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We aimed to evaluate the association of epicardial adipose tissue (EAT) with coronary CT angiography (CCTA) plaque parameters on cardiovascular outcome in patients with and without diabetes mellitus.Data of 353 patients (62.9 ± 10.4 years, 62% male), who underwent CCTA as part of their clinical workup for the evaluation of suspected or known CAD, were retrospectively analyzed. EAT volume and plaque parameters from CCTA were compared in patients with diabetes (n = 63) and without diabetes (n = 290). Follow-up was performed to record adverse cardiovascular events. The predictive value to detect adverse cardiovascular events was assessed using concordance indices (CIs) and multivariable Cox proportional hazards analysis.In total, 33 events occurred after a median follow-up of 5.1 years. In patients with diabetes, EAT volume and plaque parameters were significantly higher than in patients without diabetes (all p 0.05). A multivariable model demonstrated an incrementally improved C-index of 0.84 (95%CI 0.80-0.88) over the Framingham risk score and single measures alone. In multivariable Cox regression analysis EAT volume (Hazard ratio[HR] 1.21, p = 0.022), obstructive CAD (HR 1.18, p = 0.042), and ≥2 high-risk plaque features (HR 2.13, p = 0.031) were associated with events in patients with diabetes and obstructive CAD (HR 1.88, p = 0.017), and Agatston calcium score (HR 1.009, p = 0.039) in patients without diabetes.EAT, as a biomarker of inflammation, and plaque parameters, as an extent of atherosclerotic CAD, are higher in patients with diabetes and are associated with increased adverse cardiovascular outcomes. These parameters may help identify patients at high risk with need for more aggressive therapeutic and preventive care.

Die neuen Leitlinien der ESC zur Diagnose und Behandlung von Vorhofflimmern setzen die vorhandenen Evidenzen aus den Ergebnissen klinischer Studien in eine klare Perspektive zur klinischen Anwendung um. Deutlich wird der generelle Trend zu einer intensiveren individuellen und personalisierten Betrachtung der Patienten mit Vorhofflimmern insbesondere in 2 Bereichen: durch die Einfuhrung der Charakterisierung von Vorhofflimmern mit dem 4S-Schema (Einbeziehung von Schlaganfallrisiko, Symptome, Vorhofflimmerlast, Substrat) als prazisere Methode im Vergleich zur seit vielen Jahren gelebten „PPP“-Klassifizierung (paroxysmal, persistierend, permanent). Dieser Zugang wird auch in den Ablationsempfehlungen sichtbar, in denen geraten wird, die Rezidivrisiken fur das Wiederauftreten von Vorhofflimmern nach einer Ablationsbehandlung bereits vor der Intervention intensiv mit in die Uberlegungen einzubeziehen. Wie schon in den 2016 ESC-Leitlinien wird die integrierte Behandlung von Patienten mit Vorhofflimmern betont und mit dem ABC-Behandlungspfad ein einfacher und intuitiver Weg aufgezeigt, um die wesentlichen Behandlungsschritte klar darzustellen: A fur „anticoagulation/avoid stroke“, B fur „better symptoms“, und C fur „comorbidities“. Auserdem werden erstmalig Empfehlungen fur Qualitatsindikatoren und fur Behandlungsbewertungen durch Patienten (sog. PROs = „patient reported outcomes“) vorgestellt. Im Bereich der Antikoagulation zur Schlaganfallpravention starken die Leitlinien den Einsatz der Nicht-Vitamin-K-Antikoagulanzien entsprechend dem individuellen Schlaganfallrisiko nach CHA2DS2-VASc, empfehlen aber auch die intensivere Beachtung der Blutungsrisiken. Aufgrund fehlender neuer Studiendaten gibt es keine Anderung der Empfehlungen fur den interventionellen Vorhofohrverschluss – es bleibt bei IIb („kann erwogen werden“). Im Bereich der frequenzregularisierenden Behandlung bleiben Kalziumantagonisten und Betablocker ggf. in Kombination mit Digitalis die erste Wahl. In der Rhythmuskontrolle findet sich fur den Bereich der medikamentosen Therapie eine nachvollziehbare Abwertung fur Sotalol aufgrund der bekannten Behandlungsrisiken. Die kurz nach Veroffentlichung der Leitlinien vorgestellte EAST-Studie wird im Hinblick auf die Bedeutung einer antiarrhythmischen Therapie in diesem Kommentar besonders diskutiert. Aufgewertet wird die Katheterablation von Vorhofflimmern in den Leitlinien insbesondere fur Patienten mit Tachykardie-induzierter schwerer Herzinsuffizienz (IB-Empfehlung), aber auch fur Patienten mit Vorhofflimmern und HFrEF bei strukturellen Herzerkrankungen (IIa-Empfehlung).

INTRODUCTION The objective was to analyze the impact of patient age on clinical characteristics, procedural results, safety, and outcome of cryoballoon ablation (CBA) as the primary approach in the interventional treatment of symptomatic atrial fibrillation (AF). METHODS AND RESULTS The single-center prospective observational study investigated consecutive patients who underwent initial left atrial ablation for symptomatic paroxysmal (PAF) or persistent AF (persAF). Age groups (A-F) of less than 40, 40-49, 50-59, 60-69, 70-79 and more than or equal to 80 years were evaluated. Follow-up (FU) included ECG, Holter monitoring and assessment of AF-symptoms. From 2012 to 2016, a total of 786 patients (64 ± 11 years, range 21-85) underwent CBA. With advancing age, more cardiovascular comorbidities and larger LA diameter were observed, more females were included (each p

Supraventrikulare Tachykardien (SVT) sind haufige und in vielen Fallen (hoch)symptomatische Herzrhythmusstorungen. Die neuen ESC-Leitlinien zum Management der SVT stellen die aktuellen Empfehlungen zur Diagnostik und Behandlung supraventrikularer Tachykardien vor. Die im Vergleich zu den letzten Leitlinien aus dem Jahr 2003 wesentlichste Anderung in den neuen Leitlinien 2019 ist fur viele Formen die deutliche Praferenz der nichtmedikamentosen Behandlung durch die Katheterablation vor der medikamentosen antiarrhythmischen Therapie zur Langzeitbehandlung. Die Katheterablation wird fur fast alle Indikationen als Klasse-I-Indikation gefuhrt, Ausnahmen sind die inadaquate Sinustachykardie, multifokale atriale Tachykardien und seltene SVT bei Erwachsenen mit angeborenen Herzfehlern (EMAH). Die elektrische Kardioversion bleibt Methode der ersten Wahl zur Akuttherapie hamodynamisch relevanter Tachykardien. Zur medikamentosen Akuttherapie werden uberwiegend Adenosin, Betarezeptorenblocker und Kalziumantagonisten vom Typ Verapamil/Diltiazem empfohlen. Auch aufgrund der auserst limitierten Daten zur Effektivitat und Behandlungssicherheit der medikamentosen antiarrhythmischen Langzeittherapie von SVT wurden die Empfehlungen und Evidenzgrade fur die pharmakologische Behandlung teilweise deutlich herabgestuft.

