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Aims Atrial fibrillation (AF) and heart failure (HF) often coexist. Catheter ablation has been reported to restore left ventricular (LV) function but patients benefit differently. This study investigated the correlation between left atrial (LA) fibrosis extent and LV ejection fraction (LVEF) recovery after AF ablation. Methods and results In this study, 103 patients [64 years, 69% men, 79% persistent AF, LVEF 33% interquartile range (IQR) (25–38)] undergoing first time AF ablation were investigated. Identification of LA fibrosis and selection of ablation strategy were based on sinus rhythm voltage mapping. Continuous rhythm monitoring was used to assess ablation success. Improvement in post-ablation LVEF was measured as primary study endpoint. An absolute increase in post-ablation LVEF ≥10% was defined as ‘Super Response’. Left atrial fibrosis was present in 38% of patients. After ablation LVEF increased by absolute 15% (IQR 6–25) (P Conclusion Presence and extent of LA fibrosis predict LVEF response in HF patients undergoing AF ablation. The assessment of LA fibrosis may impact prognostic stratification and clinical management in HF patients with AF.

Background: Left atrial substrate modification targeting low voltage zones (LVZ) is an ablation strategy that—in addition to pulmonary vein (PV) isolation—tries to eliminate arrhythmogenic mechanisms harbored in such tissue. Electrophysiological findings at reablation include (a) PV reconnection, (b) reconnection over previous substrate ablation, and (c) de-novo LVZ. Objective: To study, prevalence and contribution of these arrhythmogenic electrophysiological entities in patients with atrial fibrillation (AF) recurrences. Methods: Consecutive patients with highly symptomatic AF undergoing index and reablation were included (n = 113). In all patients' PV reconnection, reconnection over previous substrate ablation and spontaneous de-novo LVZ were quantitatively assessed and integrated into an individual reablation strategy. Follow-up was based on continuous device monitoring. Results: At re-do procedure, 45 out of 113 (39.8%) patients showed PV reconnection as the only electrophysiological abnormality. Reconduction over previous lines was the only electrophysiological abnormality in 8 out of 113 (7.1%) patients. Spontaneous de-novo LVZ was the only electrophysiological abnormality in 12 out of 113 (10.6%) patients. Combined findings of PV reconnection, line reconduction, and/or spontaneous de-novo LVZ were seen in 40 out of 113 (35.4%) patients. No detectable electrophysiological abnormality was observed in 8 out of 113 (7.1%) patients. In univariate analysis, none of the tested electrophysiological characteristics independently predicted the outcome after re-do. Conclusions: In patients undergoing reablation, we could show that reconduction over previous substrate ablation as well as the development of new low voltage areas are frequent findings besides classical PV reconnection—without a clear leading cause for recurrences. These findings impact reablation strategies as well as the strategic focus during index procedures.

Background: Catheter ablation for ventricular tachycardia (VT) reduces the recurrence of VT in patients with implantable cardioverter-defibrillators (ICDs). The appropriate timing of VT ablation and its effects on mortality and heart failure progression remain a matter of debate. In patients with life-threatening arrhythmias necessitating ICD implantation, we compared outcomes of preventive VT ablation (undertaken before ICD implantation to prevent ICD shocks for VT) and deferred ablation after 3 ICD shocks for VT. Methods: The BERLIN VT study (Preventive Ablation of Ventricular Tachycardia in Patients With Myocardial Infarction) was a prospective, open, parallel, randomized trial performed at 26 centers. Patients with stable ischemic cardiomyopathy, a left ventricular ejection fraction between 30% and 50%, and documented VT were randomly assigned 1:1 to a preventive or deferred ablation strategy. The primary outcome was a composite of all-cause death and unplanned hospitalization for either symptomatic ventricular arrhythmia or worsening heart failure. Secondary outcomes included sustained ventricular tachyarrhythmia and appropriate ICD therapy. We hypothesized that preventive ablation strategy would be superior to deferred ablation strategy in the intention-to-treat population. Results: During a mean follow-up of 396±284 days, the primary end point occurred in 25 (32.9%) of 76 patients in the preventive ablation group and 23 (27.7%) of 83 patients in the deferred ablation group (hazard ratio, 1.09 [95% CI, 0.62–1.92]; P =0.77). On the basis of prespecified criteria for interim analyses, the study was terminated early for futility. In the preventive versus deferred ablation group, 6 versus 2 patients died (7.9% versus 2.4%; P =0.18), 8 versus 2 patients were admitted for worsening heart failure (10.4% versus 2.3%; P =0.062), and 15 versus 21 patients were hospitalized for symptomatic ventricular arrhythmia (19.5% versus 25.3%; P =0.27). Among secondary outcomes, the proportions of patients with sustained ventricular tachyarrhythmia (39.7% versus 48.2%; P =0.050) and appropriate ICD therapy (34.2% versus 47.0%; P =0.020) were numerically reduced in the preventive ablation group. Conclusions: Preventive VT ablation before ICD implantation did not reduce mortality or hospitalization for arrhythmia or worsening heart failure during 1 year of follow-up compared with the deferred ablation strategy. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02501005.

