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Purpose: To report survival rates in patients treated with pulmonary vein antrum isolation (PVAI), atrioventricular junctional ablation (AVJA), and antiarrhythmic and direct current cardioversion (A+DCCV) at 7 years follow-up.Methods: From February 2002-December 2004, 1,000 consecutive patients underwent PVAI or A+DCCV or AVJA. These patients were matched in a nested casecontrolled methodology. Survival rates were compared at the end of 7 years.Results: Three hundred and forty-five consecutive patients had undergone PVAI (34.5%), 157 (15.7%) consecutive patients AVJA, and 498(49.8%) A+DCCV. After matching the patients in a nested case-controlled methodology, 146 (32.3%) patients were in the PVAI group, 205 (59.4%) in the A+DCCV, and 101 (22.3%) in the AVJA. At 69+/-27 months, 63 (13.9%) patients had died in the matched population. Three (2.1%) patients died in the PVAI group, 34 (16.5%) in the A+DCCV group, and 26 (25.7%) in the AVJA group. In multivariable analysis, treatment strategy was a significant predictor of mortality. Compared to patients with PVAI (reference group), those with A+ DCCV (HR 4.9, p=0.011) and AVJA (HR 10.6, p=0.001) procedures had higher mortality risk.Conclusion: Compared to the other two procedures, patients with PVAI had the best survival rates at the end of 7 years. However, the observational case-control design of this study incurs the potential for confounding due to nonrandomized treatment selection, and creates a major limitation in making valid generalization of the findings. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein antral isolation (PVAI) is an effective treatment for atrial fibrillation and involves prolonged procedure and fluoroscopy times. This study assesses the impact of a comprehensive radiation safety program on patient and operator radiation exposure during PVAI.Methods and Results: We evaluated a comprehensive radiation safety program including: (1) verbal reinforcement of previous fluoroscopy times (2) effective collimation (3) minimizing source-intensifier distance and (4) effective lead shield use. Exposure doses in 41 consecutive patients without (group-I, n = 21) and with (group-II, n = 20) the use of radiation safety program were assessed. PVAI was done using intracardiac echo (ICE) guided roving circular mapping catheter. A 3-dimensional mapping system was used in 27% cases for additional guidance. Operator and patient exposure was measured during the PVAI. The age, gender, body mass index and AF duration were similar in both of the groups. The total procedure (166 +/- 56 vs 178 +/- 38 min, p = 0.54) and fluoroscopy times (74 +/- 24 vs 70 +/- 20 min, p = 0.72) were comparable. Group-II had significantly lower dose area product (234 +/- 120 vs 548 +/- 363 Gy cm(2), p = 0.03) compared to group-I. The mean operator exposure was reduced by half and mean patient peak skin dose by three to ten times with comprehensive radiation safety program. None of the patients were noted to have radiation related skin injuries. Additional lifetime cancer risk was significantly lower in group-II patients (0.08 vs 0.2%, p < 0.001) than group-I.Conclusions: Implementation of a comprehensive radiation safety program described above significantly decreases the radiation exposure to the patient as well as the operator. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We report the acute success and long-term follow-up in consecutive patients undergoing catheter ablation of typical right atrial flutter (AFL) using different ablation technologies. METHODS: One hundred and two patients presenting for treatment of AFL to our laboratory were included in the study. Based on availability and physician preference, ablation was performed with either a cooled-tip catheter (39 patients, group I), an 8- or 10-mm tip catheter connected to a high-power radiofrequency (RF) generator (25 patients, group II), or a 4- or 5-mm tip catheter (38 patients, group III). Acute ablation success was achieved in all group II and group III patients. Among the 38 patients undergoing ablation with the conventional catheter tip (group I), crossover to an 8-mm tip or a cooled tip ablation catheter was required in 11 patients (29%). The mean fluoroscopy time was significantly higher in group I (54.3 +/- 26.4 minutes) when compared to group II (39.6 +/- 19.6 minutes; P < 0.05) and group III (40 +/- 16 minutes; P = 0.0.5). After a mean follow up of 20 +/- 5 months no patient in group II experienced recurrence of AFL, whereas 18.4% (7 of 38 patients; P < 0.05) in group I and 10% (4 of 39 patients; P < 0.05) in group III had recurrence of AFL. Ablation technologies designed to obtain larger size lesions appeared to be more effective in achieving acute ablation success of AFL and in limiting the long-term recurrence rate of this arrhythmia. [ABSTRACT FROM AUTHOR]