Background Pulmonary vein isolation is an established strategy for catheter ablation of atrial fibrillation (AF). However, in a significant number of patients, a repeat procedure is mandatory due to arrhythmia recurrence. In this study, we report safety data and procedural details of patients undergoing index ablation versus repeat ablation in a registry-based real-life setting. Methods Patients from the German Ablation Registry, a prospective, multicentre registry of patients undergoing ablation between January 2007 and January 2010 were included. Results A total of 4155 patients were enrolled in the study. Group I (index ablation) consisted of 3377/4155 (82.1%) and group II (repeat ablation) of 738/4155 (17.9%). Patients in group I had a significantly higher ratio of paroxysmal AF (69.3% vs 61.9%, p p p p 2 vs 3325 cGy × cm2, p = 0.001), and shorter study duration (181.2 min. vs 163.6 min., p p = 0.39), MACE (0.4% vs 0.3%, p = 0.58), MACCE (0.8% vs 0.6%, p = 0.47), composite safety endpoint (1.5% vs 1.4%, p = 0.76), and arrhythmia recurrence (43.8% vs 41.9%, p = 0.37) during 1-year follow-up. Both groups reported to have improved or no symptoms (80.4% vs 77.8%, p = 0.13). Conclusion Repeat catheter ablation is safe and provides a symptomatic relief comparable to index ablation. Repeat procedures are significantly shorter and use less fluoroscopy.

Aims Symptomatic atrial arrhythmias despite complete pulmonary vein isolation (PVI) are common. The purpose was to evaluate ultra-high-density multi-electrode electroanatomical mapping-guided radiofrequency ablation (RFA) in PVI non-responders. Methods and results Ultra-high-density multi-electrode electroanatomical mapping-guided RFA in consecutive symptomatic atrial fibrillation (AF) patients after initial cryoballoon PVI was performed. Patients were included if all pulmonary veins (PVs) were still isolated. Radiofrequency targets were atrial tachycardia (AT), extra-PV trigger, and/or substrate. Procedural results and outcome were evaluated. Of 95 patients, 67 (70.5%) with complete PVI were included (70 years, CHA2DS2Vasc 2.9, left atrium 45 mm, persistent AF 45%, AT 45%). The median time to reablation was 26 months. One hundred and seven maps (1.6/patient) and 11.890 ± 9.018 electrograms were acquired in 33 ± 12 min. Twenty-eight percent of the left atrial (LA) wall showed pathological voltage signals, predominantly at the anterior (37%) and septal wall (26%). Atrial tachycardia (49 left, 4 right) were ablated in 35 patients (52%), extra-PV trigger in two patients (3%). One atrioventricular nodal re-entry tachycardia and seven right atrial isthmus ablation (10%) were performed. In 32 patients (48%), no AT was present and substrate-based ablation was performed. Mean LA area ablated was 7 ± 6 cm2 (7%). No major complication occurred. The mean follow-up time was 772 ± 317 days. Freedom from atrial arrhythmia recurrence off antiarrhythmic drugs was 49% at 12 months. Conclusion Pulmonary vein isolation non-responders are older, mainly suffering from complex atrial arrhythmias. Left atrial substrate is predominantly located at the anterior and septal wall. Ultra-high-density multi-electrode electroanatomical mapping-guided RFA is safe and effective. At 1 year, 5 out of 10 patients were in stable sinus rhythm off antiarrhythmic drugs.

Registry data add important information to randomized controlled trials (RCT) on real-life aspects of implantable cardioverter-defibrillator (ICD) patients with and without cardiac resynchronization therapy (CRT-D). This analysis of the prospectively conducted German Device Registry aims at comparing mortality rates, comorbidities, complication rates to results from RCT.The German Device registry (DEVICE) prospectively collected data on ICD and CRT-D first implantations from 50 German centres. Demographic data, details on cardiac disease, electrocardiogram (ECG), medication, and data about procedure, complications, and hospital stay were stored in electronic case report forms. One year after device implantation patients were contacted for follow-up.DEVICE included n = 4384 first ICD/CRT-D implantations (29.3% CRT-D devices). We found a strong adherence to guidelines with over 90% of patients being on ß-blocker and ACE-inhibitor medication and adequate QRS width in the majority of CRT-D patients. Patients receiving a CRT-D were older (67.6 ± 11.0 years vs. 63.9 ± 13.4 years, p .001) and had lower ejection fractions (mean 25% vs. 30%, p .001) compared to ICD patients. Dilated cardiomyopathy was the predominant underlying heart disease in CRT-D (53.3%), coronary artery disease in ICD patients (64.7%). Compared to RCT our DEVICE patients had more comorbidities (17.9% chronic kidney disease [CKD]) and higher 1-year mortality rates (10.7% ICD group, 12.3% CRT group). In multivariate analysis, CKD patients had an almost 2-fold higher risk of 1-year mortality.Despite relevant limitations of registry data, DEVICE highlights important differences between RCT and real-world registry data and the impact of comorbidities on mortality of ICD and CRT-D recipients.