Background: Atrial fibrillation (AF) ablation in an end-stage left atrial (LA) fibrotic disease is more complex, has more recurrences, and may compromise transport function and stroke risk. We explored whether a total left atrial isolation procedure (TLAI) followed by left atrial appendage occlusion is a feasible treatment concept for rhythm and stroke risk control. Methods: Patients with symptomatic AF with extended LA fibrosis were enrolled consecutively for TLAI followed by left atrial appendage occlusion. At enrollment, all patients received a sinus rhythm LA voltage map. For TLAI, LA anterior and paraseptal ablation lines were placed, combined with right atrial and epicardial line completion and right pulmonary vein isolation as needed. Rhythm follow-up was provided through continuous monitoring using implantable cardiac devices. Results: Ninety-two patients (71±9 years, 41% male, 84% persistent AF, CHA 2 DS 2 -VASc 4) underwent 104 ablation procedures. Follow-up duration measured 48±22 months. At 12-month follow-up 70 out of 92 (76%) patients were free from any atrial arrhythmia recurrence, off antiarrhythmic drugs. All intended left atrial appendage occlusion procedures were successfully performed 6 to 8 weeks after TLAI. Combination of TLAI and left atrial appendage occlusion attenuated the native 4% annual stroke risk to Conclusions: This is the first report on a structured concept of interventional electrical LA isolation and LA appendage occlusion for rhythm and stroke risk control in patients with AF at an end-stage left atrial fibrotic disease. We report feasibility, safety, and efficacy of such a treatment approach.

Supplemental Digital Content is available in the text., Rationale: Fibrosis promotes the maintenance of atrial fibrillation (AF), making it resistant to therapy. Improved understanding of the molecular mechanisms leading to atrial fibrosis will open new pathways toward effective antifibrotic therapies. Objective: This study aims to decipher the mechanistic interplay between PLK2 (polo-like kinase 2) and the profibrotic cytokine OPN (osteopontin) in the pathogenesis of atrial fibrosis and AF. Methods and Results: Atrial PLK2 mRNA expression was 10-fold higher in human fibroblasts than in cardiomyocytes. Compared with sinus rhythm, right atrial appendages and isolated right atrial fibroblasts from patients with AF showed downregulation of PLK2 mRNA and protein, along with increased PLK2 promotor methylation. Genetic deletion as well as pharmacological inhibition of PLK2 induced profibrotic phenotype conversion in cardiac fibroblasts and led to a striking de novo secretion of OPN. Accordingly, PLK2-deficient (PLK2 knockout) mice showed cardiac fibrosis and were prone to experimentally induced AF. In line with these findings, OPN plasma levels were significantly higher only in patients with AF with atrial low-voltage zones (surrogates of fibrosis) compared with sinus rhythm controls. Mechanistically, we identified ERK1/2 as the relevant downstream mediator of PLK2 leading to increased OPN expression. Finally, oral treatment with the clinically available drug mesalazine, known to inhibit ERK1/2, prevented cardiac OPN overexpression and reversed the pathological PLK2 knockout phenotype in PLK2 knockout mice. Conclusions: Abnormal PLK2/ERK1/2/OPN axis function critically contributes to AF-related atrial fibrosis, suggesting reinforcing PLK2 activity and/or OPN inhibition as innovative targets to prevent fibrosis progression in AF. Mesalazine derivatives may be used as lead compounds for the development of novel anti-AF agents targeting fibrosis.

Die Sachkunde „Invasive Elektrophysiologie“ definiert analog zu den Sachkunden „Herzschrittmachertherapie“, „Implantierbarer Kardioverter Defibrillator(ICD)-Therapie“ und „kardiale Resynchronisationstherapie (CRT)“ die fur die Diagnostik und Therapie von Herzrhythmusstorungen erforderlichen theoretischen Kenntnisse. Diese sind zusammen mit den praktischen Erfahrungen der klinischen Aus- und Weiterbildung Voraussetzung fur eine qualifizierte Behandlung von Patienten mit Herzrhythmusstorungen. Die Sachkunde umfasst Grundlagen von Herzrhythmusstorungen sowie diagnostische und therapeutische Verfahren. Sie beinhaltet dabei antiarrhythmische Therapieverfahren mittels Antiarrhythmika und Katheterablation, aber auch Grundlagen der antiarrhythmischen „Device-Therapie“. Daneben werden einzelne Arrhythmien im Speziellen von den Grundlagen bis zur Therapie besprochen. In Analogie zu vorhandenen Sachkunden stellen Einzelbeispiele und ein „Troubleshooting“ eine wesentliche Erganzung zu dem theoretischen Wissen dar. Mit den Kursen zur Herzschrittmacher‑, ICD- und CRT-Therapie wird das theoretische Angebot zur Erlangung des Zertifikats „spezielle Rhythmologie“ komplettiert.

