemia is unlikely to be the cause in patients with nonischaemic DCMP.

A 53-year-old man known to have Wolff-Parkinson-White syndrome suffered an acute posterior-wall myocardial infarction. Despite successful thrombolysis treatment with streptokinase he continued to have attacks of supraventricular tachycardia with angina. The ECG showed a short P-R interval and pre-excitation with positive delta waves in leads V1-6, as well as signs of re-infarction. The tachycardias could not be satisfactorily suppressed by drug treatment. Coronary angiography revealed triple vessel disease. During this investigation ventricular extrasystoles occurred which initiated orthodromic supraventricular tachycardia and angina, as well as monophasic S-T elevations in leads II, III and aVF. This provided the indication for immediate high-frequency catheter ablation left laterally at the mitral anulus after a left-lateral accessory conduction pathway had been identified. Three days later the stenoses of the circumflex and anterior interventricular branches were dilated. The patient has been free of symptoms for 3 months and can exercise up to 150 W. The tachycardias have not recurred.

OBJECTIVE The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients. METHODS For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared. RESULTS Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21). CONCLUSIONS Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.

Accurate and timely prediction of sudden cardiac death (SCD) is a necessary prerequisite for effective prevention and therapy. Although the largest numbers of SCD events occur in patients without overt heart disease, there are currently no tests that are of proven predictive value in this population. Efforts in risk stratification for SCD have focused primarily on predicting SCD in patients with known structural heart disease. Despite the ubiquity of tests that have been purported to predict SCD vulnerability in such patients, there is little consensus on which test, in addition to the left ventricular ejection fraction, should be used to select patients for implantable cardioverter defibrillators (ICDs). Effective therapy exists for SCD but it is costly and is associated with potential complications. Currently used strategies for selection of the best candidates for ICDs are imperfect and leave many high-risk patients unprotected. At the same time, some patients who receive ICDs will never develop ventricular tachyarrhythmia requiring ICD intervention. This article summarizes the current status and applicability of the non-invasive and invasive tests used for SCD risk assessment.

Objective: We investigated the relationship between interleukin-6 (IL-6) and the risk of experiencing spontaneous ventricular tachyarrhythmia (VT/VF) in patients with an implantable cardioverter-defibrillator (ICD). Background: Cytokine levels predict outcome in patients with advanced heart failure and are elevated in patients with coronary artery disease (CAD). Regarding heart rhythm disturbances, proinflammatory activity could predict the occurrence of atrial fibrillation. There is no data on cytokine levels and the risk of spontaneous VT/VF. Methods: IL-6 serum concentrations were determined at baseline and follow-up in 47 consecutive ICD-patients with CAD and idiopathic dilated cardiomyopathy (IDC). Data were prospectively correlated with VT/VF-incidence. Results: Thirty-six patients (76.6%) suffered from CAD and 11 (23.4%) from IDC. Mean serum concentrations of IL-6 at baseline and at 9 months follow-up were 6.12±4.98 and 4.63±6.97. 88 spontaneous VT/VF-events occurred in 13/47 patients (27.7%). Patients with VT/VF had significantly higher IL-6 levels as compared to patients without VT/VF (8.96 ± 5.97 vs. 5.04 ± 4.16 pg/ml at baseline ( p = 0.03), 7.8 ± 4.88 vs. 3.42 ± 6.32 pg/ml at follow-up ( p = 0.01)). Conclusions: Elevated IL-6 serum concentrations were prospectively associated with an increased risk of spontaneous VT/VF-events in ICD-patients with CAD or IDC. These preliminary findings support a possible association of proinflammatory activity and an increased susceptibility to spontaneous VT/VF-events.

Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disease phenotypically expressed in the general population at about 0.2%. Annual mortality rate is about 1% in unselected patients, 3-6% in patients with severe symptoms, and 17% following resuscitation from ventricular tachycardia (VT)/ventricular fibrillation (VF). 50-80% of deaths are sudden. Beneath effective treatment in severe symptoms of heart failure (most common in midlife and beyond) the prevention of sudden death (most common in young patients) continues to be a major challenge. The highest risk has been associated with any of the following markers: 1. prior cardiac arrest or spontaneous sustained VTs, 2. a family history of premature HCM-related death, 3. extreme left ventricular hypertrophy (> or = 30 mm), 4. syncope, 5. multiple bursts of nonsustained VTs, 6. hypotensive blood pressure response to exercise, and 7. marked septal scarring (hyperenhancement in magnetic resonance imaging). Treatment options in patients with drug-refractory symptoms or increased risk of sudden death are surgical myectomy, transcoronary ablation of septal hypertrophy (TASH), dual-chamber pacing, ablation of atrial fibrillation (or the AV node), and the implantable cardioverter defibrillator (ICD). 1. Surgical myectomy effectively improves symptoms, hemodynamics and probably prognosis. Long-term results are well known, but patients' preference and the number of experienced surgical centers are fading. Randomized studies are missing. 2. TASH induces quite similar improvements in symptoms and hemodynamics. It is remarkably evaluated for a postprocedural follow-up of up to 10 years, and it is the preferred mode of treatment in patients. However, information on long-term prognosis, rhythmogenic effects and randomized studies are missing. For the prevention of sudden death, TASH has to be combined with an ICD. 3. Dual-chamber pacing was evaluated in randomized crossover studies, but symptomatic and hemodynamic improvements and patients' preference are substantially lower than for TASH. 4. The ICD has the potential to alter prognosis in secondary (class I indication) and primary prevention. HCM patients should undergo a risk stratification assessment. Prophylactic implants base on a clinical profile with two or more risk markers (sometimes one risk marker). 5. Ablation of atrial fibrillation or the AV node is indicated to improve symptoms in patients with fast ventricular rates despite medical treatment. For the prevention of sudden death, it has to be combined with an ICD.

Lars S. Maier ⁎, Harald Darius , Evangelos Giannitsis , Raimund Erbel , Michael Haude , Christian Hamm , Gerd Hasenfuss , Gerd Heusch , Harald Mudra , Thomas Munzel , Claus Schmitt , Burghard Schumacher , Jochen Senges , Thomas Voigtlander , Jan B. Schuttert a a Dept. of Cardiology & Pneumology/Heart Centre, Georg-August-University, Gottingen, Germany b Dept. of Cardiology, Angiology & Intensive Care Medicine, Vivantes Hospital Neukolln, Berlin, Germany c Dept. of Cardiology, Angiology & Pneumology, Ruprecht-Karls-University, Heidelberg, Germany d Dept. of Cardiology, West-German Heart Centre, University of Essen, Germany e Dept. of Cardiology & Nephrology, Lukas Hospital, Neuss, Germany f Dept. of Cardiology, Kerckhoff Klinik, Bad Nauheim, Germany g Institute for Pathophysiology, University Duisburg-Essen, Germany h Dept. of Cardiology, Pneumology and Internal Intensive Care Medicine, Klinikum Neuperlach, Stadtisches Klinikum Munchen GmbH, Munchen, Germany i Dept. of Cardiology, Angiology & Intensive Care Medicine, Johannes Gutenberg University, Mainz, Germany j Clinic for Cardiology and Angiology, Stadtisches Klinikum Karlsruhe, Germany k 2nd Dept. of Medicine, Westpfalz-Klinikum, Kaiserslautern, Germany l Institut fur Herzinfarktforschung, Ludwigshafen, Germany m Centre for Cardiology and Angiology, Frankfurt, Germany

To assess the incidence and electrophysiological characteristics of spontaneous ventricular tachyarrhythmias after implantable cardioverter-defibrillator (ICD) implantation for primary prevention.Prospective observational study.41 consecutive patients, who fulfilled MADIT (multicenter automatic defibrillator implantation trial) I criteria, except for suppressibility by procainamide, and who received a prophylactic ICD.Subpectoral implantation of an ICD.Incidence of ventricular tachyarrhythmias and their electrophysiological characteristics with respect to timing of the arrhythmia, tachyarrhythmia cycle length, mode of termination, and clinical relevance.During a mean (SD) follow up of 30 (21) months 18 of 41 (43.9%) patients experienced 142 appropriate ICD treatments. The mean (SD) time to first event was 9.6 (15.1) months. One patient had ventricular fibrillation (VF), 12 patients ventricular tachycardia (VT), and five both VT and VF. The mean (SD) cycle length of monomorphic VT was 306 (42) ms. Of 142 episodes, 117 (82.3%) were terminated by antitachycardia pacing and another 25 (17.6%) by ICD discharges. Cumulative survival of hypothetical death, defined as treated VT with a cycle length260 ms or VF, was 83.2% after one year and 78.4% after two years.Patients with a left ventricular ejection fraction35%, a history of myocardial infarction, non-sustained VT, and inducible VT/VF are at high risk of VT/VF early after implantation. Therefore, implantation of a tiered treatment defibrillator seems to be justified.

