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Background Recent studies have shown that cryoablation and radiofrequency (RF) ablation are comparable with regard to success rates and safety in the treatment of common atrial flutter (AFL). Long-term success requires persistence of bidirectional conduction block (BCB) in the inferior cavotricuspid isthmus (CTI). Objective The purpose of this study was to determine the persistence of BCB in a prospective randomized multicenter trial of the two ablation techniques. Methods A total of 191 patients were randomized to RF ablation or cryoablation of the CTI using an 8-mm-tip catheter. In all patients, BCB was defined as the ablation end-point. Primary end-point of the study was nonpersistence of achieved BCB and/or ECG-documented relapse of common AFL within 3-month follow-up. Results Acute success rates were 91% (83/91) in the RF group and 89% (80/90) in the cryoablation group (P = NS). Invasive follow-up after 3 months with repeated electrophysiologic study was available for 60 patients in the RF group and 64 patients in the cryoablation group. Persistent BCB could be confirmed in 85% of the RF group versus 65.6% of the cryoablation group. The primary end-point was achieved in 15% of the RF group and 34.4% of the cryoablation group (P = .014). As a secondary end-point, pain perception during ablation was significant lower in the cryoablation group (P Conclusion Persistence of BCB in patients treated with cryoablation reinvestigated after 3 months is inferior to that patients treated with RF ablation, as evidenced by the higher recurrence rate of common AFL seen in this study.

External cardioversion is an established and very important tool to terminate symptomatic atrial flutter. The superiority of the biphasic waveform has been demonstrated for atrial flutter, but whether electrode position affects the efficacy of cardioversion in this population is not known. The aim of this trial was to evaluate whether anterior-lateral (A-L) compared with anterior-posterior (A-P) electrode position improves cardioversion results. Of 130 screened patients, 96 (72 men, mean age 62 +/- 12 years) were included and randomly assigned to a cardioversion protocol with either A-L or A-P electrode position. In each group, 48 patients received sequential biphasic waveform shocks using a step-up protocol consisting of 50, 75, 100, 150, or 200 J. The mean energy (65 +/- 13 J for A-L vs 77 +/- 13 J for A-P, p = 0.001) and mean number of shocks (1.48 +/- 1.01 for A-L vs 1.96 +/- 1.00 for A-P, p = 0.001) required for successful cardioversion were significantly lower in the A-L group. The efficacy of the first shock with 50 J in the A-L electrode position (35 of 48 patients [73%]) was also highly significantly greater than the first shock with 50 J in the A-P electrode position (18 of 48 patients [36%]) (p = 0.001). In conclusion, the A-L electrode position increases efficacy and requires fewer energy and shocks in external electrical cardioversion of common atrial flutter. Therefore, A-L electrode positioning should be recommended for the external cardioversion of common atrial flutter.

Background: Predictors for recurrence of syncope are lacking in patients with vasovagal syncope. The aim of this study was to identify risk factors for recurrence of syncope and develop a simple prognostic risk score of clinical value. Methods: Two hundred seventy-six patients with a history of vasovagal syncope were prospectively followed for 2 years. Diagnosis of vasovagal syncope was based on clinical history and negative standard work-up. Inclusion in the study was independent from the result of the head-up tilt test, which was performed in all cases. Risk factors for syncope recurrence were evaluated by the Cox proportional hazards regression model and implemented in a risk score, which was validated with the log-rank test and an internal cross-validation. Results: The Cox-regression analysis identified the number of previous syncopal events, history of bronchial asthma, and female gender as predictors for syncope recurrence (all P < 0.05). In contrast, head-up tilt test response had no predictive value (P = 0.881). Developing a risk score, study patients were identified as having high (recurrence rate during 2 years of follow-up: 37.2%), intermediate (24.8%), and low (6.5%) risk for syncope recurrence (receiver operating characteristic [ROC] of score 0.83, P < 0.01; Log-rank test for event-free survival, P < 0.005). Conclusions: In patients with vasovagal syncope, risk of recurrence can be stratified and is predictable based on a simple risk score.

