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Aims Although Eustachian valves and recesses have been related to resistance to block, the effect of convective cooling by the right coronary artery (RCA) has not been evaluated in the clinical setting. Methods and results The distance and course of the RCA in relation to the cavotricuspid isthmus (CTI) in addition to variants of CTI anatomy and the presence of Eustachian valves were analysed from computed tomography scans of 54 patients. Ablation power was titrated using a step-up protocol. Invasive follow-up was available for 34 patients. The RCA came closest to the CTI inferiorly separated by a mean of 5.3 ± 2.5 mm compared with 7.3 ± 3.3 mm septally and 5.7 ± 2.3 mm anteriorly ( P < 0.01). The maximum power required for CTI block correlated inversely with the distance of the RCA to the CTI, whereas the cumulative energy was highest in the presence of recesses. Neither failure of acute block nor a higher rate of conduction recurrence could be attributed to variants of CTI anatomy or the presence of a Eustachian valve. Using multivariate analysis, a position of the RCA underneath the central part of the CTI was the only significant predictor for late conduction recurrence. These patients showed a 2.7 mm larger distance of the RCA to the tricuspid valve plane ( P = 0.05). Conclusion The RCA affects CTI ablation as higher power settings are required at closer distances to the ablation site. Late conduction recurrences were observed in patients with a variation of the RCA, leaving the atrioventricular groove towards the atrial aspect.

Objectives: The effect of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARBs) on the long-term outcome after pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) is unknown. Methods: This matched-pair study included 102 patients with PAF treated with ACE-I or ARBs (group 1) and 102 control subjects (group 2) after standardized PVI. Tele-ECG recorders were used to detect the end point of the first PAF recurrence after a 3-month blanking period. Results: Median follow-up was 2.1 years (range 0.3–6.3). In group 1, 51 (50%) patients suffered recurrences, with a mean time to recurrence of 3.2 years (95% CI 2.6–3.8). In group 2, 67 (65.7%) patients presented PAF after a mean period of 2.2 years (95% CI 1.7–2.8; p = 0.009). A second ablation was performed in 31 (50%) patients from the treatment group and in 48 (66.7%) patients from the control group (p = 0.02). Multivariate Cox analysis showed treatment with ACE-I and ARBs to be the only significant predictor of a reduced recurrence rate (HR 0.49, 95% CI 0.32–0.75). Conclusion: ACE-I and ARBs were effective for the preservation of sinus rhythm after PAF ablation, and they reduced the reablation rate.

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.

Objectives 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. Background 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. Methods 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. Results 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, p Conclusions 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).

Background: 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. Methods: 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. Results: 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%, p < 0.05). 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, p < 0.05). Conclusions: 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.

Objective: Catheter ablation of ventricular tachycardia (VT) after myocardial infarction (MI) can be complex and time-consuming. We only targeted the previously documented VTs and those with similar or longer cycle lengths. Methods: 30 patients with VTs after MI were included in the study. Voltage mapping was performed using an electro-anatomic mapping system (CARTOT). Stable VTs were mapped during tachycardia and unstable VTs during sinus rhythm. Results: Clinical VTs were stable in 16 (53%) and unstable in 14 (47%) patients, and ablation was successful in 11 (69%) and 9 patients (64%), respectively (p = 0.42). During follow-up (14 ± 6 months), 4 patients (25%) treated for stable and 6 (43%) for unstable VTs had recurrences (p = 0.82); ablation was successful in none and 2 (33%) of them, respectively. Non-target VTs were inducible in 11 (55%) of 20 patients after successful ablation and non-inducible in 9 (45%). During follow-up, inducibility of non-target VTs did not predict recurrences (9 vs. 11%, p = 0.88). Conclusions: Catheter ablation of VTs after MI can be successfully performed. Acute success rates seem to be similar for stable and unstable VTs. VTs faster than those documented clinically exert a minor effect on VT recurrences during follow-up.

Background— Insights gained from noncontact mapping of ventricular tachycardia (VT) have not been systematically applied to contact maps. This study sought to unify both techniques for an individualized approach to the patient with multiple ischemic VTs irrespective of cycle length. Methods and Results— For 12 consecutive patients with chronic myocardial infarction and recurrent VT, bipolar contact maps were acquired during sinus or paced rhythm. Additional noncontact maps were obtained during 48 induced VTs (cycle length 192 to 579 ms). Endocardial exit sites were superimposed on contact maps and verified by pace-mapping. Radiofrequency lesions were extended for critical borders defined by multiple neighboring exits and followed the isovoltage contour line of contact maps. Nine critical borders were identified in 8 patients and constituted the substrate for 31 VTs. The voltage at exit sites was 0.8 mV (range 0.1 to 2.3). Noncontact maps revealed 23±18% of isthmus conduction. Thirty-seven (77%) of all and 83% of clinically documented VTs were rendered noninducible irrespective of cycle length by application of 27 radiofrequency lesions (range 18 to 56). Spontaneous transitions between distinct VTs along critical borders were demonstrated in 4 patients. Pace-mapping reproduced the QRS morphology of 81% of VTs and was associated with successful ablation ( P P Conclusion— The combined approach of contact and noncontact mapping effectively defines critical borders as the substrate of multiple VTs without limitation for unstable VTs.