Multidetector computed tomography can be used to evaluate the anatomy of pulmonary veins (PVs) in patients with AF. The study evaluated two groups. Group 1 included 61 patients assessed following PV ablation with ultrasound of RF energy. Group 2 included 15 patients undergoing ablation for AF and 14 control subjects without a history of AF matched for age and sex. The anatomy of the PVs was analyzed in this group prior to the ablation and compared to controls. Computed tomography was used to measure the ostium of the left superior, left inferior, right superior, right inferior PVs, and the left atrial appendage size. In group 1, PV stenosis was seen in 14 (30%) of 46 patients undergoing ablation with RF energy and in none of the 15 patients receiving ablation with ultrasound energy. In group 2, the ostium size was not different between patients with AF and controls. Similarly, the ostium of the PV that appeared to trigger AF was not larger than the ostium of the remaining veins. A 'clustering pattern' of PV branches near the right inferior PV ostium was seen in almost every patient, independent of the presence of the arrhythmia. Computed tomography frequently detects PV stenosis following RF ablation. Ultrasound ablation does not appear to result in PV narrowing. Overall, patients with AF do not have larger sizes of PV ostia. Multiple ramifications from the right inferior PV ostium is a common pattern and may represent a protective anatomic variant. [ABSTRACT FROM AUTHOR]

Biventricular ICDs may offer increased bene-fit for patients with severe congestive heart failure and ventricular arrhythmia. Currently there are no approved dedicated b iventricular IGDs available. Twenty-one consecutive patients who had approved nondedicated hardware implanted for biventricular pacing and defibrillation were included in this study. All device therapies were evaluated using stored electrograms. During mean follow-up at 13 ± 7 months, 8 (36%) patients had inappropriate shocks. Ventricular fibrillation therapy was delivered for slow ventricular tachycardia because of double counting in two patients. In one patient. AV nodal reentrant tachycardia below detection rate cut off triggered device therapy because of ventricular double counting. Sinus tachycardia or premature atrial contraction initiating A V conduction and ventricular double counting resulted in shocks in five patients. The number of shocks per patient ranged from 1 to 64. Two patients required transient disconnection of the LV lead and subsequent ICD generator replacement for premature battery depletion. Two patients required AV junction ablation and three needed slow pall: way ablation. Two patients were treated by upgrading to a device that was capable of a higher atrial tracking rate. The patients with impaired AV conduction or constant ventricular pacing did not have inappropriate therapy for sinus tachycardia or supraventricular arrhythmia. Use of conventional nondedicated hardware for biventricular pacer/defibrillator is feasible but should be considered only in patients with poor AV node function or less likely to require arititachycardic therapy, to avoid ICD double counting of ventricular sensed events and consequent high incidence of inappropriate therapies. [ABSTRACT FROM AUTHOR]

Objectives We report the first clinical experiences with the CARTO-Merge (Biosense-Webster, Diamond Bar, CA, USA) combined with intracardiac ultrasound (ICE) (Acuson, Mountain View, CA, USA) both used for navigation and catheter ablation of atrial fibrillation (AF). Methods 18 patients (15 men, 61±10 years) underwent pulmonary vein antrum isolation for symptomatic, drug-resistant AF using Lasso catheter, ICE and CARTO-Merge. The latter system integrated 3D CTA images of the left atrium and pulmonary veins with virtual CARTO maps. Firstly, 3-4 points (Landmarks) were registered on CTA scan according to the real-time position on the electroanatomical map, than 20-40 surface points of the CARTO map were added to finish the registration of the CT scan. Subsequently, the 3D CT anatomical map was used for catheter navigation. Correlation between this reconstruction, ICE and fluoroscopy was documented. Accuracy of the system was evaluated by the software statistical analysis. Results The mean surface inaccuracy was: 2.1±1.6 mm and the mean Landmarks inaccuracy was 8.9±3.0 mm, which reaches the recommended range. Conclusion This novel system appears to have a reliable correlation between CTA and real-time CARTO maps. [ABSTRACT FROM PUBLISHER]