Aims Beneficial effects of atrial fibrillation (AF) ablation have been demonstrated in patients with congestive heart failure (CHF) and significantly impaired left ventricular ejection fraction (LVEF). However, the impact of pulmonary vein isolation (PVI) on cardiac function in patients with paroxysmal AF and impaired LVEF remains under discussion. This study aimed to evaluate the impact of PVI for paroxysmal AF on cardiac function in patients with impaired LVEF using cardiac magnetic resonance imaging (CMRI). Methods and results A total number of 70 patients with paroxysmal AF and episodes � 24 h were scanned on a 1.5-T-CMRI before and 6 months after PVI during sinus rhythm. End-diastolic volume, end-systolic volume, and LVEF were determined by epicardial and endocardial measurements. Patients were categorized into two groups regarding cardiac function as assessed by CMRI: group 1 patients (n ¼ 18) with an LVEF , 50% and patients with an LVEF . 50% (group 2, n ¼ 52). Group 1 patients demonstrated a significant lower success rate than patients of group 2 after a follow-up of 152+ 40 days (50 vs. 73%, P , 0.05). Cardiac magnetic resonance imaging in group 1 patients demonstrated a significant improvement in cardiac function after AF ablation (41+ 6v s. 51+ 12%, P ¼ 0.004), whereas group 2 patients did not show significant differences (60+ 6v s. 59+ 9%, P ¼ 0.22) after a 6 months follow-up. Conclusion Pulmonary vein isolation improves cardiac function in patients with paroxysmal AF and impaired LVEF. These data suggest that an impaired LV function can be partially attributed to AF with short-lasting paroxysms.

Aims Rhythm follow-up after catheter ablation of atrial fibrillation (AF ablation) is mainly based on Holter electrocardiogramm (ECG), tele-ECG or on patients symptoms. However, studies using 7-day Holter or tele-ECG follow-up revealed a significant number of asymptomatic recurrences. Thus, the aim of this study was to analyse continuous atrial recordings in pacemaker patients with an incorporated Holter function before and after AF ablation in order to determine all AF recurrences and thereby the ‘real’ success rates. Methods and results The study comprised 37 patients (64.6 ± 10 years) with prior pacemaker/implantable cardioverter defibrillator (ICD) implantation including an atrial Holter function referred for AF ablation. Holter data were obtained and correlated to patients’ symptoms before and every 3-month after AF ablation. AF recurrence was defined as an atrial high frequency episode of less than 330 ms (180 b.p.m.) lasting longer than 30 s. The ablation procedure consisted of pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF, n = 20) and additional substrate modification aiming arrhythmia termination in patients with persistent or inducible AF after PVI as well as in patients with a history of long-lasting persistent AF (PersAF, n = 17). The mean atrial Holter monitoring period was 7.4 ± 3.3 months before and 13.5 ± 4.2 months after ablation with an overall AF burden of 33.7% prior to ablation. During follow-up, AF burden decreased from 17.3–0.65% ( P = 0.001) in PAF patients and from 57.4 to 13.9% ( P = 0.024) in patients with PersAF. Complete AF freedom was observed in 85% (17 patients) of PAF patients and 59% (10 patients) in patients with PersAF. The absence of symptoms correlated well with documented freedom of AF. Conclusion In the present study we could show, that freedom from AF can be achieved by catheter ablation in a high percentage of patients even with PersAF. Continuous atrial monitoring reveals AF ablation success rates comparable with those assessed by clinical evaluation. Symptomatic freedom of AF correlated well with the actual freedom of AF at least in this highly symptomatic patient cohort.

AP localization can be predicted by analyzing the polarity of the delta wave, QRS polarity, and R/S ratio in patients with Wolff-Parkinson-White syndrome. However, the estimation of AP location is limited in patients with concealed pathways during atrioventricular reentrant tachycardias (AVRT). Thus, we analyzed retrograde P-wave polarity during orthodromic AVRT and developed an algorithm to predict the localization of concealed accessory pathways (AP).A total number of 131 patients with a single AP and inducible orthodromic AVRT were included. The initial 61 patients were analyzed retrospectively for algorithm development, whereas 70 patients were evaluated prospectively. The retrograde P-wave polarity was analyzed by subtracting the superimposing T-wave during orthodromic AVRT using custom-designed software. Four leads of the surface electrocardiogram (ECG) were identified to accurately distinguish AP locations assigned to four different regions around each AV annulus: I, aVR, aVL, and V(1). Lead V(1) was used to differentiate right (negative or isoelectric) from left (solely positive) APs. Retrograde P-wave in lead I was negative in left posterior APs exclusively and became more positive with an AP location shifting towards right anterior. P-wave polarity in lead aVR demonstrated a shift from a positive polarity from left APs to isoelectric in right APs. The opposite direction (shift from positive to isoelectric) was observed for lead aVL. The subsequently developed algorithm for concealed AP localization using these surface ECG leads demonstrated a high sensitivity, specificity, and positive predictive value particularly for common AP localizations (left posterior and inferior, and right septal) when applied in a prospective fashion.Concealed AP localization can be accurately predicted by the analysis of retrograde P-wave polarity during orthodromic AVRT using the algorithm derived from the presented study.

