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Aims Implantable cardioverter defibrillator (ICD) therapy, which includes the risk of shocks, is considered the primary culprit of reductions in patient reported outcomes (PROs; e.g. health status and distress), thereby negating the role of underlying disease severity. We examined the relative influence of living with an ICD vs. congestive heart failure (CHF) on PROs and compared (i) ICD patients without CHF (ICD only), (ii) CHF patients without an ICD (CHF-only), and (iii) CHF patients with an ICD (ICD + CHF). Methods and results Separate cohorts of ICD and CHF patients (N = 435; 75% men) completed PROs at baseline, 6 and 12 months. Groups differed on physical health status only at baseline (F-(2,F-415) = 7.15, P = 0.001) and on anxiety at 12 months (F-(2,F-415) = 4.04, P = 0.01); ICD CHF patients had the most impaired physical health status but the lowest anxiety level followed by the ICD only and CHF only patients. Congestive heart failure only patients had the most impaired mental health status and Conclusion Congestive heart failure patients reported worse PROs as compared to ICD patients, although the magnitude of the differences was relatively small. This suggests that the well being of patients is not necessarily negatively influenced by the implantation of an ICD, and that underlying heart disease may have at least an equal if not greater influence on PROs.

Safety concerns about the Riata ICD shock lead were recently raised, with insulation failure due to conductor externalisation. Its incidence and presentation were assessed, and predictors of insulation failure and lead survival of the Riata 1580-1582 were studied, retrospectively, before the official recall. All 374 patients at the Erasmus Medical Center between July 2003 and December 2007 with a 1580, 1581 or 1582 shock lead. The majority of the patients were male (78 %), with a median age of 60 years (IQR 52-70); primary prevention in 61 %. Median follow-up was 60.3 months (IQR 35.5-73.2), with 117 (31 %) patients dying. Electrical abnormalities (mainly noise, 65 %) were observed in 20/257 patients (7.8 %). Definite conductor externalisation was confirmed with fluoroscopy or chest X-ray in 16 patients, and in one after extraction. One patient presented with a drop in the high-voltage impedance trend with a short cir A high incidence of insulation defects associated with conductor externalisation in the Riata ICD lead family is observed. The mode of presentation is diverse. This type of insulation failure can lead to failure of therapy delivery.

Introduction Remote magnetic navigated ablation has proven its feasibility in a large group of arrhythmias. Until now only scarce data are available on the use for atrial flutter. In this study we compared remote magnetic navigation (RMN), using non-irrigated and irrigated tip catheters, to manual radiofrequency ablation for ablating typical atrial flutter. Methods The 3 study groups consisted of 17 patients treated with RMN 8-mm tip; 14 patients with RMN irrigated tip; and 24 patients with a manual 8-mm tip. The primary outcome was the number of patients in whom bidirectional isthmus block could be obtained with 15 applications. Secondary end points were the median number of applications needed, the need to switch to a manual irrigated tip catheter, the procedural and fluoroscopy times. Results There was no significant difference in the primary end point (RMN 8 mm-tip group: 59%, RMN irrigated tip group: 64% and manual group: 83%). The median number of applications needed to obtain block was higher in the RMN groups compared to the manual group. In 5 patients from the RMN 8-mm tip group, 1 in the RMN irrigated tip group and 1 in the manual group, a switch to a manually irrigated tip catheter was performed. There was no difference in fluoroscopy time, but procedural time was significantly longer in the RMN groups compared to the manual group (P = 0.03). Conclusions The use of magnetic navigation for the ablation of atrial flutter is feasible but not superior to a manual approach. There was no difference concerning the primary end point of acute success within 15 applications. Overall, more applications were needed and procedure times were longer with RMN but RMN with the irrigating tip is promising.