PURPOSE To investigate the long-term prognostic value of coronary computed tomography angiography (cCTA)-derived plaque information on major adverse cardiac events (MACE) in patients with and without diabetes mellitus. MATERIALS AND METHODS In all, 64 patients with diabetes (63.3±10.1 y, 66% male) and suspected coronary artery disease who underwent cCTA were matched with 297 patients without diabetes according to age, sex, cardiovascular risk factors, and statin and antithrombotic therapy. MACE were recorded. cCTA-derived risk scores and plaque measures were assessed. The discriminatory power to identify MACE was evaluated using multivariable regression analysis and concordance indices. RESULTS After a median follow-up of 5.4 years, MACE occurred in 31 patients (8.6%). In patients with diabetes, cCTA risk scores and plaque measures were significantly higher compared with nondiabetic patients (all P

Background Data on the optimal treatment strategy for antiarrhythmic drug therapy (AAD) after atrial fibrillation (AF) catheter ablation are inconsistent. While AAD potentially stabilizes sinus rhythm, it also increases the patients' treatment burden. Methods Patients from the prospective German Ablation Registry (n=3275) discharged with or without AAD after AF catheter ablation were compared regarding long-term success, cardiovascular events and patient reported outcome. Results In patients with paroxysmal AF (n=2138) recurrence and rehospitalization rates did not differ when discharged with (n=1051) or without (n=1087) AAD (recurrence: adjusted odds ratio (OR) 1.13, 95% confidence interval (CI) [0.95–1.35]; rehospitalization: OR 1.08, 95% CI [0.90–1.30]). The reablation rate was higher and reduced treatment satisfaction was reported more often in those discharged with AAD (reablation: OR 1.30, 95% CI [1.05–1.61]; reduced treatment satisfaction: OR 1.76, 95% CI [1.20–2.58]). Similar rates of recurrences, rehospitalisations, reablations and treatment satisfaction were found in patients with persistent AF (n=1137) discharged with (n=641) or without (n=496) AAD (recurrence: OR 1.22, 95% CI [0.95–1.56]; rehospitalization: OR 1.16, 95% CI [0.90–1.50]; reablation: OR 1.21, 95% CI [0.91–1.61]; treatment satisfaction: OR 1.24, 95% CI [0.74–2.08]). The incidence of cardiovascular events and mortality did not differ at follow-up in paroxysmal and persistent AF patients discharged with or without AAD. Conclusion The rates of recurrences, cardiovascular events and mortality did not differ between patients discharged with or without AAD after AF catheter ablation. However, AAD should be considered carefully in patients with paroxysmal AF, in whom it was associated with a higher reablation rate and reduced treatment satisfaction. Funding Acknowledgement Type of funding sources: None.

Background Left atrial appendage (LAA) is a potential source of atrial fibrillation (AF) triggers. Hypothesis LAA morphology and dimensions are associated with AF recurrence after pulmonary vein isolation (PVI). Methods From cardiac computed tomography angiography (CCTA), left atrial (LA), pulmonary vein (PV), and LAA anatomy were assessed in cryoballoon ablation (CBA) patients. Results Among 1103 patients undergoing second‐generation CBA, 725 (65.7%) received CCTA with 473 (42.9%) qualifying for detailed LAA analysis (66.3 ± 9.5 years). Symptomatic AF reoccurred in 166 (35.1%) patients during a median follow‐up of 19 months. Independent predictors of recurrence were LA volume, female sex, and mitral regurgitation ≥°II. LAA volume and AF‐type were dependent predictors of recurrence due to their strong correlations with LA volume. LA volumes ≥122.7 ml (sensitivity 0.53, specificity 0.69, area under the curve [AUC] 0.63) and LAA volumes ≥11.25 ml (sensitivity 0.39, specificity 0.79, AUC 0.59) were associated with recurrence. LA volume was significantly smaller in females. LAA volumes showed no sex‐specific difference. LAA morphology, classified as windsock (51.4%), chicken‐wing (20.7%), cactus (12.5%), and cauliflower‐type (15.2%), did not predict successful PVI (log‐rank; p = 0.596). Conclusions LAA volume was strongly correlated to LA volume and was a dependent predictor of recurrence after CBA. Main independent predictors were LA volume, female sex, and mitral regurgitation ≥°II. Gender differences in LA volumes were observed. Individual LAA morphology was not associated with AF recurrence after cryo‐PVI. Our results indicate that preprocedural CCTA might be a useful imaging modality to evaluate ablation strategies for patients with recurrences despite successful PVI.

OBJECTIVES Left ventricular (LV) hypertrophy in resistant hypertensive patients is associated with a reduced intramyocardial perfusion. Renal sympathetic denervation (RDN) has been shown to reduce blood pressure (BP) and sympathetic tone. We aimed to prospectively investigate the effect of RDN on functional myocardial parameters and myocardial perfusion reserve (MPR) using cardiac magnetic resonance imaging (cMRI) in patients with resistant hypertension. METHODS A total of 15 resistant hypertensive patients (11 male individuals, mean age 62±13 y) were included. Adenosine stress-induced cMRI was performed at baseline, 3, 6, and 12 months after RDN. RDN was performed using a single soft-tip radiofrequency catheter (Symplicity). cMRI semiquantitative perfusion analysis was performed using the upslope of myocardial signal enhancement to derive the myocardial perfusion reserve index. RESULTS Both systolic-BP and diastolic-BP significantly decreased from 148±14 to 133±14 mm Hg and 87±14 to 80±10 mm Hg, respectively (P

Aims To evaluate the effectiveness and safety of cryoballoon ablation (CBA) compared with radiofrequency ablation (RFA) for symptomatic paroxysmal or drug-refractory persistent atrial fibrillation (AF). Methods and results Prospective cluster cohort study in experienced CBA and RFA centres. Primary endpoint was ‘atrial arrhythmia recurrence’, secondary endpoints were as follows: procedural results, safety, and clinical course. A total of 4189 patients were included: CBA 2329 (55.6%) and RFA 1860 (44.4%). Cryoballoon ablation population was younger, with fewer comorbidities. Procedure time was longer in the RFA group (P = 0.01). Radiation exposure was 2487 (CBA) and 1792 cGycm2 (RFA) (P Conclusions The primary endpoint did not differ between CBA and RFA. Cryoballoon ablation was completed rapidly; the radiation exposure was greater. Rehospitalization due to re-ablations and adverse events during follow-up were observed significantly less frequently after CBA than after RFA. Subgroup analysis suggested a lower risk of recurrence after CBA in paroxysmal AF. Trial Registration ClinicalTrials.gov (NCT01360008), https://clinicaltrials.gov/ct2/show/NCT01360008.