This study sought to determine the association of exercise-induced ventricular ectopic activity with thallium perfusion defects and severity of angiographic coronary artery disease (CAD). Two cohorts consisting of adults without heart failure or known severe ventricular ectopic activity at rest were studied. The first cohort consisted of adults (n = 2,743) who underwent maximum exercise thallium stress testing. The second cohort consisted of adults (n = 423) who underwent coronary angiography within 90 days of treadmill testing. Significant exercise-induced ventricular ectopic activity was defined as frequent ventricular premature complexes or nonsustained ventricular tachycardia. Severe CAD was defined as left main CAD (> or = 50% stenosis), 3-vessel CAD (> or = 70% stenosis), or 2-vessel CAD with > or = 70% stenosis of the proximal left anterior descending artery. In the thallium cohort, exercise-induced ventricular ectopic activity was associated with a greater frequency of thallium defects (35.2% vs 18.7%, odds ratio [OR] 2.35, 95% confidence intervals [CI] 1.62 to 3.42, p <0.001); after adjusting for possible confounders, this association persisted (for any defect adjusted OR 1.66, 95% CI 1.09 to 2.53, p = 0.02; for septal defect adjusted OR 2.77, 95% CI 1.51 to 5.07, p <0.001). There was no association between exercise-induced ventricular ectopic activity and mortality during 2 years of follow-up. In the angiographic cohort, there was no association of exercise-induced ventricular ectopy with severe CAD (19% vs 20%, OR 0.93, 95% CI 0.41 to 2.09, p = NS). Exercise-induced ventricular ectopic activity was associated with a greater likelihood of thallium perfusion defects, but was not associated with angiographic severity of coronary disease or with short-term mortality. [ABSTRACT FROM AUTHOR]

The 13.2 h half-life radioisotope 123I is widely used in clinical nuclear medicine diagnosis. At present it is mostly produced in nca form by proton irradiation of highly enriched 124Xe in dedicated gas target set-ups and relying on the decay chain 123Cs–123Xe–123I.Depending on the irradiation conditions contamination with long-lived 121Te, a daughter product of the co-produced rather short lived 121I, occurs and can limit the useful shelf life of the 123I solution. Excitation function of the 124Xe(p,α)121I, 124Xe(p,2n)123Cs and 124Xe(p,2p)123Xe reactions are measured up to 35 MeV using the stacked gas cell technique and high-resolution γ-ray spectrometry. The experimental data were compared with the earlier literature values, with new results of the ALICE-IPPE and EMPIRE-II codes and with the data taken from the TENDL-2009 database. Existing discrepancies in cross-section data are largely solved and new recommended values are proposed. From fits to the new excitation curves integral 123I batch yields and 121Te contaminations for realistic production conditions are derived. Optimization of irradiation and cooling times and energy degradation in the target can strongly influence the contamination level. [ABSTRACT FROM AUTHOR]

Purpose: The following is a comparative analysis on the treatment outcomes of corneal perforations using amniotic membrane transplantation (AMT) or penetrating keratoplasty (PK)., Methods: This monocentric retrospective study was performed at the Department of Ophthalmology, University Hospital Ulm, Germany. A total of 78 eyes of 78 patients were included. Thirty-nine eyes received an AMT, and 39 patients were treated with a PK. Primary outcome was recurrence of perforation. Secondary outcomes were patient mortality and visual acuity., Results: No statistically significant difference was observed with regard to a recurrence of perforation between the two groups (26% in AMT vs 23% in PK, p > 0.99). The time of recurrences was within the first two years and did not differ statistically (p = 0.97). In addition, a proportional hazards model with cox regression regarding recurrent perforation showed no significant differences (p = 0.5). After AMT, 41% and after KP, 28% of the patients died during follow-up (p = 0.2), respectively. The Charlson Comorbidity Index (p < 0.0001) and the age at the time of surgery (p = 0.0002) were statistically significantly higher in those who were deceased. A mean follow-up of 485 ± 517 days was recorded., Conclusion: Both surgical methods show good results and no statistically significant difference regarding recurrent perforation rate. About a third of the patients died during the follow-up period. The decision regarding the appropriate method should therefore be based on a combination of all factors., (© 2023. The Author(s).)