Das implantatbasierte Telemonitoring bei Patienten mit erhohtem Risiko fur plotzlichen Herztod und bei Herzinsuffizienz ermoglicht im Vergleich zur konventionellen Nachsorge die fruhere Erkennung technischer und klinischer Konstellationen, durch welche Patienten in Lebensqualitat und Uberleben gefahrdet sein konnen. Unterschiedliche Methoden der Datenakquisition und variable Definitionen von therapeutischen Reaktionen auf Befunde aus dem Telemonitoring wurden in bisherigen Studien zur Evaluation des Telemonitorings angewandt. Zur Analyse der Wirksamkeit des implantatbasierten Telemonitorings erscheinen die Gesamtsterblichkeit und die kardiovaskulare Sterblichkeit als adaquate Endpunkte. Die Hospitalisation als Endpunkt ist weniger geeignet, da sich in diesem Parameter Krankenhausbehandlungen als erforderliche Reaktion auf fruh detektierte Dekompensationen und Hospitalisationen aufgrund klinischer Verschlechterung in schwer zu differenzierender Weise mischen. Die modifizierte Analyse und Metaanalyse der vom IQWiG zur Bewertung des Telemonitorings herangezogenen Studien zeigt, dass bei zeitlich engmaschiger und umfangreicher Datenakquisition und strukturierter verbindlicher Vorgabe von Behandlungskonsequenzen aus spezifischen Befundkonstellationen das implantatbasierte Telemonitoring die Gesamtsterblichkeit und kardiovaskulare Sterblichkeit relevant und signifikant mindert. Dagegen ist die reine Datenakquisition ohne strukturierte Konsequenz nicht wirksam. Die pauschale Negation eines Zusatznutzens durch das implantatbasierte Telemonitoring im deutschen Gesundheitswesen wurde Patienten in Deutschland eine international geforderte innovative Methode zur verbesserten Versorgung vorenthalten. Zusatzlich waren gravierende juristische Folgen zu erwarten, wenn das implantatbasierte Telemonitoring generell disqualifiziert wurde. Stattdessen sollte Telemonitoring in sinnvoller und wirksamer Weise gemeinsam breit etabliert werden.

Die Analgosedierung des Patienten im Rahmen rhythmologischer Eingriffe ist von erheblicher Bedeutung fur einen erfolgreichen und risikoarmen Eingriff und tragt wesentlich zum Komfort des Patienten und Untersuchers bei. Das Spektrum der Kardioanalgosedierung reicht von einer sanften Anxiolyse bis hin zur tiefen Analgosedierung beim spontan atmenden Patienten. Die erste Auflage dieses Positionspapiers zur Kardioanalgosedierung mit Fokus auf Eingriffe in der Rhythmologie gibt Empfehlungen zu deren Anwendung im Rahmen von elektrophysiologischen Eingriffen, Implantationen kardialer Devices, wie z. B. Herzschrittmacher oder Defibrillatoren, sowie anderen kardiologischen Eingriffen. Dieses Papier erlautert Indikationen, Ziele und Patientenselektion inklusive Risikostratifizierung des individuellen Patienten fur Sedierung. Es gibt eine Ubersicht uber die Pharmakologie der unterschiedlichen Sedativa und Analgetika hinsichtlich ihrer Sicherheit und Wirksamkeit. Auch definiert es Standards fur die optimale Patientenvorbereitung und Aufklarung uber die Sedierung. Die personellen und apparativen Voraussetzungen fur die Durchfuhrung und Dokumentation der Sedierung sowie die klinische Uberwachung im Rahmen des Eingriffes werden ebenso definiert wie die Anforderungen an die Aus‑, Fort- und Weiterbildung des Personals.