To capture the overall dynamics of urbanisation in the research space of FOR2432, this study tracks the land cover changes within the two transects across the rural–urban interface of Bengaluru. It covers a retrospective period of almost three decades, with observations in 1992, 2000, 2011, and 2016, based on Landsat and Sentinel satellite images, and aims at unravelling the dynamics of land use change as a prelude to deeper explorations of its drives. The spatio-temporal analysis of broad land cover classes relates it to the agricultural activities described in subsequent chapters of this volume, while for built-up land cover the focus lies on urban sprawl and the evolution of the Survey Stratification Index (SSI). The results underpin that the loss of vegetated and agricultural area increases both, along a spatial gradient towards the city, and over time. The spatial urbanisation pattern described by the SSI remains rather stable if data are aggregated over rural, transitional, and urban regions, or over six predefined strata, while individual villages show pronounced shifts in the SSI, that characterise them as nuclei of urbanisation. Characteristics of the “urban fringe” are highly variable between successive land cover classifications and have high dynamics of change.

Field margins are areas of natural or semi-natural vegetation located adjacent to agricultural fields. They form the interface between different crops and to other land use and land cover types. In most analyses of cropping patterns field margin vegetation (FMV) is neither accounted for nor is it a part of so-called natural ecosystems. Nevertheless, FMV provides important ecosystem services, is integrated in the farming practices of traditional smallholder agriculture, and contributes to farmers’ income. The area, composition and functions of FMV change as agroecosystems are transformed under progressing urbanisation, as encountered in the periphery of Bengaluru, India. This study is a first attempt to systematically assess FMV in such a context. It focuses on different characteristics of FMV along a spatial rural–urban gradient, and its interrelation with changes in crop and farm management.

Urbanisation is a global trend and a major challenge to human societies as well as to the planetary environment and resource pools, and the research landscape related to these issues is accordingly large and diverse. The collaborative Indo-German research project FOR2432 tackles urbanisation-related transformations by an interdisciplinary approach focused on the South Indian metropolitan area of Bengaluru. This editorial sketches the overarching research design, to which most of the book chapters refer, and describes some baseline characteristics of the research space. It thus illustrates the common background for the specific topics and targets of the subsequent studies collated in this volume.

Rural–urban transformation has major implications on agricultural land use. This is also the case in the southern Indian city of Bengaluru, where farmers shift from low intensity subsistence agriculture under rainfed conditions to irrigated, market-oriented production of crops and vegetables. As little is known about the effects of this intensification on water use, nutrient leaching, losses of carbon and nitrogen, and soil quality, a long-term experiment was established under well-defined on-station conditions to generate a typical intensity gradient in an in situ laboratory of change. Measurements of key agronomic, soil-related, and meteorological parameters at high temporal and spatial resolution allow to assess externalities and efficiencies of resource use and to predict long-term consequences of intensification on agricultural sustainability. The two long-term rotation experiments established under rainfed and irrigated conditions also allow to collect and calibrate ground-based multi- and hyperspectral crop reflectance data needed for upscaling to high resolution satellite images that cover a North–South research transect across the rural–urban interface of Bengaluru.

This editorial concludes the volume by reviewing the key findings of the contributions and putting them in context to each other. It highlights the challenges and merits of interdisciplinary approaches and sketches an outlook for future research.

Background: Hypertension (HTN) constitutes a risk factor for the development of atrial fibrillation (AF), as well as for thromboembolic and bleeding events. We analysed the outcome after catheter ablation of AF in HTN in a cohort from the prospective multicenter German Ablation Registry. Methods: Between 03/2008 and 01/2010, 626 patients undergoing AF-ablation were analysed. Patients diagnosed with HTN (n = 386) were compared with patients without HTN (n = 240) with respect to baseline, procedural and long-term outcome parameters. Results: Patients with HTN were older and more often presented with persistent forms of AF and cardiac comorbidities. Major and moderate in-hospital complications were low. At long-term follow-up, major cardiovascular events were rare in both groups. Rates of AF-recurrence, freedom from antiarrhythmic medication and repeat ablation were not statistically different between groups. Most patients reported improvement of symptoms and satisfaction with the treatment. However, patients with HTN more frequently complained of dyspnea of New York Heart Association (NYHA) class &ge, II and angina. They were more often rehospitalized, particularly when persistent AF had been diagnosed. Conclusion: Catheter ablation of AF is associated with low complication rates and favorable arrhythmia-related results in patients with HTN. Residual clinical symptoms may be due to cardiac comorbidities and require additional attention in this important subgroup of AF-patients.

Purpose Increased angiogenesis after myocardial infarction is considered an important favorable prognostic parameter. The αvβ3 integrin is a key mediator of cell-cell and cell-matrix interactions and an important molecular target for imaging of neovasculature and repair processes after MI. Thus, imaging of αvβ3 expression might provide a novel biomarker for assessment of myocardial angiogenesis as a prognostic marker of left ventricular remodeling after MI. Currently, there is limited data available regarding the association of myocardial blood flow and αvβ3 integrin expression after myocardial infarction in humans. Methods Twelve patients were examined 31 ± 14 days after MI with PET/CT using [18F]Galacto-RGD and [13N]NH3 and with cardiac MRI including late enhancement on the same day. Normal myocardium (remote) and areas of infarction (lesion) were identified on the [18F]Galacto-RGD PET/CT images by correlation with [13N]NH3 PET and cardiac MRI. Lesion/liver-, lesion/blood-, and lesion/remote ratios were calculated. Blood flow and [18F]Galacto-RGD uptake were quantified and correlated for each myocardial segment (AHA 17-segment model). Results In 5 patients, increased [18F]Galacto-RGD uptake was notable within or adjacent to the infarction areas with a lesion/remote ratio of 46% (26–83%; lesion/blood 1.15 ± 0.06; lesion/liver 0.61 ± 0.18). [18F]Galacto-RGD uptake correlated significantly with infarct size (R = 0.73; p = 0.016). Moreover, it correlated significantly with restricted blood flow for all myocardial segments (R = − 0.39; p R = − 0.75; p Conclusion [18F]Galacto-RGD PET/CT allows the visualization and quantification of myocardial αvβ3 expression as a key player in angiogenesis in a subset of patients after MI. αvβ3 expression was more pronounced in patients with larger infarcts and was generally more intense but not restricted to areas with more impaired blood flow, proving that tracer uptake was largely independent of unspecific perfusion effects. Based on these promising results, larger prospective studies are warranted to evaluate the potential of αvβ3 imaging for assessment of myocardial angiogenesis and prediction of ventricular remodeling.

