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Background Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. Methods We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1‑year follow-up data were gathered. Results At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). Conclusions Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.

Background Low oesophageal temperatures (OTs) during cryoballoon pulmonary vein isolation (PVI) have been associated with complications. This study assessed the incidence of low OT in clinical practice during cryoballoon PVI and verified possible predictive values for low OT. Methods Consecutive patients who underwent PVI using the second-generation cryoballoon were retrospectively included. The distance from the oesophagus to the different pulmonary veins (PVs) (OP distance), body mass index (BMI), sex, age, balloon temperature and application time were studied as potential predictors of low OTs. Computed tomography was performed before the procedure to determine the OP distance. OT was measured using an oesophageal temperature probe. Applications were ended prematurely if the OT reached Results Two hundred and four patients were included. Low OT was observed in 54 patients (26%) and 27 patients (13%) reached ultralow OTs. OP distance was the only predictor of low OTs after multivariate analysis. A cut-off value of 19 mm showed 96.2% sensitivity and 37.8% specificity in predicting low OTs. No clinically relevant relation was found between low OTs and BMI, age, sex, balloon temperature or application duration. Conclusions The incidence of low OT was 26% for cryoballoon PVI. OP distance was the only predictor of low OTs. Since an OP distance

AIMS: Cryoballoon pulmonary vein (PV) isolation in patients with atrial fibrillation has proven to be effective in short-term and long-term follow-up. To visualise the PV anatomy, pre-ablation contrast pulmonary venography is commonly performed. Three-dimensional (3D) computed tomography (CT) overlay is a new technique creating a live 3D image of the left atrium by integrating a previously obtained CT scan during fluoroscopy. To evaluate the benefits of 3D CT overlay during cryoballoon ablation, we studied the use of 3D CT overlay versus contrast pulmonary venography in a randomised fashion in patients with paroxysmal atrial fibrillation undergoing cryoballoon PV isolation. METHODS AND RESULTS: Between October 2012 and June 2013, 30 patients accepted for PV isolation were randomised to cryoballoon PV isolation using either 3D CT overlay or contrast pulmonary venography. All patients underwent a pre-procedural cardiac CT for evaluation of the anatomy of the left atrium (LA) and the PVs. In the 3D CT overlay group, a 3D reconstruction of the LA and PVs was made. An overlay of the CT reconstruction was then projected over live fluoroscopy. Patients in the contrast pulmonary venography group received significantly more contrast agent (77.1 ± 21.2 cc vs 40.1 ± 17.6 cc, p < 0.001) and radiation (43.0 ± 21.9 Gy.cm2 vs 28.41 ± 11.7 Gy.cm2, p = 0.04) than subjects in the 3D CT overlay group. There was no difference in total procedure time, fluoroscopy time and the amount of cryoapplications between the two groups. CONCLUSION: The use of 3D CT overlay decreases radiation and contrast dye exposure and can assist in guiding cryoballoon-based PV isolation.

Systematic outcome measurement enables to continuously improve treatment results and stimulates dissemination of best practices. For patients with coronary artery disease, no examples yet exist of standard sets of patient-relevant outcome measures that have already been fully implemented at a large scale in clinical care. The aim of this paper is twofold: (1) to share the standard set of outcome measures as developed by Meetbaar Beter, and (2) to show how the standard set is presented and published to support improvement of cardiac care. A step-wise approach was followed by an expert panel to construct a standard set of outcome measures. This resulted in a comprehensive set of relevant outcome measures, comprising 4 generic and 11 treatment-specific outcomes. Both short-term and long-term outcomes measures up to 5 years of follow-up were included. Relevant initial conditions were selected to enable case-mix adjustment. The standard set has been implemented in 21 hospitals across the Netherlands. The results and experiences have been used to finetune the set in 4 reporting cycles in 2012 to 2016, using an annual maintenance cycle. Currently about 83,000 percutaneous coronary interventions and 30,000 coronary artery bypass graftings are included in the dataset, covering the majority of all percutaneous coronary interventions and coronary artery bypass graftings in the Netherlands. In conclusion, Meetbaar Beter has defined and implemented a comprehensive set of patient-relevant outcome measures for coronary artery disease, and the variation of the results among the centers indicates that there are sufficient opportunities to further improve cardiac care in the Netherlands. (C) 2018 Elsevier Inc. All rights reserved.