Our purpose was to investigate the impact of short-lasting atrial fibrillation (AF) on the electrophysiological properties of the atria and pulmonary veins (PVs) in patients devoid of AF.The presence of AF is associated with electrical remodeling processes that promote a substrate for arrhythmia maintenance in the atria, which has been termed "AF begets AF." However, it is unclear whether those electrical alterations also occur in the PVs.Thirty-five patients with a left-sided accessory pathway and without a prior history of AF were included. After successful ablation, the effective refractory periods (ERPs) and conduction times of the right atrium (RA), left atrium (LA), and the PVs were determined. Afterwards, AF was induced and maintained for a period of 15 min. Thereafter, the stimulation protocol was repeated.At baseline, the PVs had significantly longer ERPs than the atria. After exposure to AF, the ERPs of both the atria and the PVs decreased significantly. The ERPs of the PVs, however, decreased by a significantly greater extent than the ERPs of the atria (PVs: 248 +/- 27 ms vs. 211 +/- 40 ms, p0.001; LA: 233 +/- 23 ms vs. 214 +/- 20 ms, p = 0.004; RA: 226 +/- 29 ms vs. 188 +/- 20 ms; p = 0.003). After AF exposure, the PVs demonstrated a significant conduction slowing whereas the atria did not (PVs: 125 +/- 33 ms vs. 159 +/- 37 ms, p0.001; LA: 129 +/- 26 ms vs. 130 +/- 24 ms, p = NS; RA: 192 +/- 36 ms vs. 196 +/- 32 ms, p = NS). Finally, AF was more frequently induced after the presence of AF, particularly by pacing in the PVs (14% vs. 49%, p = 0.001).New-onset, short-lasting AF creates electrical characteristics similar to those of patients with AF. However, these alterations are pronounced in the PVs compared with the atria, indicating that "AF begets AF in the PVs" (Electrophysiological Properties of the Pulmonary Veins; NCT00530608).

External cardioversion is effective to terminate persistent atrial flutter. Biphasic shocks have been shown to be superior to monophasic shocks for ventricular defibrillation and atrial fibrillation cardioversion. The purpose of this trial was to compare the efficacy of rectilinear biphasic versus standard damped sine wave monophasic shocks in symptomatic patients with typical atrial flutter.135 consecutive patients were screened, 95 (70 males, mean age 62 +/- 13 years) were included. Patients were randomly assigned to a monophasic or biphasic cardioversion protocol. Forty-seven patients randomized to the monophasic protocol received sequential shocks of 100, 150, 200, 300 and 360 J. Forty-eight patients with the biphasic protocol received 50, 75, 100, 150 or 200 J.First-shock efficacy with 50-Joule, biphasic shocks (23/48 patients, 48%) was significantly greater than with the 100-Joule, monophasic waveform (13/47 patients, 28%, p = 0.04). The cumulative second-shock efficacy with the 50- and 75-Joule, biphasic waveform (39/48 patients, 81%) was significantly greater than with the 100- and 150-Joule, monophasic waveform (25/47 patients, 53%, p0.05). The cumulative efficacy for the higher energy levels showed naturally no significant difference between the two groups. The amount of the mean delivered energy was significantly lower in the biphasic group (76 +/- 39 J) compared to the monophasic one (177 +/- 78 J, p0.05).For transthoracic cardioversion of typical atrial flutter, biphasic shocks have greater efficacy and the mean delivered current is lower than for monophasic shocks. Therefore, biphasic cardioversion with lower starting energies should be recommended.