Als wissenschaftliche Fachgesellschaft vertritt die Deutsche Gesellschaft fur Kardiologie den Standpunkt, dass die Standards zur Durchfuhrung einer Katheterablation bei Patienten mit Vorhofflimmern (VHF) stetig kritisch betrachtet und angepasst werden mussen, um dauerhaft eine gute Behandlungsqualitat mit hoher Erfolgs- und geringer Komplikationsrate zu gewahrleisten. Das ist insbesondere auch deshalb notwendig, weil die Anzahl von Zentren und Kardiologen, die diese Intervention durchfuhren, rasant ansteigt. Im vorliegenden Positionspapier werden daher zunachst die aktuelle Datenlage zur Katheterablation von VHF sowie die Indikationsstellung zur Ablation, Komplikationen des Verfahrens und neueste Entwicklungen detailliert ausgefuhrt, bevor abschliesend eine Darstellung der personellen, technischen und raumlichen, strukturellen sowie organisatorischen Anforderungen an klinische Zentren erfolgt, an denen Katheterablationen von VHF durchgefuhrt werden.

Background The relation of left atrial low voltage zones (LVZ) to left ventricular function in patients undergoing pulmonary vein isolation (PVI) is not known. Objective To explore the relationship of left atrial low voltage zones (LVZ) on left ventricular function in patients with atrial fibrillation. Methods From June to Nov. 2018, 107 (mean age 67y, 70 men, 73 persistent AF) consecutive patients with symptomatic AF underwent a PVI with LVZ mapping. Before PVI the left ventricular ejection fraction (EF) and stroke volume (SV) were measured by cardiac magnetic resonance imaging (CMR). From feature-tracking of CMR-cine images left ventricular global, systolic and diastolic longitudinal strains (GLS), circumferential strains (GCS) and radial strains (GRS) were calculated. Results Of 59 patients CMR scanning in sinus rhythm was performed, LVZ were present in 24 patients. LVEF was significantly lower in patients with left atrial LVZ (62±9% vs. 55±15%) (p=0,03). Left ventricular stroke volume was significantly decreased by the extent of LVZ (94±23 vs. 72±21ml), (p=0,03). The left ventricular diastolic strains during ventricular filling (caused by atrial contraction) of GLS (r=−0,52), GCS (r=−0,65) and GRS (r=−0,65) were highly signifcantly correlated to the occurence and extent of LVZ (each p The only systolic ventricular strain was GLS, which decreased (r=−0,3, p=0,03) by the occurance of atrial low voltage. Conclusion The active, atrial part of diastolic left ventricular filling properties is impaired by the occurrence and extent of left atrial LVZ. In patients with left atrial LVZ the left ventricular stroke volume and ejection fraction is decreased already in sinus rhythm. It seems possible that atrial mechanical dysfunction and presence of atrial low voltage maybe predicted by LV diastolic strain analysis.

Background Bipolar voltage mapping is a widely accepted approach to identify areas of arrhythmogenic substrate in patients presenting for atrial fibrillation (AF) ablation. However, until now little is known about the correlation of left atrial (LA) bipolar voltage distribution and LA transport function. Purpose To study the impact of LA low voltage zones (LVZ) on LA transport function. Methods 107 consecutive patients presenting for ablation of symptomatic AF (34 paroxysmal AF, 73 persistent AF) were prospectively enrolled. Each patient underwent cardiac magnetic resonance imaging (CMR) within 24 hours prior to the ablation procedure. 59 patients were in sinus rhythm (SR) and 48 in AF. LA phasic indexed volumes (LAVi) and ejection fractions were calculated using biplane area length formula. In addition LA phasic strains and strain rates were analyzed using dedicated software (Figure 1A & B). LA bipolar voltage mapping was performed prior to beginning of ablation in sinus rhythm using a 3-dimensional mapping system and LVZ were defined as areas of bipolar voltage Results LVZ were present in 47 patients (23 in SR). The area of LVZ was 14.6cm2 (5.3–34.0). For patients in AF at the time of CMR only elevated minimal and maximal LAVi (p=0.001 and p=0.002 respectively) but no LA functional parameter was predictive for the occurrence of LVZ. In contrast for patients in SR all LA phasic volumes (endsystolic, pre atrial contraction and enddiastolic LAVi) and LA function parameters (passive, active and total ejection fraction (EF), reservoir, conduit and booster pump strains and strain rates) were predictive for the occurrence of LVZ. After clustered and pooled multivariate logistic regression only impaired booster pump strain rate was still predictive for occurrence of LVZ (OR 0.974, 95% CI 0.950–0.998, p=0.036). In addition Pearson correlation analysis revealed a strong link between LA booster pump functional parameters and cm2 expansion of LVZ areas: LA active EF, LA booster pump strain and SR (r=−0.42, p=0.044; r=−0.47, p=0.024; r=−0.65, p=0.001 [Figure 1C] respectively). Conclusion For patients in SR LA transport function is closely linked to the occurrence of LA LVZ and outperforms LA volumetric measurements for the prediction of LA LVZ. Furthermore LA booster pump function parameters show robust correlation to the extension of LA LVZ.