Background and Purpose The electromechanical window (EMW), the interval between the end of the T-wave and the end of the left ventricular pressure (LVP) curve, has recently been proposed as a predictor of risk of Torsade de Pointes (TdP) in healthy animals, whereby a negative EMW (mechanical relaxation earlier than repolarization) after drug administration indicates an increased TdP risk. The aims of this study were to assess (i) the effect of the ventricular remodelling in the canine chronic, complete atrioventricular block (CAVB) model on EMW; (ii) the effect of the IKr-blocker dofetilide on EMW; and (iii) the correlation of EMW with TdP inducibility. Experimental Approach Our 11 year database of experiments of CAVB in dogs under general anaesthesia was reviewed and experiments included if ECG and LVP were recorded simultaneously at spontaneous rhythm. In total, 89 experiments in 44 dogs were appropriate and were analysed. Key Results During normally conducted sinus rhythm or acute atrioventricular block, EMW was positive. During CAVB, EMW was decreased to negative values. Dofetilide further reduced EMW before inducing repetitive TdP in 82% of the experiments. However, subclassification into inducible and non-inducible dogs revealed no difference in EMW. Analysis of the components of EMW revealed that the observed changes in EMW were solely caused by QT prolongation. Conclusions and Implications In the canine CAVB model, ventricular remodelling and IKr block by dofetilide are associated with negative EMW values, but this reflects QT prolongation, and implies that the EMW lacks specificity to predict dofetilide-induced TdP.

Background: The dog model of chronic complete AV-block (CAVB) demonstrates a considerable incidence of (witnessed) sudden death (16/117 dogs). In this study we tried to: (1) elucidate the mechanisms of sudden death using an ECG telemetry device and (2) identify retrospectively the risk parameters indicative of this arrhythmogenic death. Methods: Between 1994 and 1998, 78 anesthetized dogs underwent an extensive electrophysiological study including: (1) left- (LV) and right ventricular (RV) monophasic action potential (MAP) recordings to assess ΔMAPD (LV APD minus RV APD) and (2) pacing protocols (PES) to induce torsade de pointes arrhythmias (TdP) at 4–6 weeks CAVB. Eight animals experienced sudden cardiac death (SCD) during the follow-up period (mean 7±3 weeks CAVB). Since the response of the CAVB dog to class III drugs is not uniform we also made comparisons among the SCD group, TdP drug responders and non-responders. For this purpose we selected all animals which (1) received almokalant ( n = 15, 0.12 mg/kg/5 min) or ibutilide ( n = 9, 0.025 mg/kg/5 min) as an additional challenge to induce TdP and (2) had a follow-up period of at least 4 weeks. Results: Six out of eight SCD dogs showed inducible TdP at baseline. Two of eight dogs had telemetric ECG surveillance and both revealed polymorphic VT as the cause of SCD. Baseline ΔMAPD of the SCD (90±15 ms) was significantly higher than the non-scD group ( n = 70, 60±30 ms). Of the 24 dogs which received class III drugs, 12 belonged to the TdP responder group. ΔMAPD of the TdP responder group (80±15 ms) was similar to the SCD group and significantly higher compared to the non-responder group ( n = 12, 40±25 ms). QT-time and cycle length of idioventricular rhythm were not different. Conclusion: In the CAVB dog model, SCD is (1) most probably related to TdP while (2) inducible TdP and the measure of ΔMAPD at baseline indicate susceptibility to SCD.

Recent studies have demonstrated that radiofrequency isolation of the pulmonary veins (PVI) is an effective treatment for symptomatic atrial fibrillation. Based on these positive results, non- pharmacological therapy has been incorporated in the guidelines for drug refractory atrial fibrillation, resulting in an increased popularity. The prevention of thromboembolic complications remains an important issue.In January 2010, we adopted an anticoagulation strategy based on continuation of vitamin K antagonists (VKAs) and selective use of transoesophageal echocardiogram (TEE). We retrospectively analysed the results of this strategy in all patients referred for PVI treatment. VKAs were started for all patients 2 months prior to treatment. Discontinuation of oral anticoagulation was considered 3 months after treatment based on thromboembolic and bleeding risk profile. Bleeding and thromboembolic complications were registered during outpatient clinic follow-up up until 3 months.We performed 151 PVI procedures from January 2010 to March 2011. All patients were seen 6 weeks after discharge. No transient ischaemic accidents or ischaemic cerebrovascular incidents occurred pre-, peri- or postprocedure. Four (2.7%) procedures were complicated by tamponade requiring pericardiocentesis.Our data support the increasing evidence for continuation of periprocedural administration of VKAs complemented by a selective TEE approach as a safe therapy for thromboembolic complications.

Pacemaker/implantable cardioverter-defibrillator (ICD) lead endocarditis remains a challenging diagnosis in cardiology. Several parameters can be involved in the clinical path leading to the definite diagnosis. Clinical appearance and physical findings, together with transoesophageal echocardiography and serum levels of inflammatory parameters, are necessary in the workup towards the diagnosis. It is highly unlikely that ICD-lead vegetation is accompanied by positive blood cultures solely. We describe a case of ICD-infected endocarditis with positive blood cultures for Staphylococcus epidermidis without any physical findings or raised inflammatory parameters in serum plasma levels. In this case, three-dimensional echocardiography demonstrated an added value to two-dimensional echocardiography.