Aims To investigate the effectiveness of additional substrate modification (SM) by left atrial (LA) linear lesions as compared with pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrilla- tion (AF) in a prospective randomized study. Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF. The benefit of PVI alone and additional linear lesions has not been validated in a randomized study so far. Methods and results Sixty-two patients with persistent AF (median duration 7, range 1-18 months) were randomly assigned to either PVI alone (n ¼ 30) or additional SM (n ¼ 32) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus. Procedures including SM were performed using a three-dimensional mapping system (EnSite NavX TM , St Jude Medical, St Paul, MN, USA). Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups. Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient's symptoms. PVI was successful in 98% of all targeted veins in both groups. Additional SM did not increase fluoroscopy time (72.1+ 18.7 vs. 72.9+ 17.3 min, P ¼ 0.92) because of the use of three-dimensional navigation in the PVI þ SM group. AF recurrences within the first 4 weeks following ablation were more common after PVI alone (77%) than additional SM (44%, P ¼ 0.002). After a follow-up time of 487 (429-570) days, only 20% of patients undergoing stand alone PVI remained in sinus rhythm when compared with 69% following PVI combined with SM (P ¼ 0.0001). Two patients assigned to PVI þ SM experienced procedure-related complications (cardiac tamponade and minor stroke) which resolved without sequelae. Conclusion PVI alone is insufficient in the treatment of persistent AF. However, additional left linear lesions increase the success rate significantly. Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM.

Background— Neutrophils and monocytes are centrally linked to vascular inflammatory disease, and leukocyte-derived myeloperoxidase (MPO) has emerged as an important mechanistic participant in impaired vasomotor function. MPO binds to and transcytoses endothelial cells in a glycosaminoglycan-dependent manner, and MPO binding to the vessel wall is a prerequisite for MPO-dependent oxidation of endothelium-derived nitric oxide (NO) and impairment of endothelial function in animal models. In the present study, we investigated whether heparin mobilizes MPO from vascular compartments in humans and defined whether this translates into increased vascular NO bioavailability and function. Methods and Results— Plasma MPO levels before and after heparin administration were assessed by ELISA in 109 patients undergoing coronary angiography. Whereas baseline plasma MPO levels did not differ between patients with or without angiographically detectable coronary artery disease (CAD), the increase in MPO plasma content on bolus heparin administration was higher in patients with CAD ( P =0.01). Heparin treatment also improved endothelial NO bioavailability, as evidenced by flow-mediated dilation ( P P r =0.69, P Conclusions— Mobilization of vessel-associated MPO may represent an important mechanism by which heparins exert antiinflammatory effects and increase vascular NO bioavailability. These data add to the growing body of evidence for a causal role of MPO in compromised vascular NO signaling in humans.

Introduction: Currently, definition of success following atrial fibrillation (AF) ablation is commonly based on the lack of symptoms. The purpose of this study was to evaluate the correlation between symptoms and the underlying rhythm after AF ablation. Methods and Results: Eighty consecutive patients (pts) were treated for paroxysmal episodes of AF by segmental ostial ablation of all pulmonary veins and right atrial isthmus ablation. For 6 months pts transmitted transtelephonic (T-) ECG recordings in combination with comments daily or in the event of symptoms. Eligible comments were classified as: (1) asymptomatic, (2) symptomatic. Analysis was performed at 1-month intervals, defining an acute (first month) and chronic period (second to sixth month) after ablation. Overall 6,835 T-ECGs were analyzed. Of these 5,437 (79.5%) showed sinus rhythm (SR) and 1,398 (20.5%) showed AF. Pts in SR reported symptoms for 593 (10.9%) episodes, whereas 4,844 (89.1%) episodes were asymptomatic. During AF, 646 (46.2%) episodes were associated with symptoms, and 752 (53.8%) episodes remained asymptomatic. Exclusively asymptomatic were 7 (8.8%) pts. In 30 (52.6%) of 57 pts with AF, arrhythmic events were confined to the acute phase. Of the remaining 27 pts 14 (52%) reported an improvement, 12 (44%) the same, and 1 (4%) worsened symptoms after 3 months. A significant change (P < 0.01) toward more asymptomatic episodes from the acute (43.5%) to the chronic (57.5 ± 4.5%) period was evident. Conclusion: Assessment of success after AF ablation cannot be based on the absence of symptoms due to a high prevalence of asymptomatic episodes.