Purpose: Acanthamoeba keratitis is often misdiagnosed at disease onset. This study presents data to confirm the diagnosis using calcofluor white (CFW) staining., Methods: Forty three patients were retrospectively included who presented to the Department of Ophthalmology at the University Hospital Ulm with keratitis between 2000 and 2022. Condition positive cases were diagnosed based on the typical clinical presentation of Acanthamoeba keratitis with a positive polymerase chain reaction (PCR). Condition negative were patients with ulcers due to other causing pathogens with a negative Acanthamoeba PCR result. The condition was compared with the CFW test results., Results: After symptom onset, time until presentation was 17 ± 12 days and until diagnosis 27 ± 13 days in the 15 condition positive patients. Among the 35 patients with additional CFW test, 7 patients were condition positive and 28 negative. 5 of the 7 patients were true positive, 2 were false negative. In the 28 condition negative patients, 1 was false positive. Sensitivity of CFW was 71% and specificity 96%. The positive PCR results were available 3.4 ± 2.3 days after corneal scraping, the positive CFW test results on the same day in each case., Conclusion: Our data demonstrate that diagnosis of Acanthamoeba keratitis remains difficult and therapy is initiated late. A positive CFW test confirms the diagnosis as there are almost no false positive results and it was available faster than PCR. In case of a negative CFW test, Acanthamoeba keratitis cannot be ruled out because of a high false negative rate., (© 2023. The Author(s).)

Aims: Benefits of automatic remote home monitoring (HM) among implantable cardioverter defibrillator (ICD) patients may require high transmission frequency. However, transmission reliability and effects on battery longevity remain uncertain. We hypothesized that HM would have high transmission success permitting punctual guideline based follow-up, and improve battery longevity. This was tested in the prospective randomized TRUST trial., Methods and Results: Implantable cardioverter defibrillator patients were randomized post-implant 2:1 to HM (n = 908) (transmit daily) or to Conventional in-person monitoring [conventional management (CM), n = 431 (HM disabled)]. In both groups, five evaluations were scheduled every 3 months for 15 months. Home Monitoring technology performance was assessed by transmissions received vs. total possible, and number of scheduled HM checks failing because of missed transmissions. Battery longevity was compared in HM vs. CM at 15 months, and again in HM 3 years post-implant using continuously transmitted data. Transmission success per patient was 91% (median follow-up of 434 days). Overall, daily HM transmissions were received in 315 795 of a potential 363 450 days (87%). Only 55/3759 (1.46%) of unsuccessful scheduled evaluations in HM were attributed to transmission loss. Shock frequency and pacing percentage were similar in HM vs. CM. Fifteen month battery longevity was 12% greater in HM (93.2 ± 8.8% vs. 83.5 ± 6.0% CM, P < 0.001). In extended follow-up of HM patients, estimated battery longevity was 50.9 ± 9.1% (median 52%) at 36 months., Conclusion: Automatic remote HM demonstrated robust transmission reliability. Daily transmission load may be sustained without reducing battery longevity. Home Monitoring conserves battery longevity and tracks long term device performance., Clinical Trial Registration: ClinicalTrials.gov; NCT00336284.

Background: Whether catheter ablation (CA) is superior to amiodarone (AMIO) for the treatment of persistent atrial fibrillation (AF) in patients with heart failure is unknown., Methods and Results: This was an open-label, randomized, parallel-group, multicenter study. Patients with persistent AF, dual-chamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator, New York Heart Association II to III, and left ventricular ejection fraction <40% within the past 6 months were randomly assigned (1:1 ratio) to undergo CA for AF (group 1, n=102) or receive AMIO (group 2, n=101). Recurrence of AF was the primary end point. All-cause mortality and unplanned hospitalization were the secondary end points. Patients were followed up for a minimum of 24 months. At the end of follow-up, 71 (70%; 95% confidence interval, 60%-78%) patients in group 1 were recurrence free after an average of 1.4±0.6 procedures in comparison with 34 (34%; 95% confidence interval, 25%-44%) in group 2 (log-rank P<0.001). The success rate of CA in the different centers after a single procedure ranged from 29% to 61%. After adjusting for covariates in the multivariable model, AMIO therapy was found to be significantly more likely to fail (hazard ratio, 2.5; 95% confidence interval, 1.5-4.3; P<0.001) than CA. Over the 2-year follow-up, the unplanned hospitalization rate was (32 [31%] in group 1 and 58 [57%] in group 2; P<0.001), showing 45% relative risk reduction (relative risk, 0.55; 95% confidence interval, 0.39-0.76). A significantly lower mortality was observed in CA (8 [8%] versus AMIO (18 [18%]; P=0.037)., Conclusions: This multicenter randomized study shows that CA of AF is superior to AMIO in achieving freedom from AF at long-term follow-up and reducing unplanned hospitalization and mortality in patients with heart failure and persistent AF., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00729911., (© 2016 American Heart Association, Inc.)