Even among biomarker-negative patients undergoing elective percutaneous coronary intervention (PCI), periprocedural thrombotic and bleeding complications can lead to increased morbidity and mortality. Whether stronger platelet inhibition by an intensified oral loading strategy (ILS) before PCI impacts on outcomes among these patients in contemporary practice remains unclear.This multicenter, randomized, assessor-blinded trial tested the hypothesis that in elective PCI prasugrel 60 mg (ILS) is superior to standard loading strategy with clopidogrel 600 mg regarding a composite primary end point of all-cause death, any myocardial infarction, definite/probable stent thrombosis, stroke, or urgent vessel revascularization. After PCI, all patients were on clopidogrel 75 mg/day and aspirin. The trial was terminated prematurely because of slower-than-expected recruitment and funding discontinuation.Of 781 patients included in the final analysis, 382 were assigned to ILS and 399 to standard loading strategy. At 30 days, the primary end point occurred in 66 patients (17.3%) assigned to ILS and 74 patients (18.6%) assigned to standard loading strategy (odds ratio, 0.92 [95% CI, 0.63-1.32];In biomarker-negative stable and unstable angina patients undergoing elective PCI, the trial did not find a conclusive difference in efficacy or safety. This observation should be interpreted in the context of wide CIs and premature termination of the trial. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02548611.

Background: Even among biomarker-negative patients undergoing elective percutaneous coronary intervention (PCI), periprocedural thrombotic and bleeding complications can lead to increased morbidity and mortality. Whether stronger platelet inhibition by an intensified oral loading strategy (ILS) before PCI impacts on outcomes among these patients in contemporary practice remains unclear. Methods: This multicenter, randomized, assessor-blinded trial tested the hypothesis that in elective PCI prasugrel 60 mg (ILS) is superior to standard loading strategy with clopidogrel 600 mg regarding a composite primary end point of all-cause death, any myocardial infarction, definite/probable stent thrombosis, stroke, or urgent vessel revascularization. After PCI, all patients were on clopidogrel 75 mg/day and aspirin. The trial was terminated prematurely because of slower-than-expected recruitment and funding discontinuation. Results: Of 781 patients included in the final analysis, 382 were assigned to ILS and 399 to standard loading strategy. At 30 days, the primary end point occurred in 66 patients (17.3%) assigned to ILS and 74 patients (18.6%) assigned to standard loading strategy (odds ratio, 0.92 [95% CI, 0.63–1.32]; P =0.64). Any myocardial infarction and Bleeding Academic Research Consortium ≥2 bleeding rates were similar among ILS and standard loading strategy groups 16.2% versus 17.5%, odds ratio, 0.91 (95% CI, 0.62–1.32), P =0.62 and 4.2% versus 4.8%, odds ratio 0.87 (95% CI, 0.44–1.73), P =0.70, respectively. Conclusions: In biomarker-negative stable and unstable angina patients undergoing elective PCI, the trial did not find a conclusive difference in efficacy or safety. This observation should be interpreted in the context of wide CIs and premature termination of the trial. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02548611.

To evaluate the long-term prognostic value of coronary CT angiography (cCTA)-derived plaque measures and clinical parameters on major adverse cardiac events (MACE) using machine learning (ML). Datasets of 361 patients (61.9 ± 10.3 years, 65% male) with suspected coronary artery disease (CAD) who underwent cCTA were retrospectively analyzed. MACE was recorded. cCTA-derived adverse plaque features and conventional CT risk scores together with cardiovascular risk factors were provided to a ML model to predict MACE. A boosted ensemble algorithm (RUSBoost) utilizing decision trees as weak learners with repeated nested cross-validation to train and validate the model was used. Performance of the ML model was calculated using the area under the curve (AUC). MACE was observed in 31 patients (8.6%) after a median follow-up of 5.4 years. Discriminatory power was significantly higher for the ML model (AUC 0.96 [95%CI 0.93–0.98]) compared with conventional CT risk scores including Agatston calcium score (AUC 0.84 [95%CI 0.80–0.87]), segment involvement score (AUC 0.88 [95%CI 0.84–0.91]), and segment stenosis score (AUC 0.89 [95%CI 0.86–0.92], all p

Field margin vegetation (FMV) refers to the plant community in the interface between agriculture and natural environments. Substantial work has been carried out on the management of field margins in European countries with the aim of conserving field-level biodiversity and enhancing agronomic benefits. India, instead, is lagging behind in the assessment of FMV and formulating subsequent management strategies for biodiversity conservation at the field boundaries. This study is a first step to better understand the structural and functional dimensions of field margin vegetation along an agricultural transformation gradient near the megacity of Bengaluru, India. Empirical field studies along with the detection of vegetation change using remote sensing and geo-informatics technique were used to record information on field margin vegetation. The phytosociological study, revealed a total of 81 species, comprising 29 species of trees, 21 shrubs and 31 herbs at the field margins of six selected villages of northern Bengaluru. Randomly selected 355 field boundaries were delineated from high-resolution Worldview 3 images for the year 2018 and from Google Earth images for the year 2004–2005. The FMV area was around to 85.40 ha in 2004–2005 but declined to 76.69 ha in 2017–2018. The survey also indicated that local farmers have in-depth ecological knowledge on the importance of FMV in ensuring a sustainable flow of resources within the agricultural landscape. The results demonstrate that rural and transition zones of the study area have higher dominance of planted tree species on the margins, whereas urban zone exhibits comparatively uniform dominance for all species. Our study also highlights the need for conservation of FMV to ensure agroecosystem health as a prerequisite for sustainable socioecological development.