AVNRT in the Elderly. Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common regular supraventricular tachycardia in the general population as well as in elderly patients. The purpose of thestudy was to investigate the success and complication rate particularly regarding the induction of an atrioventricular (AV) block by radiofrequency (RF) ablation in elderly patients with and without a preexisting AV block. Methods and Results: Between February 1998 and July 2004, all patients with symptomatic AVNRT referred for slow-pathway ablation in our institution were included and divided into two groups: group 1 patients younger than 75 years (n = 508) and group 2 patients >75 years (n = 70). A preexisting prolonged PR interval was present in 17 (3.3%) patients of group 1 and in 26 (37%, P < 0.0001) patients of group 2. Following successful slow-pathway ablation (follow-up time group 1: 37 ′ 22, group 2: 37 ′ 24 months) no induction of an AV block was observed in group 2 but in four patients of group 1 (0.79%) a complete heart block was induced requiring a pacemaker implantation. In group 1, 15 (2.95%) patients with a recurrence of AVNRT were readmitted for a repeat ablation procedure. No recurrences occurred in group 2. Conclusion: Despite a higher incidence of preexisting prolonged PR intervals slow-pathway ablation in elderly patients is both effective and safe and should be considered as the first line therapy also in this patient population.

Discrimination of local and far field potentials during sinus rhythm and atrial fibrillation (AF) is essential for successful pulmonary vein (PV) isolation. We sought to introduce an expert system for the classification of electrophysiologic PV signals. For the expert system database, we analyzed ablation procedures of 50 patients with paroxysmal and persistent AF. Standard circumferential catheters and bipolar recordings were required. In a prospective trial, the expert system was compared with the performing electrophysiologists’ classifications of potentials during 15 procedures. A total of 1,343 recordings of local PV and far field signals were validated by the sudden disappearance of local potentials during ablation, the presence of dissociated PV activity, and pacing maneuvers. A fast Fourier transform was applied to the individual potentials. Analysis continued in the amplitude and phase representation. Four parameters significant (p

Post-MI Narrow QRS Dyssynchrony. Introduction: The mechanism of mechanical dyssynchrony in postinfarction patients with a narrow QRS complex is not defined but essential for cardiac resynchronization therapy (CRT). Methods and Results: Left ventricular electrical activation and subsequent wall motion were recorded for 16 patients with ischemic cardiomyopathy during intrinsic rhythm using a modified NOGA electromechanical mapping system. Ten patients presented mechanical dyssynchrony on tissue Doppler imaging, while 6 patients served as control subjects. The local activation time (LAT) was set by the maximum downslope of the unipolar electrogram. Local wall motion time (LMT) was defined as the time needed for the catheter tip to traverse half of its maximum inward deflection during systole. LAT and LMT were measured relative to the onset of the QRS complex. Electrical activation showed a septal-to-lateral pattern in all patients with a mean endocardial activation time of 65 ± 13 ms. Control subjects exhibited 97.5% of all LMTs 300 ms) showed no slowing of conduction. Wall motion time corrected for differences in electrical activation (LMT-LAT) was significantly longer in delayed (289 ± 34 ms) than in regular (204 ± 24 ms) motion areas (P = 0.002). Delayed motion segments were hypokinetic on echocardiography and presented a lower maximum inward motion (9.9 ± 1.1 mm) compared to regular segments (10.9 ± 1.2 mm) on electromechanical maps (P = 0.004). Viability, however, was preserved with unipolar and bipolar voltage amplitude >7 mV and >1.5 mV for 79% of all delayed motion areas. Conclusion: Dyssynchronous segments of an ischemic myocardium show unimpaired local activation but slow wall motion, thereby limiting the benefit of ventricular preexcitation via CRT. (J Cardiovasc Electrophysiol, Vol. 21, pp. 70–77, January 2010)

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.

Background: Air embolism in patients undergoing percutaneous interventions requiring access to the left atrium (LA) represents a potentially fatal complication. Here we tested if a decline in LA pressures following sedation represents an important mechanistic link underlying air intrusion into the LA. Methods and Results: Left atrial pressures were measured in 26 consecutive patients (49 ± 14 years; 27% male), who underwent percutaneous atrial septal occlusion for persistent foramen ovale or secundum atrial septal defects. Patients either received sedation by propofol allowing for guidance by transesophageal echocardiography (n = 13) or underwent occluder implantation without sedation and under fluoroscopic control only (n = 13). Whereas mean exspiratory LA pressures remained unchanged in either group, sedation provoked a marked decline in the mean inspiratory LA pressure as compared to non-sedated patients (Δp 6.9 ± 8.6 mm Hg vs. 0.1 ± 1.2 mm Hg in nonsedated patients, P < 0.001). Ex vivo experiments evaluating the air-tightness of different sheaths in response to negative pressures revealed air aspiration at –13.4 ± 1.2 mm Hg of suction in all cases, once a guide wire was inserted. Conclusions: Negative LA pressures in conjunction with air-leaking sheaths are identified as potentially important factors for air intrusion into the LA with the patient's sedation being a primary risk factor to lower LA pressure levels. The results advocate close monitoring of LA pressures during intervention, prevention of airway collapse and protection of LA sheaths from communication with the atmosphere, during procedures under sedation. © 2008 Wiley-Liss, Inc.

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.

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.

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.