Aims In the setting of right ventricular outflow tract-tachycardia (RVOT-T), data about long-term follow-up (FU) with respect to the therapeutic strategies are missing. All patients (pts) referred to our institution during the last 20 years for the treatment of RVOT-T were studied in a retrospective analysis to assess mortality and efficacy of treatment. Methods and results One hundred and thirty-three patients (77 female; 39 ± 13 years) with sustained RVOT-T were included in this study. At the time of first presentation, diagnosis of RVOT-T was made by complete invasive and non-invasive diagnostic assessment, including electrophysiology study and two-dimensional echocardiography. After 135 ± 68 months (median 136, range 29–248), patients were invited to undergo clinical assessment. Of the 133 pts, 127 (95%) survived and six (5%) died from non-cardiac disease. Anti-arrhythmic (AA) drugs were given to 62 of the 133 pts (47%); of them 32 (52%) had recurrences during follow-up. The mean time to recurrence was 10.02 years (95% CI 7.46–12.59). The other 71 study patients (53%) underwent catheter ablation. The procedure was successful in 58 pts (82%). During follow-up, 30 (52%) of the 58 successfully treated patients had recurrences of RVOT-T. The mean time to recurrence was 6.28 years (95% CI 4.96–7.6). RVOT-T recurrences were similar in morphology to those treated previously in 33% and different in 67% of cases. Conclusions Long-term follow-up in patients with RVOT-T is favourable. Catheter ablation is effective in this setting. However, late recurrences with similar or different morphology may arise in half of the patients after initially successful treatment. AA drug therapy is a valid initial therapeutic option, since it is effective in about half of the patients.

Background The accuracy of three-dimensional mapping systems is affected by cardiac contraction and respiration. Objective The study sought to determine relative motion of cardiac and thoracic structures to assess positional errors and guide the choice of an optimized spatial reference. Methods Motion of catheters placed at the coronary sinus (CS), pulmonary vein (PV) ostia, left atrial (LA) isthmus and roof, cavotricuspid isthmus (CTI), and right atrial appendage (RAA) were recorded for 30 patients using Ensite-NavX. The right subclavian vein, left brachiocephalic vein, azygos vein, pulmonary arteries, and a static reference were included. The displacement from a mean position was calculated for each pair of sites. Respiration effects were assessed by the shift of the motion curve during in- and expiration phases. Results The PVs showed a mean interpair displacement of 4.1 ± 0.2 mm and a shift of 5.0 ± 0.5 mm. Proximal CS references for all LA structures (4.0 ± 1.1 mm) were superior to the static reference (4.9 ± 0.7 mm; P = .01). In addition, the shift due to respiration was less pronounced at 3.5 ± 0.8 mm versus 4.9 ± 0.5 mm ( P = .004), respectively. Motion of extracardiac vessels was influenced by a mean shift of 6.8 ± 1 mm. The remote subclavian and brachiocephalic veins were more affected (7.6 ± 0.7 mm) than the pulmonary arteries (5.9 ± 0.4 mm; P = .002). For the CTI, a minimized mean displacement of less than 4.6 ± 2.0 mm relative to the proximal CS, RAA, and azygos vein was found. Conclusion Respiration is the major source of relative motion, which increases with distance from the heart. For LA procedures, a proximal CS reference position is superior to a static reference position.

Coronary artery disease (CAD) and erectile dysfunction (ED) of vascular origin are closely related and share common risk factors. The endogenous NO synthase inhibitor asymmetrical dimethylarginine (ADMA) has recently been identified as an independent risk marker for cardiovascular disease and it was the purpose of the present study to investigate the role ADMA in ED with and without underlying CAD.We determined plasma ADMA levels in 132 men with ED. Patients were divided into a group of 56 men with underlying CAD (ED-CAD) and a group of 76 men without clinical evidence for underlying CAD (ED-No-CAD). Diagnosis of ED was based on the International Index of Erectile Function Score (IIEF-5). Plasma ADMA concentrations in the ED-CAD group were elevated as compared to the ED-No-CAD group, median (IQR): 0.76 (0.65-0.91) micromol/l ADMA vs. 0.49 (0.36-0.71) micromol/l, p0.001. In a multiple logistic regression analysis adjusting for hypertension, hypercholesterolemia, low HDL cholesterol and diabetes or fasting glucoseor =6.1 mmol/l, ADMA remained a strong and independent predictor for presence of CAD. Odds ratios for second and third tertiles as compared to lowest tertile of plasma ADMA were 3.3 (95%CI, 1.1-10.3; p = 0.041) and 8.7 (95%CI, 2.8-27.2; p0.001), respectively.As elevation of ADMA has been found to be associated with many risk factors for both CAD and ED, our data provide further strong evidence for the close interrelation of CAD and ED. Determination of ADMA may help to identify underlying cardiovascular disease in men with ED.