Die kardiale Computertomographie mit Kalziumscoring zur Quantifizierung des Koronarkalks und kontrastmittelgestutzter CT-Angiographie (cCTA) zur nichtinvasiven morphologischen und funktionellen Beurteilung von Koronarstenosen ist ein etabliertes Verfahren in der Diagnostik der koronaren Herzerkrankung (KHK) und der zielgerichteten interventionellen Behandlung. Die kardiale Computertomographie eignet sich bei Patienten mit niedriger bis intermediarer Vortestwahrscheinlichkeit zur Risikostratifizierung (Kalziumscoring) und zum Ausschluss einer KHK mittels cCTA. Die rein anatomische Darstellung von Koronarstenosen kann zukunftig durch funktionelle Analysen aufgrund neuer technischer Entwicklungen erganzt werden und erlaubt somit neben einer morphologischen Beurteilung eine Aussage uber die hamodynamische Signifikanz von Koronarstenosen. Durch die vielversprechende kombinierte anatomische und funktionelle Diagnostik konnte der kardialen Computertomographie in Zukunft eine wesentliche Gatekeeper-Funktion hinsichtlich der Indikationsstellung fur Koronarinterventionen zukommen.

Catheter ablation (CA) for atrial fibrillation (AF) has emerged as a widespread first or second line treatment option. However, up to 45% of patients (pts) show recurrence of AF within 12 month after CA. We present prospective multicenter registry data comparing characteristics of pts with and without recurrence of AF within the first year after CA. This study comprises all pts with complete follow-up one year after CA (1-y-FU; n = 3679). During 1y-FU in 1687 (45.9%) pts recurrence of AF occurred. The multivariate analysis revealed female sex and AF type prior to the procedure as predictors for AF recurrence. Furthermore, comorbidities such as valvular heart disease and renal failure as well as an early AF relapse were also predictors of AF recurrence during 1-y-FU. However, despite an AF recurrence rate of 45.9%, the majority of these pts (72.4%) reported a significant alleviation of clinical symptoms. In conclusion in pts with initially successful CA for AF female sex, AF type, in-hospital AF relapse and comorbidities such as renal failure and valvular heart disease are independent predictors for AF recurrence during 1-y-FU. However, the majority of pts deemed their interventions as successful with significant reduction of symptoms irrespective of AF.

We investigated the impact of iterative beam-hardening correction (IBHC) with advanced modeled iterative reconstruction (ADMIRE) of ultra-low radiation-dose tin filtered (Sn100 kVp) CACS acquisitions on image quality, calcium quantification, and risk classification.CT data of 60 patients (55% male, age 62.3 ± 9.8years) who underwent a 3rd generation dual-source CACS scan using a prospectively ECG-triggered 100 kVp sequential acquisition protocol with tin filtration (Sn100 kVp) were reconstructed using IBHC with filtered back projection (FBP) and ADMIRE with strength levels of three and five. Image noise was calculated and Agatston scores were derived from all reconstructions. Image noise, Agatston score categories, and percentile-based cardiac risk categorization of the respective reconstruction techniques were compared.The mean estimated radiation dose equivalent of CACS acquisitions in the study population was 0.20 ± 0.07 mSv. Mean image noise significantly decreased with ADMIRE compared to FBP (both p 0.0001). Agatston scores derived from the respective reconstructions were significantly different in a paired comparison (median [25th and 75th percentile]): FBP 34.7 [1.9, 153.6], ADMIRE 3 28.6 [1.1, 134.5], ADMIRE 5 22.7 [0.3, 116.8]; both p 0.0001). Agatston score categories and cardiac risk categorization showed excellent agreement of ADMIRE 3 and ADMIRE 5 with FBP (ĸ = 0.92 [0.86-0.98] and ĸ = 0.86 [0.79-0.94]; ĸ = 0.94 [0.87-1.00] and ĸ = 0.91 [0.83-0.99]; however, modest cardiac risk reclassifications of 3% and 7% for ADMIRE 3 and ADMIRE 5, respectively, were observed.Iterative reconstruction using IBHC ADMIRE in low voltage, ultra-low dose CACS with tin filtration significantly decreased image noise. However, it also reduced Agatston scores compared to FBP, which may have an impact on subsequent cardiac risk classification, although risk reclassification occurred only in a modest number of subjects.

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.

This study investigated the discriminatory value of quantitative atherosclerotic plaque markers derived from coronary computed tomography angiography (cCTA) in patients with first acute coronary syndrome (ACS) compared with patients with stable coronary artery disease (CAD). Forty patients (56.9 ± 9.3 years, 55% men) admitted with their first ACS and Framingham risk score-matched controls with stable CAD were retrospectively analyzed. All patients had undergone cCTA followed by invasive coronary angiography. Total plaque volume, calcified and noncalcified plaque volumes, plaque burden (in %), remodeling index, lesion length, presence of napkin-ring sign, segment involvement score, and segment stenosis score were derived from cCTA and compared between both groups on a per-lesion and per-patient level. Patients with ACS showed a significant higher number of obstructive CAD and higher values for segment stenosis score, segment involvement score, noncalcified plaque volume, lesion length, and remodeling index than the stable angina group (all p0.05). On a per-lesion level, culprit lesions had significantly higher values for plaque burden, total plaque volume, noncalcified plaque volume, remodeling index, lesion length, and prevalence of napkin-ring sign in comparison to nonculprit lesions (all p0.05). On receiver-operating characteristics (ROC) analysis, a stepwise model demonstrated incremental discriminatory power for identifying ACS both per-patient (area under the curve 0.92, p0.0001) as well as per-lesion (area under the curve 0.88, p0.0001). cCTA-derived culprit plaque markers show discriminatory value both on a per-patient and per-lesion level. A combination of markers added to the Framingham risk score yields the greatest discriminatory ability.