A 58-year-old female presented with typical chest pain, which had started a week ago. She presented late because she first suspected that her symptoms were due to severe stress related to the terminal illness of her father.

We describe a cardiac tamponade after venous graft perforation due to stent inflation. The complications and therapeutic options are discussed.

A 69-year old male with a large pulmonary embolism is described before and after thrombolytic treatment. The echocardiographic and electrocardiographic hallmarks of right ventricular pressure overload and dilatation are illustrated.

Few published human data are available concerning the acute toxicity of the new antiepileptic drug oxcarbazepine of which the metabolite 10- monohydroxy derivate (MHD) is the pharmacologically effective compound. Two hours after a documented overdosage of more than 100 tablets oxcarbazepine, the serum level of the parent compound was 10-fold higher than the therapeutic dosage (31.6 mg l(-1)). However, the concentration of MHD, which peaked 7 h after intake, was only twofold higher (59.0 mg l(-1)). No life-threatening situations occurred and the patient fully recovered. The fact that oxcarbazepine is a prodrug and that the formation of the active MHD metabolite is a rate-limiting process may contribute to the relative low toxicity of the drug in overdose.

A 44-year-old man presented with a 6-month history of progressive dyspnoea (NYHA class III). The electrocardiogram showed sinus rhythm with continuous short runs of atrial tachycardia resulting in a heart rate of 200 beats/min (Fig. 1a). An echocardiogram demonstrated left ventricular dilatation and a reduced ejection fraction of 15–25%. During runs of atrial tachycardia, the mitral valve failed to open due to high end-diastolic pressures, resulting in impaired filling of the left ventricle (Fig. 1b). As a consequence there was a virtual absence of blood flow through the aortic valve during tachycardic runs (Fig. 1c). Effective cardiac output was only seen during sinus beats, which came at a rate of 25–30 beats per minute. The patient was diagnosed with tachycardiomyopathy due to incessant atrial tachycardia. Cryoablation of the atrial focus eliminated the tachycardia. Three months later, tachycardias were still absent and the patient’s left ventricular systolic function and clinical condition had markedly improved. Fig. 1 a Rhythm strip demonstrating sinus rhythm and episodes of atrial tachycardia. b and c) Echocardiogram with apical views demonstrating absence of flow through the mitral valve and aortic valve during a run of atrial tachycardia Tachycardiomyopathy is an abnormality of systolic and/or diastolic function of the heart, resulting in atrial and ventricular dilatation and ultimately development of heart failure symptoms. Tachycardiomyopathy is usually caused by atrial arrhythmias that results in a high and/or irregular ventricular rate. Myocardial dysfunction is completely or partially reversible after normalisation of heart rate and/or rhythm irregularity [1]. The mechanisms responsible for the contractile dysfunction and structural changes in tachycardiomyopathy are not yet fully understood. This case illustrates the direct effect of tachyarrhythmia on cardiac function and its haemodynamic consequences in a patient with tachycardiomyopathy.

In the anesthetized dog with complete chronic AV block (CAVB), we evaluated and compared the acute electrophysiologic effects of dronedarone i.v. (Dron, 2 times 2.5 mg/kg/10 min) and amiodarone i.v. (Amio, 2 times 5 mg/kg/10 min). This canine model with a high sensitivity for acquired torsade de pointes (TdP) provides an ideal substrate to evaluate ventricular repolarization abnormalities. Six ECG leads and two endocardial monophasic action potential (MAP) recordings in the left and right ventricle (LV and RV) were simultaneously recorded to measure QT time, action-potential duration (APD), interventricular dispersion (deltaAPD = LV(APD) - RV(APD)), early afterdepolarizations (EADs), ectopic beats (EBs), and TdP. Measurements were made at the spontaneous idioventricular rhythm (IVR) and 1,000-ms steady-state pacing. To investigate its short-term, antiarrhythmic properties, Dron was given after almokalant (0.12 mg/kg)-induced TdP. Furthermore, in another set of experiments, oral Dron (20 mg/kg, b.i.d) was given for 3 weeks to conscious CAVB dogs. Dron, i.v., shortened ventricular repolarization (QT, 435 +/- 60 to 360 +/- 55; LV(APD) 395 +/- 75 to 335 +/- 60 ms; p < 0.05), whereas IVR and ventricular effective refractory period (VERP, 225 +/- 30 to 230 +/- 30 ms) remained similar. Therefore the VERP/QT ratio increased (0.55 +/- 0.04 to 0.61 +/- 0.03; p < 0.05). Similar results were obtained with Amio, i.v.. Almokalant-induced TdP was characterized by an increased repolarization duration, deltaAPD, and EADs. Dron, i.v., suppressed the EADs, EBs, and TdP by a reduction and homogenization of repolarization (LV(APD), 505 +/- 110 to 455 +/- 80 ms, and deltaAPD, 110 +/- 55 to 65 +/- 40 ms). Long-term oral Dron increased the PP interval, CL-IVR, and QT(c) time. In contrast to oral treatment, Dron i.v. shortens ventricular repolarization parameters, resulting in suppression of EAD-dependent acquired TdP. The increased VERP/QT ratio after Dron i.v. may indicate an important second antiarrhythmic property.