The initial purpose of implantable loop recorders was the sole identification of causal arrhythmia in patients with palpitations and syncope. Nowadays, continuous monitoring is a standardized practice in this clinical setting. Their promising performance has led to miniaturization and further development in detection algorithms. Consequently, the scope of their use included other indications. They are increasingly being used in patients with diagnosed atrial fibrillation to guide clinical management, as well as in patients with stroke and suspected thromboembolism. However, at present, there are no clear recommendations for the preferred monitor type or duration for these indications. Implantable loop recorder can detect ventricular tachycardia and other irregular ventricular activity in patients with cardiomyopathies, but the role of continuous rhythm monitoring in risk stratification remains unclear. The considerable amount of data generated through continuous monitoring is likely to be useful in their validation. Moreover, it could deliver valuable information regarding efficacy of diverse therapeutic strategies and pathophysiology of the underlying conditions.

Aims: To describe the extent and distribution of low voltage zones (LVZ) in a large cohort of patients undergoing ablation for paroxysmal and persistent atrial fibrillation (AF), and to explore baseline predictors of LVZ in these patients.Methods and results: Consecutive patients who underwent a bipolar voltage map guided AF ablation, were enrolled. Voltage maps were conducted for each patient using 3-dimensional electroanatomical mapping system and LVZ were defined as areas of bipolar voltage Conclusion: In a large cohort of patients undergoing ablation for AF, the prevalence of LVZ was higher and LVZ areas larger in patients with persistent as compared with paroxysmal AF. The most frequent localization of LVZ was anterior wall, septum and posterior wall. Presence of LVZ was associated with higher age, female gender, larger LA surface area, and sinoatrial node dysfunction.

We explored whether the use of a novel fluoroscopy image integrated 3-dimensional electroanatomic mapping (F-EAM) system could result in a reduction of overall fluoroscopy time and radiation doses during the whole procedure of atrial fibrillation (AF) ablation.Eighty patients (44 men (55%); mean age 63 ± 10 years) who underwent catheter ablation due to paroxysmal AF were recruited consecutively in the present study. Patients were randomized (1:1) into 2 arms for AF ablation: one using a conventional 3-dimensional electroanatomical mapping (EAM) system and the other using the F-EAM system.Fluoroscopy time (10:42 [interquartile range {IQR} 8:45-12:46] minutes:seconds vs 1:45 [IQR 1:05-2:22] minutes:seconds; P.001) and radiation doses (2440 [IQR 1593-3091] cGy·cm(2) vs 652 [IQR 326-1489] cGy·cm(2); P.001) in the EAM group were significantly greater than those in the F-EAM group. The majority of reduction of radiation exposure was achieved after transseptal puncture, which was near-zero fluoroscopic exposure. In total, approximately 84% of fluoroscopy time and 73% of radiation doses have been reduced during the AF ablation procedure using the F-EAM system compared to using the conventional EAM system. However, procedure time did not differ significantly (1:39 [IQR 1:18-2:10] hours:minutes vs 1:37 [IQR 1:17-1:50] hours:minutes; P = .362). During follow-up (5.9 ± 1.3 months), 61 patients (76.3%) had no recurrence of atrial arrhythmias. The recurrence rate between the 2 groups did not differ.AF catheter ablation using the F-EAM system was safe and resulted in a significant reduction of radiation exposure to patients and staff without complicating the workflow of the procedure. A near-zero fluoroscopic catheter ablation procedure could be performed without compromising acute/mid-term efficacy and safety.

Aims Recently cardiac magnetic resonance (CMR) imaging has been found feasible for the visualization of the underlying substrate for cardiac arrhythmias as well as for the visualization of cardiac catheters for diagnostic and ablation procedures. Real-time CMR-guided cavotricuspid isthmus ablation was performed in a series of six patients using a combination of active catheter tracking and catheter visualization using real-time MR imaging. Methods and results Cardiac magnetic resonance utilizing a 1.5 T system was performed in patients under deep propofol sedation. A three-dimensional-whole-heart sequence with navigator technique and a fast automated segmentation algorithm was used for online segmentation of all cardiac chambers, which were thereafter displayed on a dedicated image guidance platform. In three out of six patients complete isthmus block could be achieved in the MR scanner, two of these patients did not need any additional fluoroscopy. In the first patient technical issues called for a completion of the procedure in a conventional laboratory, in another two patients the isthmus was partially blocked by magnetic resonance imaging (MRI)-guided ablation. The mean procedural time for the MR procedure was 109 ± 58 min. The intubation of the CS was performed within a mean time of 2.75 ± 2.21 min. Total fluoroscopy time for completion of the isthmus block ranged from 0 to 7.5 min. Conclusion The combination of active catheter tracking and passive real-time visualization in CMR-guided electrophysiologic (EP) studies using advanced interventional hardware and software was safe and enabled efficient navigation, mapping, and ablation. These cases demonstrate significant progress in the development of MR-guided EP procedures.