Background In the ICD Sports Safety Registry, death, arrhythmia- or shock-related physical injury did not occur in athletes who continue competitive sports after implantable cardioverter-defibrillator (ICD) implantation. However, data from non-competitive ICD recipients is lacking. This report describes arrhythmic events and lead performance in intensive recreational athletes with ICDs enrolled in the European recreational arm of the Registry, and compares their outcome with those of the competitive athletes in the Registry. Methods The Registry recruited 317 competitive athletes ≥ 18 years old, receiving an ICD for primary or secondary prevention (234 US; 83 non-US). In Europe, Israel and Australia only, an additional cohort of 80 ‘auto-competitive’ recreational athletes was also included, engaged in intense physical activity on a regular basis (≥2×/week and/or ≥ 2 h/week) with the explicit aim to improve their physical performance limits. Athletes were followed for a median of 44 and 49 months, respectively. ICD shock data and clinical outcomes were adjudicated by three electrophysiologists. Results Compared with competitive athletes, recreational athletes were older (median 44 vs. 37 years; p = 0.0004), more frequently men (79% vs. 68%; p = 0.06), with less idiopathic ventricular fibrillation or catecholaminergic polymorphic ventricular tachycardia (1.3% vs. 15.4%), less congenital heart disease (1.3% vs. 6.9%) and more arrhythmogenic right ventricular cardiomyopathy (23.8% vs. 13.6%) ( p Conclusions Participants in recreational sports had less frequent appropriate and inappropriate shocks during physical activity than participants in competitive sports. Shocks did not cause death or injury. Recreational athletes with ICDs can engage in sports without severe adverse outcomes unless other reasons preclude continuation.

Age-Related Complication Rates in AF AblationIntroduction Despite a rising demand for catheter ablation (CA) of atrial fibrillation (AF) in an elderly population, complication and success rates are not fully elucidated. We sought to compare complication rates of CA of AF in patients ≥75 versus

Background Different catheter ablation (CA) strategies have been established in the treatment of persistent atrial fibrillation (persAF). Pulmonary vein isolation (PVI) only might be an option for the initial ablation procedure. There is a paucity of outcome data on second-generation cryoballoon (CBG2) PVI in persAF. Methods Patients with symptomatic drug-refractory persAF who underwent initial CA of AF were prospectively enrolled and PVI was performed with CBG2. The primary composite endpoint was freedom from AF, atrial tachycardia, or related symptoms after a 3-month blanking period. The secondary endpoint referred to periprocedural complications. Results One hundred seventy-three consecutive patients (64 ± 10 years, 29% female) with symptomatic drug-refractory persAF were identified. Acute PVI was achieved in 100% of pulmonary veins with the CB technique. The left atrial procedure time was 112 ± 30 min. Major complications occurred in 1.7% (3 of 173 patients) including two phrenic nerve palsies (1%), which resolved until discharge, and one pericardial effusion (0.6%). Follow-up ≥12 months was completed for 157 of 173 patients (91%). Median follow-up was 14 months. At 12 months, the primary composite endpoint was achieved in 129 of 157 patients (82%). However, 22 of 129 patients at risk (17%) were still on antiarrhythmic drugs. A relapse during the blanking period was identified as the only independent predictor for AF recurrence. Conclusion PVI using the second-generation cryoballoon is a reasonable treatment option for patients with symptomatic drug-refractory persAF with a favorable rate of freedom from AF and a low complication rate.

Objective: To evaluate quantitative markers derived from coronary CT angiography (coronary CTA) performed prior to percutaneous coronary intervention (PCI) with stent placement for predicting in-stent restenosis (ISR) as defined by quantitative coronary angiography (QCA).Materials and methods: We retrospectively analyzed the data of 74 patients (60 +/- 12 years, 72% male) who had undergone dual-source coronary CTA within 3 months prior to a PCI procedure that included stent placement. Quantitative markers of the target vessel were derived from coronary CTA: Total plaque volume (TPV), calcified and non-calcified plaque volumes (CPV and NCPV), plaque burden (PB in %), remodeling index (RI), and lesion length (LL). Marker performance for predicting ISR, as defined by QCA at follow-up, was assessed.Results: Twenty-one of 74 stented lesions showed ISR on follow-up (mean 616 +/- 447 days). When comparing stent length and LL in patients with ISR, a trend towards less complete stent coverage of the target lesion was observed in cases with ISR (17/21 vs. 4/53 cases, p = 0.07). In multivariate analysis (corrected for dyslipidemia), the following markers showed predictive value for ISR (odds ratio [OR]): NCPV (OR 1.08, p = 0.045), LL (OR 138, p = 0.0024), and RI (OR 1.13, p = 0.0019). Sensitivity and specificity for ISR were: NCPV 65% and 80%, LL 74% and 74%, and RI 71% and 78%. At receiver-operating characteristics analysis, NCPV (0.72, p = 0.001), LL (0.77, p Conclusion: Coronary CTA-derived NCPV, LL, and RI portend predictive value for ISR with incremental predictive value when combining these parameters. (C) 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Stratification of patients with atrial fibrillation (AF) according to mechanistic and prognostic criteria may optimize the effectiveness and safety of catheter ablation. In women, AF is associated with more severe symptoms and worse prognosis.We sought to assess sex-related differences in catheter ablation procedures and outcome in a large cohort of patients with AF.A total of 3652 patients (1198 women [33%]; 2454 men [67%]) included in the German Ablation Registry were analyzed. Periprocedural parameters and outcome at 12-month follow-up were compared between male and female patients.Women were older at the time of ablation (women: 63.6 years; men: 59.1 years; P.0001) and exhibited a higher prevalence of paroxysmal AF (women: 72%; men: 61%; P.0001). They were less often affected by cardiovascular disease and reduced left ventricular function. Energy application duration and overall procedure duration were shorter in women. Conversely, the rate of major inhospital complications was increased in female patients (1.9% vs 0.8%; P = .023) and mainly driven by major bleeding events. At follow-up, women experienced higher AF recurrence rates (women: 50%; men: 45%; P = .017) and more often received oral medication for rhythm and rate control. In addition, the rate of pacemaker implantation was higher in the female cohort. Women more frequently reported femoral access site complications (women: 6%; men: 3%; P.001). Overall, male patients were more often free from AF-related symptoms and satisfied with the treatment.Catheter ablation of AF was associated with a distinct sex-related outcome and complication profile that requires consideration in clinical practice.