Elevated plasma aldosterone levels represent an independent risk factor for increased mortality in congestive heart failure. Sudden cardiac deaths contribute substantially to the excessive mortality in congestive heart failure and so does atrial fibrillation as one of the major causes of stroke in elderly persons. So far, the electrophysiological properties of aldosterone have not been thoroughly characterized. In the present study, the effects of aldosterone on intracardiac monophasic action potentials were investigated in humans.Monophasic action potentials were recorded in six patients with supraventricular arrhythmias. Eleven ml of 0.9% NaCl (placebo) were injected intravenously, and monophasic action potentials recorded for 10 min. Thereafter, aldosterone (0.5 mg in 0.9% NaCl) was injected and recording of monophasic action potentials continued as previously. The mean action potential duration at 90% repolarization was calculated for the entire 10-min period of each treatment. All patients were in sinus rhythm and had normal electrolyte status. In the placebo period, mean MAPd90 was 287+/-22 ms (mean+/-S.D.), and 299+/-25 ms following aldosterone (P0.02). After adjustment for heart rate, the difference remained statistically significant (P0.01). The maximal effect of aldosterone was seen 4-6 min after injection.Aldosterone increases monophasic action potential duration within minutes after intravenous application. Therefore, this effect is likely to be mediated nongenomically. It may be hypothesized that aldosterone exerts its unfavorable effects partly via altering myocardial repolarization.

Background We investigated the current management of unstable angina pectoris (UAP) in certified chest pain units (CPUs) in Germany and focused on the European Society of Cardiology (ESC) guideline-adherence in the timing of invasive strategies or choice of conservative treatment options. More specifically, we analyzed differences in clinical outcome with respect to guideline-adherence. Method Prospective data from 1400 UAP patients were collected. Analyses of high-risk criteria with indication for invasive management and 3-month clinical outcome data were performed. Guideline-adherence was tested for a primarily conservative strategy as well as for percutaneous coronary intervention (PCI) within Results Overall guideline-conforming management was performed in 38.2%. In UAP patients at risk, undertreatment caused by an insufficient consideration of risk criteria was obvious in 78%. Reciprocally, overtreatment in the absence of adequate risk markers was performed in 27%, whereas a guideline-conforming primarily conservative strategy was chosen in 73% of the low-risk patients. Together, the 3-month major adverse coronary and cerebrovascular events (MACCE) were low (3.6%). Nonetheless, guideline-conforming treatment was even associated with significantly lower MACCE rates (1.6% vs. 4.0%, p Conclusion The data suggest an inadequate adherence to ESC guidelines in nearly two thirds of the patients, particularly in those patients at high to intermediate risk with secondary risk factors, emphasizing the need for further attention to consistent risk profiling in the CPU and its certification process.

BACKGROUND: An increasing number of patients with heart failure receive implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation defibrillators (CRT-Ds) with telemonitoring function. Early detection of worsening heart failure, or upstream factors predisposing to worsening heart failure, by implant-based telemonitoring might enable pre-emptive intervention and improve outcomes, but the evidence is weak. We investigated this possibility in IN-TIME, a clinical trial.METHODS: We did this randomised, controlled trial at 36 tertiary clinical centres and hospitals in Australia, Europe, and Israel. We enrolled patients with chronic heart failure, NYHA class II-III symptoms, ejection fraction of no more than 35%, optimal drug treatment, no permanent atrial fibrillation, and a recent dual-chamber ICD or CRT-D implantation. After a 1 month run-in phase, patients were randomly assigned (1:1) to either automatic, daily, implant-based, multiparameter telemonitoring in addition to standard care or standard care without telemonitoring. Investigators were not masked to treatment allocation. Patients were masked to allocation unless they were contacted because of telemonitoring findings. Follow-up was 1 year. The primary outcome measure was a composite clinical score combining all-cause death, overnight hospital admission for heart failure, change in NYHA class, and change in patient global self-assessment, for the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT00538356.FINDINGS: We enrolled 716 patients, of whom 664 were randomly assigned (333 to telemonitoring, 331 to control). Mean age was 65·5 years and mean ejection fraction was 26%. 285 (43%) of patients had NYHA functional class II and 378 (57%) had NYHA class III. Most patients received CRT-Ds (390; 58·7%). At 1 year, 63 (18·9%) of 333 patients in the telemonitoring group versus 90 (27·2%) of 331 in the control group (p=0·013) had worsened composite score (odds ratio 0·63, 95% CI 0·43-0·90). Ten versus 27 patients died during follow-up.INTERPRETATION: Automatic, daily, implant-based, multiparameter telemonitoring can significantly improve clinical outcomes for patients with heart failure. Such telemonitoring is feasible and should be used in clinical practice.FUNDING: Biotronik SE & Co. KG.