BACKGROUND Thromboembolic complications remain one of the most severe adverse events associated with catheter ablation of atrial fibrillation (AF), but data on such events are limited. OBJECTIVE The purpose of this study was to evaluate the incidence, characteristics, and risk factors of thromboembolic complications after AF ablation. METHODS Cerebral thromboembolic complications occurring within 1 month of 3360 consecutive AF radiofrequency catheter ablations were assessed. Stroke was defined as a neurologic deficit lasting more than 24 hours or with imaging study showing new infarction. Transient ischemic attack (TIA) was defined as a deficit lasting less than 24 hours and without documented infarction. RESULTS There were 17 peri-interventional cerebral thromboembolic events (0.5%). Nine cases (53%) were diagnosed as strokes and 8 (47%) as TIAs. Sixty percent of the events occurred within 48 hours after the ablation; the rest occurred within 1 week. In univariate analysis, peri-interventional thromboembolism was associated with peripheral vascular disease (P ¼ .010), impaired left ventricular ejection fraction (P ¼ .040), periprocedural bridging with heparin (P ¼ .007), and previous stroke (P ¼ .026). Multivariable analysis demonstrated that peripheral vascular disease (odds ratio [OR] 8.81, confidence interval [CI] 1.61–48.31, P ¼ .012) and previous stroke (OR 6.13, CI 1.18–31.91, P ¼ .031) were independent predictors. In a different model, the CHA2DS2VASc score was associated with thromboembolism (OR 1.35, CI 1.00–1.80, P ¼ .049). CONCLUSION Cerebral thromboembolic complications after AF radiofrequency catheter ablation are rare. They mostly occur within 48 hours after the procedure and remain without lasting neurologic deficits in the majority of cases. Such complications are associated with peripheral vascular disease, previous stroke, and the CHA2DS2VASc score.

Erratum zu: Der Kardiologe 2017 https://doi.org/10.1007/s12181-017-0179-4 Im Abschnitt „Narkotika“, Unterabschnitt „Propofol“ wurde eine fehlerhafte Umrechnung der Medikamentendosis in eine Perfusorlaufrate angegeben. Wir bitten um Beachtung des unten angefugten, korrigierten Abschnitts und bitten …

Telemonitoringsysteme stehen heute zur Uberwachung von Patienten mit implantierten Herzschrittmachern, Defibrillatoren (ICD) und kardialen Resynchronisationssystemen (CRT) in der klinischen Praxis zur Verfugung. Trotz unterschiedlicher technischer Umsetzungen der Hersteller haben diese Systeme einen einheitlichen Aufbau. Mit Telemonitoring konnen Daten zum Aggregat-, Arrhythmie- und Herzinsuffizienzmanagement zeitnah ubertragen werden. Die Arzte konnen uber passwortgeschutzte Internetplattformen jederzeit sicher auf diese Daten zugreifen.

The scope of application for implantable loop recorders has shifted away from the evaluation of unclear palpitations and syncope episodes to more complex conditions. This article focuses on rare indications of growing importance such as rhythm monitoring after ablation of atrial fibrillation or after cryptogenic stroke. Furthermore, forthcoming applications in various clinical settings are described, e. g., arrhythmia detection after myocardial infarction, after catheter-based valve interventions, in heart failure, and in cardiomyopathies. Enhancement of the capabilities of implantable loop recorders could broaden their fields of use.

Insertable cardiac monitor (ICM) increases the detection rate of occult atrial fibrillation (AF) after cryptogenic stroke. The aim of this study was to evaluate the prognostic significance of total atrial conduction time (TACT) assessed by tissue Doppler imaging (PA-TDI interval) to predict AF presence in patients with cryptogenic stroke. Ninety patients (57.7 ± 12.3 years, 48 % women) after acute cryptogenic stroke and ICM implantation were prospective recruited at four centers for continuous rhythm monitoring. In all patients, TACT was measured by PA-TDI interval via echocardiography. Patients were followed up (331 ± 186 days) for detection of AF (defined by episode lasting ≥30 s). AF was detected in 16 patients (18 %) during follow-up (331 ± 186 days). The median period to AF detection was 30 days (q1–q3; 16–62 days). Patients who exhibited occult AF were characterized by significantly longer PA-TDI intervals (154.7 ± 12.6 vs. 133.9 ± 9.5 ms, p