Navigation System for Ablation of Typical AFL. Introduction: Ensite® NavX (NavX) is a novel mapping and navigation system that allows visualization of conventional catheters for diagnostic and ablative purposes and uses them to create a three-dimensional (3D) geometry of the heart. NavX is particularly suitable for ablation procedures utilizing an anatomic approach, as in the setting of common-type atrial flutter (AFL). The aim of this study was to compare NavX-guided and conventional ablation procedures for AFL. Methods and Results: Forty consecutive patients (32 male, 59 ′ 12 years) with documented AFL were randomized to undergo fluoroscopy-guided (group I, 20 patients) or NavX-guided (group II, 20 patients) ablation, including 3D isthmus reconstruction. The same catheter setup was used in both groups. The endpoint of bidirectional isthmus block was obtained in all patients. Compared to conventional approaches, NavX-guided procedures significantly reduced fluoroscopy time (5.1 ′ 1.4 min vs 20 ′ 11 min, P < 0.01) and total x-ray exposure (5.1 ′ 3.1 Gycm 2 vs 24.9 ′ 1.6 Gycm 2 , P < 0.01). Isthmus geometry reconstruction could be performed in all patients of group II. In 4 patients (20%) of group II, anatomic isthmus variations were detected by NavX. No significant differences in radiofrequency current applications and procedural times were found between the two groups. Conclusion: NavX technology allows geometry reconstruction of the cavotricuspid isthmus. NavX-guided ablation of AFL reduces total x-ray exposure compared to the fluoroscopy-guided approach but does not prolong procedure time.

The most widely accepted criterion for successful radiofrequency catheter (RFC) ablation of typical atrial flutter is the development of bi-directional isthmus block. In a subset of patients, conventional RFC ablation fails to achieve this endpoint because deeper and wider lesions are required. We investigated the efficacy of a long 8-mm tip catheter in these cases. One hundred and seventy-four consecutive patients (137 male; 61 +/- 9 years) with recurrent typical atrial flutter underwent conventional RFC ablation first with a standard 4 mm tip catheter. In resistant cases (n = 52), ablation was continued using a large tip 8-mm catheter when the 4-mm tip catheter failed. Resistant atrial flutter was identified when 21 RFC pulses failed to reach the selected endpoint of bi-directional isthmus block or in cases of transient bi- directional block (at least 3 episodes). In 122 of the 174 patients (70%) conventional atrial flutter ablation was successfully performed with 13 +/- 5 RFC applications. In the remaining 52 subjects (30%), the ablation procedure was completed using the large tip electrode catheter. In 30 of these 52 patients (58%), the catheter was changed because of persistent intra-atrial conduction after 21 RFC pulses and in 22 (42%) because of intermittent conduction block after 11 +/- 5 applications. Using the large tip electrode catheter, the selected endpoint was achieved in all patients of both groups with 3 +/- 2 RFC pulses (power output of 50-60 W, pulse duration of 60 sec). No post-procedure complications were observed. After 15 +/- 5 months of follow-up, 16 patients (9%) had recurrence of atrial flutter. Five of the patients had been in the resistant group. In patients with atrial flutter resistant to conventional ablation therapy, the long tip (8-mm) catheter appears to be a safe and effective alternative to use of the conventional 4-mm tip catheter.

We developed the NIKOS-system as a minimal invasive technique to image stenosis in coronary arteries after injection of iodine containing contrast material into a brachial vein. This technique uses dichromography whereby with monochromatic X-rays one image for subtraction is taken at an energy below and the other one above the K-edge of iodine. Immediately after the investigation of the patient the subtracted image is displayed under assistance of a newly designed graphical user interface (GUI). The images are automatically preprocessed by correcting for technical influences. With the help of the GUI the physician can apply different image processing algorithms on, the subtraction image to enable an accurate diagnosis. Because the GUI has a simple handling and the implemented algorithms react very rapidly, the physicians accepted the use of the GUI.

Syncope is a common clinical condition,1 which for obvious reasons constitutes a very drastic form of driving impairment. The legislative and expert panels in most countries have therefore issued laws or guidelines regarding driving and syncope.2–4 So far, however, little is known about the impact of driving recommendations on the behaviour of patients or the incidence of traffic crashes. All patients referred to us for investigation of syncope who hold a driving licence are routinely given verbal advice on driving by the physician doing the diagnostic work up. From February 1998 until June 2000 we conducted an anonymous survey among these patients. The survey was based on self reporting and consisted of two short structured interviews about history of syncope, driving, and crashes. We did the first interview on the day of head-up tilt table testing, and …