Purpose: Atrial fibrillation (AF) is the most common supraventricular arrhythmia in patients with an implantable cardioverter defibrillator (ICD). We evaluated the prognostic significance of AF in ICD patients with ischemic or dilated heart disease. Methods: 647 consecutive patients with ischemic or dilated heart disease (81% male, mean age 64±10 years, 70% primary prevention) receiving an ICD in the Thoraxcenter Twente were included. Demographic data, including existence and type of AF (permanent or non-permanent) was collected. Primary endpoints were all cause mortality and ICD discharge (appropriate or inappropriate). Results: At implantation, 183 (28%) had a history of AF (13% non-permanent and 15% permanent. During 41±15 months follow up, 135 (21%) patient died, 142 (22%) patients experienced an ICD shock, of which 104 (16%) appropriate and 58 (9%) inappropriate. After multivariate analysis permanent AF was significantly related to mortality (HR 1.63 (95% CI: 1.08-2.47)) and shock therapy (HR 2.10 (95% CI 1.39-3.15), both appropriate (HR 1.67 (95% CI 1.03-2.71) and inappropriate (HR 3.62 (95% CI 1.92-6.84)). Non-permanent AF was only related to inappropriate shock therapy (HR 2.43 (95% CI 1.21-4.87)). During follow up, 29 patients (6.3%) with sinusrhythm developed AF, this was related to inappropriate shock therapy (HR 2.83 (95% CI 1.08-7.41). Conclusion: In real-world ICD recipients, almost a third have a history of permanent or non-permanent AF, which leads to higher rates of mortality and ICD discharge. Especially permanent AF is associated with higher rates of mortality and ICD discharge (both appropriate and inappropriate). Non-permanent AF and new onset AF are associated with inappropriate ICD discharge.

Recently, several studies of cryoablation using balloon technology versus radiofrequency ablation of the pulmonary veins have shown that cryoablation of paroxysmal atrial fibrillation (PAF) promises to be an effective therapy with success rates similar to that of radiofrequency ablation. Cryothermal energy is known to be safer than other energy sources. The most frequently occurring complication of cryoablation by using a balloon is phrenic nerve palsy, which often occurs by positioning the balloon deep in a pulmonary vein (PV). We report a case of a 65-year old man with PAF in whom we performed a successful PV isolation using a 23-mm cryoballoon (Arctic Front, Medtronic Inc, Quebec Canada). The application of cryothermal energy in the left inferior PV [LIPV] was relatively deep in the PV (Figure 1A, arrows pointing to balloon [BL]). Temperatures reached 64°C. Four days after the procedure, the patient presented at the hospital with hemoptysis. A thoracic computed tomography (CT) scan showed no abnormalities. Bronchoscopy showed an erosion with blood effusion (diameter 3 to 4 mm) on the ventral side at the division of

Aims Although cardiac resynchronisation therapy (CRT) is an established treatment to improve cardiac function, a significant amount of patients do not experience noticeable improvement in their cardiac function. Optimal timing of the delay between atrial and ventricular pacing pulses (AV delay) is of major importance for effective CRT treatment and this optimum may differ between resting and exercise conditions. In this study the feasibility of haemodynamic measurements by the non-invasive finger plethysmographic method (Nexfin) was used to optimise the AV delay during exercise. Methods and results Thirty-one patients implanted with a CRT device in the last 4 years participated in the study. During rest and in exercise, stroke volume (SV) was measured using the Nexfin device for several AV delays. The optimal AV delay at rest and in exercise was determined using the least squares estimates (LSE) method. Optimisation created a clinically significant improvement in SV of 10 %. The relation between HR and the optimal AV delay was patient dependent. Conclusion A potential increase in SV of 10 % can be achieved using Nexfin for optimisation of AV delay during exercise. A considerable number of patients showed benefit with lengthening of the AV delay during exercise.