Die Katheterablation von Vorhofflimmern (VHF) mittels Pulmonalvenenisolation (PVI) hat sich als Therapieverfahren weithin etabliert, und ihre Indikation ist in den aktuellen VHF-Leitlinien entsprechend definiert. Anfanglich ausschlieslich auf Patienten mit paroxysmalem VHF ohne strukturelle Herzerkrankung beschrankt, wird eine PVI zwischenzeitlich auch in breiteren Patientenpopulationen eingesetzt. Die PVI ist unverandert einem fliesenden methodologischen und technischen Fortschritt unterworfen, gleichzeitig werden unterschiedliche Erfolgsraten der Prozedur berichtet. Der Erfolg der PVI kann klinisch und/oder elektrokardiographisch definiert werden. Bis jetzt fehlen Empfehlungen bezuglich einer einheitlichen Nachbeobachtung. Daruber hinaus variiert die klinische Praxis der Verlaufsbeobachtung nach PVI zwischen spezialisierten Zentren, Kardiologen, Internisten und Allgemeinmedizinern, aber auch innerhalb der entsprechenden Sektoren der Patientenversorgung. Die Erarbeitung diesbezuglicher Empfehlungen ist daher wunschenswert. Um den aktuellen Stand der Nachbeobachtung zu erfassen, hat die Arbeitsgruppe Rhythmologie der DGK eine Umfrage unter niedergelassenen Kardiologen sowie akademischen und/oder universitaren Krankenhausern initiiert, um ihr Vorgehen hinsichtlich Indikationsstellung und Praxis nach PVI zu erfassen. In der vorliegenden Ubersicht wird in diesem Kontext der aktuelle Stand der Literatur zusammengefasst.

BACKGROUND: The aim of this prospective study was to determine the differences in left ventricular (LV) lead positioning for cardiac resynchronization therapy (CRT): comparing a percutaneous transvenous approach via the coronary sinus versus epimyocardial placement via a left lateral mini-thoracotomy. METHODS: Eighty consecutive patients with symptomatic left ventricular dysfunction and an indication for CRT were randomized to receive either a transvenous (n = 40) or epicardial (n = 40) LV-lead placement. Postoperative follow-up included assessment of NYHA functional class, ECG and echocardiography. RESULTS: The transvenous group had a shorter ICU stay (0.66 vs. 3.8 days) and shorter ventilation times (0.34 vs. 3.2 h). The epicardial group had less exposure to radiation (7.4 vs. 23 min) and required less use of contrast medium (3.24 vs. 61 ml). At 6 months follow-up, no major differences in LV-lead parameters (threshold, sensing, and impedance) were observed. CONCLUSION: Both epicardial and transvenous LV-lead placement for CRT therapy are safe and effective. The transvenous approach is less invasive and should be considered the standard procedure for patients without renal insufficiency. However, in a case of difficult coronary venous anatomy with the inability to position the lead as desired, epicardial LV-lead placement remains an alternative option.

The Brugada syndrome (BS) and arrhythmogenic right ventricular cardiomyopathy (ARVC) are currently seen as 2 distinct clinical entities. However, several genetic mutations linked to reduced sodium transmembrane flow and disrupted integrity of the desmosome with resulting fatty infiltration have been identified, corresponding to BS and ARVC, respectively.1 A 22-year-old male patient was admitted to our hospital with repeated discharges of the implantable cardioverter defibrillator caused by pleomorphic ventricular tachycardia. He had a previous history of survived sudden cardiac death and an implanted single-chamber implantable cardioverter defibrillator in 2010. No data on work-up of genetic arrhythmias had been available to date. On current clinical presentation in echocardiography, normal ejection fraction and heart diameter could be determined. Because of abnormal ECG pattern in a sense of an incomplete right bundle branch block with slightly elevated ST-segments and T-wave inversions in the right precordial leads, an ajmaline test was conducted (Figure A). This resulted in prominent coved-type Brugada ECG (Figure B). Figure. A , Baseline …

Conventional fluoroscopy is the main technology for intracardiac device tracking in interventional cardiovascular procedures. For therapy delivery it carries the advantage of being able to instantaneously localize the device and its spatial relationship with respect to the moving target organ. However, besides the associated X-ray exposure, fluoroscopy only provides 2D orientation. For treatment of complex cardiac anatomies and substrates such as in interventional electrophysiology, 3-D mapping technologies have been introduced to facilitate spatial, anatomic, and electrical orientation. A new technological platform (MediGuide(™)) offers the option to continuously display the catheter tip on a prerecorded cine-loop allowing better anatomic understanding of the underlying substrate. We describe our initial experience using the system with diagnostic catheters only and the first procedures with the MediGuide(™) equipped ablation catheter (available since May 2012). We could show a significant decrease of fluoroscopy time in all types of procedures with comparable procedure times. No increase in complication rates was observed.