This study evaluated the incidence of atrial premature beats (APBs) and the impact of various provocative maneuvers in patients with focally initiated AF. Fifty patients (39 men, 57 +/- 0.4 years) with focally initiated, paroxysmal AF underwent Holter recording and a standardized protocol of provocative maneuvers: vagomechanical stimulation, adenosine 12 mg i.v., esmolol 500 ng/kg i.v., orciprenaline i.v. 5 mg/50 mL saline 0.9%, and atropine 0.01 mg/kg i.v. A surface ECG was recorded for 20 minutes at baseline and following each part of the protocol. High focal activity was defined asor = 1 APB/minute. During Holter ECG, 29 (58%) patients had an amount of200 APBs, 12 (24%) patients700or = 200, and 9 (18%) patientsor = 700 APBs. Less than 1 hour of high focal activity was observed in 34 (68%) of the 50 patients. Before starting provocative maneuvers 15 (30%) patients had high focal activity whereas 35 (70%) presented1 APB/minute. In 29 (58%) patients APBs increased byor = 1/min during provocative maneuvers: by vagomechanical stimulation in 11 patients, after adenosine in 15, esmolol in 12, orciprenaline in 15, and after atropine in 9 patients. In all patients withor = 1 APB/min at baseline, focal activity decreased or disappeared during some single provocative maneuvers. AF occurred in eight patients under provocative maneuvers. No predictive factors of a successful provocative maneuver were detected with regard to the baseline patients characteristics and Holter results. In conclusion, patients with focally initiated AF have a low incidence of spontaneous APBs. Various provocative maneuvers successfully increase APBs in more than half of the patients; orciprenaline had the highest efficacy. Some provocative maneuvers may suppress APBs in the setting of high focal activity at baseline.

Isolation of arrhythmogenic pulmonary veins (PVs) by radiofrequency current (RF) application has been introduced as a curative treatment for patients (pts) with paroxysmal atrial fibrillation (AF). The present study sought to investigate the feasibility and efficacy of this approach guided by conventional and electroanatomical mapping (CARTO).Twenty pts (13 male; 57 +/- 8 years) with recurrent documented focally triggered idiopathic AF refractory to multiple antiarrhythmic drugs were prospectively included. Atrial premature beats were present at baseline in 9 pts and could be provoked in further 8 pts. Empirical ablation of both superior PVs was performed in 3 pts with no focal activity. After transseptal puncture selective angiography of all PVs was obtained. Thirty-six PVs (left superior: n = 18, right superior: n = 10, left inferior: n = 8) were targeted for RF ablation. A complete left atrial CARTO-map including the left atrial (LA) to pulmonary vein (PV) junction was obtained during sinus rhythm and/or coronary sinus pacing. RF was initially applied at the PV-LA junction at areas with the shortest left atrial- to PV potential interval (target 50 degrees C, max. 30 W, duration 60 sec). Isolation was confirmed by the complete disappearance of specific PV potentials. RF lesions were analyzed with respect to the number of segment-quarters covering the PV ostium.Functional isolation could be achieved in 35 out of 36 PVs following 10 +/- 5 RF applications for each PV. RF applications covered 2 or less quarter segments of the overall PV circumference in 29 (80%) PVs. Total session duration was 6.5 +/- 1.6 h with a mean fluoro-time of 54 +/- 18 minutes. For CARTO mapping and ablation a mean fluoro time of 34 +/- 6 min was required. During a mean follow up period of 8.3 +/- 2.5 months AF relapsed in 9 pts (46%). A second approach was performed in 5 pts. and demonstrated either new foci (n = 2) or recurrence of previously isolated PV (n = 8). The second RF ablation procedure led to stable sinus rhythm in 3 out 5 pts. Thus, the overall success rate including the second procedure was 70%.CARTO guided functional isolation of presumed arrhythmogenic PVs by RF lesions covering 2 or less segments of the PV ostium in most patients is feasible. However, repeat procedures are often warranted to permanently treat paroxysmal atrial fibrillation.