Background Autologous progenitor cell therapy comprising granulocyte-colony stimulating factor (G-CSF) for mobilization of bone-marrow derived progenitor cells (BMPCs) into peripheral blood and inhibition of dipeptidylpeptidase-IV by sitagliptin for enhanced myocardial recruitment of circulating BMPCs has been shown to improve survival after acute myocardial infarction (MI) in preclinical studies. In the SITAGRAMI trial we found that during short-term follow-up G-CSF plus sitagliptin (GS) failed to show a beneficial effect on cardiac function and clinical events in patients with acute MI that underwent successful PCI. The objective of the present analysis was to assess the impact of GS versus placebo treatment on long-term clinical outcomes of the SITAGRAMI trial patient population. Methods In the randomized, prospective, double-blind, placebo-controlled SITAGRAMI trial, 174 patients with acute MI were assigned to GS or placebo in a 1:1 ratio. The primary outcome for the present long-term analysis was the composite of death, MI or stroke on long-term follow-up. Results The median [IQR] follow-up duration was 4.50 [3.56–5.95] years. The primary outcome occurred in 12.8% of patients assigned to placebo and 9.2% assigned to GS (HR 0.69, 95% CI 0.28–1.69; p=0.42). The incidence of the combined cardiovascular outcome was 47.7% in the placebo- and 41.4% in the GS-group (HR 0.75, 95% CI 0.48–1.18; p=0.21). Overall, there was no significant difference in MACCE rates between both treatment groups (p=0.41). Conclusion These long-term follow-up data indicate that GS therapy does not improve clinical outcomes of patients with acute MI.

Background Although radiofrequency (RF) ablation has long been the standard of care for atrial fibrillation (AF) ablation, cryoballoon technology has emerged as a feasible approach with promising results. Prospective multicenter registry data referring to both ablation technologies in AF ablation are lacking so far. Objective The purpose of this study was to report data from the German ablation registry with respect to efficacy and safety in pulmonary vein ablation with different energy sources for paroxysmal AF after 1-year follow-up. Methods A total of 2306 patients with symptomatic paroxysmal AF from the German ablation registry were included in this analysis. The cohort was divided into two groups according to the ablation energy source used: cryoballoon and RF ablation. MACCE was defined as a combination of death, myocardial infarction, or stroke. Results AF recurrence rate after a single ablation procedure at 1 year follow-up was not significantly different between the two groups (45.8% after cryoablation and 45.4% after RF ablation, P = .87). Also, the rate of patients without AF recurrence and free of antiarrhythmic drug at 12-month follow-up was similar (cryoablation 44.2% and RF 41.4%, P = .25). MACCE occurred with an incidence of 0.7% within 500 days after cryoablation and 1.4% after RF ablation ( P = .30). Persistent phrenic nerve palsy was more common after cryoablation compared to RF ablation (1.1% vs 0.3%, P Conclusion AF recurrence rate at 1-year follow-up was similar in RF ablation compared to cryoablation, whereas the spectrum and relevance of complications were significantly different between the two ablation methods. This finding might influence the choice of ablation method offered to the individual paroxysmal AF patient.

Introduction Time-to-isolation (TTI) guided ablation protocols have been developed to ensure durable pulmonary vein isolation (PVI) in cryoballoon ablation (CBA). The aim was to determine the feasibility and safety of the fourth generation cryoballoon (CBG4) with a shortened tip. Methods and results Consecutive patients scheduled for initial atrial fibrillation (AF) ablation were prospectively included. PVI with the 28 mm CBG4 and the latest 20 mm spiral-mapping catheter (SMC) was performed. A total of 302 pulmonary veins (PVs) in 76 patients (64.8 ± 10.4 years, paroxysmal AF 49%) were treated with 617 applications. Left atrium (LA) time, fluoroscopy time, and dose-area product were 65.5 ± 19.2 minutes, 14.6 ± 5.6 minutes, and 1094 (738; 2097) cGy·cm2 , respectively. PVI in cryoballoon technique was achieved in 302 of 302 (100%) PVs. TTI was determined in 256 (84.8%) of PVs. The mean TTI was 45.3 ± 26.4 seconds. Single-shot isolation was achieved in 247 (82%) PVs. In 6 of 302 (2.0%) PV the SMC was changed to a stiff wire to isolate the PV because of instability, and in 17 of 302 (5.6%) of PVs, the 23 mm CB was used to isolate. No radiofrequency touch-up applications were applied. The mean nadir balloon temperature was -44.8°C ± 6.6°C. Balloon dislodgement during positioning occurred in 3 of 617 (0.5%) applications without complications. One PN palsy occurred which resolved until discharge. One patient suffered from the inflammatory syndrome. Conclusion The CBG4 with a shorter distal tip seems to be safe and effective, and allows determining the TTI in 84.8% of PVs. In case of balloon instability, the exchange of the SMC to a stiff wire or, in small PV, the 23 mm cryoballoon facilitate PVI.

According to current guidelines prophylactic implantable cardioverter-defibrillator (ICD) therapy is recommended in patients with significantly impaired left ventricular systolic function. However, the recently published DANISH trial did not find a significantly lower long-term rate of death from any cause compared with usual clinical care in patients with non-ischemic cardiomyopathy. We investigated whether registry data from a multi-center ‘real-life’ registry on patients with non-ischemic cardiomyopathy are similar to this trial. The German Device Registry (DEVICE) is a nationwide, prospective registry with one-year follow-up investigating 5451 patients receiving device implantations in 50 German centers. The present analysis of DEVICE focused on patients with non-ischemic cardiomyopathy and a left ventricular ejection fraction ≤35% who received a prophylactic ICD. Out of 779 patients with symptomatic heart failure and nonischemic cardiomyopathy, 33.1% received a single chamber ICD (VVI), while 11.0% were implanted with a dual-chamber ICD (DDD), and 55.8% received a defibrillator system for cardiac resynchronization therapy. Median follow-up was 16.1 months. 90.7% were alive at follow-up, 9.3% had died during this period. Overall mortality after one year was 5.4%. Overall mortality one year after implantation was significantly increased in patients 68 years and older(7.9%) as compared to younger patients (59–68 years: 2.5%; < 59 years: 3.8%; p