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 using radiofrequency energy has become an accepted and safe treatment of cardiac arrhythmias. Nevertheless, it is important to determine the risk-to-benefit ratio of a specific procedure, especially when treating subjects with non-life-threatening cardiac arrhythmias, such as AV-nodal reentrant tachycardia or atrial fibrillation, and efforts have to be made to reduce the incidence of complications associated with these procedures, which are in the vast majority of cases not directly attributable to RF energy application but rather with obtaining peripheral vascular access or intracardiac catheter manipulation. Although complication rates in atrial fibrillation (AF) ablation have decreased with improvements of the ablation technique and a change of ablation concepts since the introduction of this technique, the risk of complication is still considerable and significantly higher compared to ablation procedures of other supraventricular tachycardia, including potentially life-threatening events. The higher incidence of AF ablation associated complications may be explained by the complex technique, the need for trans-septal puncture or extensive manipulation in the thin walled left atrium, as well as possible adverse effects of sedation. Even "new" complications associated with AF catheter ablation were identified, such as pulmonary vein stenosis or atrio-esophageal fistula formation. This article will review general risks and complications that can occur during RF catheter ablation procedures and conscious sedation with a particular attention on AF ablation procedures.

In several studies, ICD therapy has been shown to be an effective treatment option for patients suffering from or being at risk of malignant ventricular arrhythmias. Given the increasing rate of ICD implantations with the need for in-office interrogations at least twice a year, the number of follow-up visits is constantly growing. Remote transmission of relevant ICD data is a way to reduce follow-up burden for the physician, travel costs for the patient, and the time delay between onset of medical or device problems and an adequate physician response. In several studies, it has been demonstrated that remote ICD follow-up is safe and reduces follow-up resources for both the patient and the physician. With ongoing studies, the questions of whether remote ICD interrogations can offer additional diagnostic and therapeutic options that go beyond pure device follow-up and allow for a more complex management of ICD patients, who in fact represent a large percentage of the heart failure population, will have to be answered.

Detailed analysis of stored electrograms is essential for the interpretation of arrhythmias, programming changes, and optimization of the medical therapy in patients with implanted pacemakers and defibrillators. The physician who cares for patients with implantable electrical devices has to be able to understand the detection and treatment algorithms of those devices. Biotronik pacemakers of newer generations are capable of storing intracardiac electrograms. Earlier devices store up to 12 electrograms of 10 s duration after certain trigger events, like atrial tachycardia or high ventricular rates. Cardiac resynchronization systems can store electrograms after patient activation with magnets in addition to the above mentioned trigger-activated electrograms. Defibrillators store intracardiac electrograms during tachycardia episodes with near-field and far-field electrograms of the right ventricular lead in addition to the markers in single and dual chamber defibrillators (in addition to an atrial electrogram) and near field electrograms of the atrial, the right, and the left ventricular electrode in addition to the markers in resynchronization systems. Each channel has a maximum storing capacity of 32 min. If there are more episodes than storing capacity, electrograms of older episodes will be overwritten, but if the newer episodes are all classified as supraventricular, the last two ventricular episodes (VT or VF) will remain in the episode memory. This article describes stored electrograms, detection, and treatment algorithms of implantable cardiac devices manufactured by Biotronik.

Continuous rhythm monitoring is the gold standard of objective rhythm assessment in patients with atrial fibrillation, thus, facilitating accurate detection of symptomatic and asymptomatic atrial fibrillation. This is of scientific and clinical interest for the understanding of this arrhythmia, the establishment of evidence-based therapeutic approaches, the definition of clinically indicated monitoring strategies, and for decision-making about oral anticoagulation. This article illustrates the importance of continuous monitoring of atrial fibrillation and presents developing technologies with their advantages and limitations as well as initial clinical experience.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is increasing with age. With aging of the population treatment of atrial fibrillation especially in elderly population is a growing task for all medical staff working with elderly patients. Treatment of atrial fibrillation especially in elderly patients has to focus on prevention of thromboembolism as well as symptom relief with rate or rhythm control. This review article will focus on medical and non-pharmacological treatment options for the treatment of atrial fibrillation in elderly patients.

The Lotus valve, a second-generation transcatheter aortic valve implantation device, shows good performance in REPRISE II.