Intravenous coronary angiography with synchrotron radiation is a novel and minimally invasive technique for coronary imaging. At the Hamburger Synchrotronstrahlungslabor HASYLAB at DESY, a dedicated angiography system has been developed, which has been shown to provide detailed images of coronary artery segments. For each scan, two monochromatic X-ray images below and above the K-edge of iodine were recorded simultaneously. The two images were subtracted logarithmically to produce a maximal contrast enhancement of the iodine. To date, the procedure has been carried out on 379 outpatients. No complications occurred during or after the angiographic procedure, and hospitalization was not required in any subject. The acceptance by patient is extremely high. Five outside reviewers, blinded as to the clinical data or prior angiographic interpretation, reviewed the images for the presence or absence of 70% or more occlusion of a vessel. They reached a sensitivity of 79% and a specificity of 99%. The study has demonstrated that the synchrotron method has satisfactory sensitivity and very high specificity for severe stenoses. The new method has several advantages over magnetic resonance imaging (MRI), electron beam computed tomography (EBCT), and multi-slice computed tomography (MSCT). Neither vascular calcification (CT) nor the presence of metal stents (MRI) impairs the evaluation of perfusion of segments of the coronary arteries. Furthermore, the spatial resolution is three or four times higher using synchrotron angiography, and problems due to respiratory motion are eliminated.

The aim of this study was to assess the efficacy of lipophilic beta-blockers in preventing recurrent neurocardiogenic syncope and the value of head-up tilt test (HUT) in predicting response to therapy. The efficacy of beta-blockers in recurrent syncope is controversial. The value of HUT in predicting efficacy of therapy has not been investigated. Fifty-six patients (44+/-18 years, 36 women) with recurrent syncope (> 1 event in the last 6 months) of suspected neurocardiogenic origin were included in the study. Independent of the response to HUT, patients were randomized to receive metoprolol or propanolol at the maximal tolerated dose (28 patients, group A, 86+/-23 vs 98+/-29 mg/d) or no pharmacological therapy (28 patients, group B). The primary endpoint was the first recurrence of syncope. During the 1-year of follow-up, 20 patients of group A and 8 of group B had no recurrence. In group A, of 20 patients without recurrences 12 had a positive and 8 a negative HUT result while of 8 patients with recurrences 5 had a positive and 3 a negative response to HUT. In the group B, of 20 patients with recurrences 10 had a positive and 10 a negative HUT result while of 8 patients without recurrences 4 had a positive and 4 a negative response to HUT. In a multivariate Cox-regression analysis, medical therapy was the only independent factor for predicting recurrence of syncope (P = 0.004); HUT had no influence in this regard (P = 0.773). In conclusion, lipophilic beta-blockers appear efficacious in preventing recurrent syncope of suspected neurocardiogenic origin. The efficacy of therapy seems to be not predicted by HUT.

Aims The relationship between syncope and psychiatric disorders is little investigated. This study evaluated the prevalence of psychiatric diseases and prognostic outcome in patients with recurrent unexplained syncope. Methods and Results After an inconclusive standard diagnostic work-up for syncope, including head-up tilt testing, a psychiatric evaluation was offered to 50 consecutive patients with recurrent syncope. The evaluation was accepted by 26 patients (77% females, 36±16 years) and refused by 24 (63% females, 50±19 years). A psychiatric disorder was diagnosed in 21 (81%) patients: 12 had depression, four panic attacks, two general anxiety, and three a somatization disorder. Only five patients showed normal psychosocial function. Of the patients with psychiatric disorders four accepted psychiatric care, such as psychotherapy and/or pharmacotherapy; 17 patients refused treatment. During 6 months of follow-up no patient under psychiatric care had syncope, while all patients without psycho- or pharmacotherapy had recurrent syncopal events. In these patients the median of syncopal episodes was three in a 6 months interval before and after clinical assessment. Patients who refused both psychiatric evaluation and therapy continued to experience syncope as before. Conclusions In patients with recurrent unexplained syncope psychiatric alteration is common. However, patients seldom accepted a psychiatric evaluation and treatment.