Background-A rapidly growing number of long-QT syndrome (LQTS) patients are being treated with an implantable cardioverter-defibrillator (ICD). ICDs may pose problems, especially in the young. We sought to determine the characteristics of the LQTS patients receiving an ICD, the indications, and the aftermath. Methods and Results-The study population included 233 patients. Beginning in 2002, data were collected prospectively. Female patients (77%) and LQT3 patients (22% of genotype positive) were overrepresented; mean QTc was 516 +/- 65 milliseconds; mean age at implantation was 30 +/- 17 years; and genotype was known in 59% of patients. Unexpectedly, 9% of patients were asymptomatic before implantation. Asymptomatic patients, almost absent among LQT1 and LQT2 patients, represented 45% of LQT3 patients. Patients with cardiac symptoms made up 91% of all study participants, but only 44% had cardiac arrest before ICD implantation. In addition, 41% of patients received an ICD without having first been on LQTS therapy. During follow-up, 4.6 +/- 3.2 years, at least 1 appropriate shock was received by 28% of patients, and adverse events occurred in 25%. Appropriate ICD therapies were predicted by age <20 years at implantation, a QTc >500 milliseconds, prior cardiac arrest, and cardiac events despite therapy; within 7 years, appropriate shocks occurred in no patients with none of these factors and in 70% of those with all factors. Conclusions-Reflecting previous concepts, ICDs were implanted in some LQTS patients whose high risk now appears questionable. Refined criteria for implantation, reassessment of pros and cons, ICD reprogramming, and consideration for other existing therapeutic options are necessary. (Circulation. 2010;122:1272-1282.)

The 28 mm cryoballoon catheter is a device used for pulmonary vein isolation (PVI). The aim of this study was to evaluate the extent of the ablation in the antral regions of the left atrium. Eighteen patients with drug refractory, symptomatic, paroxysmal AF were enrolled. A 3D electroanatomic reconstruction of the left atrium was made before and after successful PVI with the 28 mm cryoballoon. Markers were placed at the ostium. Sixteen patients were mapped. Fourteen patients had 4 veins each, and 2 patients had a common ostium of the left sided veins. All separate ostia were isolated in the antral region. The two common ostia showed ostial isolation. There was a significant difference in vein size between the common (29 and 31 mm) and the separate ostia (19 +/- 4 mm) (p < 0.01). The performance of an additional segmental ablation if balloon PVI did not eliminate all electrical activity, did not influence the extent of the ablation. The earliest left atrial activation during sinus rhythm was located in the superior septal region before ablation in all patients. After ablation, two patients showed a substantial downward shift towards the middle and inferior septal region respectively (NS). Four patients demonstrated a slight downward shift of the first activation. In cryoballoon PVI, the majority of the veins undergo antral isolation. Veins with a diameter larger than the balloon, are isolated ostially. In individual cases, the left atrial activation sequence appears to be altered after ablation.

Patients with Ehlers-Danlos syndrome type IV have thin-walled, friable arteries and veins. Invasive procedures carry a significantly increased risk for perforation of blood vessels. The aim of this case report is to demonstrate the feasibility and potential benefits of using a stereotactic magnetic navigation system (MNS) for mapping and ablation under these very special circumstances. A 45-year-old woman is presented with daily episodes of typical atrio-ventricular nodal re-entry tachycardias (AVNRT) and known Ehlers-Danlos syndrome type IV. Transcatheter ablation procedure of the AVNRT was undertaken using the MNS, with a non-traumatic single floppy catheter and the capability of advanced navigation.

Objectives To compare the acute success and short-term follow-up of ablation of atrial flutter using 8 mm tip radiofrequency (RF) and cryocatheters. Methods Sixty-two patients with atrial flutter were randomized to RF or cryocatheter (cryo) ablation. Right atrial angiography was performed to assess the isthmus. End point was bidirectional isthmus block on multiple criteria. A pain score was used and the analgesics were recorded. Patients were followed for at least 3 months. Results The acute success rate for RF was 83% vs 69% for cryo (NS). Procedure times were similar (mean 144 +/- 48 min for RF, vs 158 +/- 49 min for cryo). More applications were given with RF than with cryo (26 +/- 17 vs. 18 +/- 10, p +/- 0.05). Fluoroscopy time was longer with RF (29 +/- 15 vs. 19 +/- 12 min, p +/- 0.02). Peak CK, CK-MB and CK-MB mass were higher, also after 24 h in the cryo group. Troponin T did not differ. Repeated transient block during application (usually with cryoablation) seemed to predict failure. Cryothermy required significantly less analgesia (p +/- 0.01), and no use of long sheaths (p +/- 0.005). The isthmus tended to be longer in the failed procedures (p +/- 0.117). This was similar for both groups, as was the distribution of anatomic variations. Recurrences and complaints in the successful patients were similar for both groups, with a very low recurrence of atrial flutter after initial success. Conclusions In this randomized study there was no statistical difference but a trend to less favorable outcome with 8 mm tip cryocatheters compared to RF catheters for atrial flutter ablation. Cryoablation was associated with less discomfort, fewer applications, shorter fluoroscopy times and similar procedure times. The recurrence rate was very low. Cryotherapy can be considered for atrial flutter ablation under certain circumstances especially when it has been used previously in the same patient, such as in an AF ablation.