Automatic threshold tracking in cardiac pacemakers allows ventricular capture verification and self-adaptive pacing output regulation. The Autocapture algorithm detects the evoked response (ER) signal immediately after the pacing pulse to verify the efficacy of ventricular pacing. Before hospital delivery, the ER sensitivity must be programmed individually so that the pacemaker detects the ER signal adequately without sensing lead polarization. The aims of the study were to assess the frequency of patients in whom Autocapture could be activated and whether the ER sensitivity had to be adjusted after hospital discharge. The study included 44 patients who received the VVIR pacemaker Regency SR+ (St. Jude Medical) connected to the model 1450 T pacing lead. ER signal, lead polarization, and ER sensitivity were evaluated before hospital discharge and 1, 3, and 6 months after implantation. The system recommended activating Autocapture in 42 of 44 patients. The mean ER signal was 8.4+/-1.2 mV at discharge, 9.0+/-3.9 mV at month 1, 8.9+/-4.9 mV at month 3, and 9.3+/-4.5 mV at month 6. Polarization was 1.0+/-0.1 mV at discharge, 1.1+/-0.5 mV at month 1, 1.1+/-0.2 mV at month 3, and 1.1+/-0.5 mV at month 6. Mean ER sensitivity was 3.7+/-1.8 mV at discharge, 4.0+/-1.8 mV after 1, 4.1+/-2.2 mV after 3, and 4.1+/-1.8 mV after 6 months. ER sensitivity could remain unadjusted in 14 patients. Programming to a less sensitive ER setting from 2.9+/-1.2 mV to 4.3+/-1.5 mV was possible in 21 patients. Programming to a more sensitive ER setting from 4.1+/-1.1 mV to 2.5+/-0.9 mV was required in nine patients because of the decrease of the ER signal. The automatic threshold tracking algorithm Autocapture could be activated in 95% of patients. Programming to more sensitive ER settings was recommended in 21% of the patients after hospital discharge. Therefore, ER signal and polarization must be checked at each follow-up, as a decrease in ER signal amplitude can make reprogramming of the ER sensitivity necessary. There is no risk for the patient if the ER is not sensed, as high voltage backup stimulation is present.

Electroanatomic vs Conventional Mapping for Atrial Flutter Ablation. Introduction: Three-dimensional electroanatomic (CARTO) activation mapping of the cavotricuspid isthmus can be helpful to guide atrial flutter ablation, but to date has not heen investigated in comparison to conventional strategies. The aim of the present study was to assess the efficacy of the CARTO navigation system, especially with respect to the fluoroscopy time required for successful atrial flutter ablation. Methods and Results: Eighty patients with recurrent common-type atrial flutter were randomly assigned to temperature-controlled radiofrequency (RF) catheter ablation, either guided by conventional criteria (group 1) or additionally oriented on electroanatomic mapping (group 2). In all patients, similar multipolar catheters were inserted into the coronary sinus and placed at the tricuspid annulus. respectively. In group 2, positioning of the mapping electrode and delivery of RF pulses within the cavotricuspid isthmus was mainly oriented on the CARTO map to achieve the most linear and continuous RF lesions. Abolition of intra-atrial conduction verified by conventional criteria (group 1) and electroanatomic mapping (group 2) could be verified in all patients. The overall number of RF pulses (group 1: 16.7 ± 6.5; group 2: 13.2 ± 5.3) and mean procedure duration (group 1: 172.5 ± 47.4 min; group 2: 169.3 ± 47.3 min) were not different between the two groups, but mean fluoroscopy time was significantly shorter when the CARTO tecbnology was used (group 1: 29.2 ± 9.4 min; group 2: 7.7 ± 2.8 min; F = 0.0001). Recurrence of atrial flutter was observed in 3 (9%) patients in each group after a mean follow-up of 8.5 ± 2.months. Conclusion: Atrial flutter can be abolished effectively using the conventional technique as well as oriented on electroanatomic mapping. However, overall X-ray exposure can he significantly reduced by the CARTO-guided approach without prolongation of procedure duration.

The Autocapture function controls and optimizes the output of the ventricular pulse amplitude automatically. For this reason an automatic test has to be performed during follow-up to measure the evoked response signal and lead polarization for the calculation of the appropriate evoked response sensitivity setting. The aim of the study was to assess whether body position and exercise influence the evoked response and polarization. Both parameters were determined in the supine and upright position and subsequently during supine and upright symptom-limited ergometry. The study included 14 patients with the VVIR pacemaker Regency SR+ who had received the ventricular pacing leads Membrane E 1450 T (n = 8), CapSure Z 5034 (n = 4), or SX 60 (n = 2). The evoked response signal was 7.4 +/- 3.3 mV during supine and increased to 9.7 +/- 5.6 mV (+35%) during upright position (P < 0.05). The exercise tests were terminated at 105 +/- 36 W (supine) and 110 +/- 34 W (upright). There was a gradual insignificant decrease of the evoked response during each exercise test with a mean decrease of -1.1 +/- 0.9 mV (-15%; supine) and -1.6 +/- 2.1 mV (-16%; upright). The evoked response increased within 5 minutes during recovery to the initial values. Polarization remained unchanged during both tests. The pacemaker did not recommend activating autocapture in four patients who all had received high-ohmic pacing leads. In conclusions, the measurement of the evoked response in supine position seems to represent the worst case. Physical activities did not effect autocapture function in patients with the recommended lead, but the pacemaker did not always recommend Autocapture activation in some patients with high-ohmic pacing leads.

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