Introduction: The incidence of unscheduled encounters and problem occurrence between ICD implant and first in-person evaluation (IPE) recommended at 12 weeks is unknown. Automatic remote home monitoring (HM) may be useful in this potentially unstable period., Methods and Results: ICD patients were randomized 2:1 to HM enabled post-implant (n = 908) or to conventional monitoring (CM; n = 431). Groups were compared between implant and prior to first scheduled IPE for IPE incidence, causes, and actionability (reprogramming, system revision, medication changes) and event detection time. HM and CM patients were similar (mean age 63 years, 72% male, LVEF 29%, primary prevention 73%, DDD 57%). In the post-implant interval assessed (HM 100 ± 21.3 days vs. CM 101 ± 20.8 days, P = 0.54), 85.4% (776/908) HM patients and 87.7% CM (378/431) patients had no cause for IPE (P = 0.31). When IPE occurred, actionability in HM (64/177 [36.2%]) was greater versus CM (15/62 [24.2%], P = 0.12). Actionable items were discovered sooner with HM (P = 0.025). Device reprogramming or lead revision was triggered following 53/177 (29.9%) IPEs in HM versus 9/62 (14.5%) in CM (P = 0.018). Arrhythmia detection was enhanced by HM: 276 atrial and ventricular episodes were detected in 135 follow-ups in contrast to CM (65 episodes at 17 IPEs). More silent arrhythmic episodes were discovered by HM (7.2% vs. 1.5% [P = 0.15]). Since 27/42 (64.3%) IPEs driven by HM alerts were actionable, event notification was a valuable method for problem detection. Importantly, HM did not increase incidence of non-actionable IPEs (P = 0.72)., Conclusion: Activation of automatic remote monitoring should be encouraged soon post-ICD implant., (© 2015 Wiley Periodicals, Inc.)

Background: Monitoring performance of implantable cardioverter-defibrillator (ICD) generators and leads is important. Methods available are with in-person evaluations or by automatic remote home monitoring (HM). These were prospectively evaluated and compared in the TRUST trial. The HM technology tested performed daily self-checks and databasing with rapid event notifications for out-of-range (including asymptomatic) conditions., Methods and Results: Patients (n=1339) were randomly assigned after ICD implant 2:1 to HM or to conventional groups. Both groups underwent scheduled checks every 3 months and were followed for 15 months. In HM, in-person office visits were scheduled at 3 and 15 months. At 6, 9, and 12 months, HM only was used with subsequent office visits if necessary. Between these time points, ICDs triggered event notifications for system integrity problems. Patients randomly assigned to conventional follow-up were evaluated with office visits only. HM and conventional patients were similar (age, 63.3±12.8 versus 64.0±12.1 years; 72.0% versus 73.1% male; New York Heart Association II class, 55.9% versus 60.4%; left ventricular ejection fraction, 29.0±10.7% versus 28.5±9.8%; coronary artery disease, 64.8% versus 71.7%; primary prevention, 72.2% versus 73.8%; DDD devices, 57.8% versus 56.6%). Four patients crossed over from conventional to HM because of advisories. Scheduled checks were more successfully accomplished in HM (92.7% versus 89.2% in conventional, P<0.001). Sixty-two device-related events (53 in HM versus 9 in conventional) were observed in 46 patients (40 [4.4%] in HM versus 6 [1.39%] in conventional, P=0.004). Forty-seven percent were asymptomatic. HM detected generator and lead problems earlier (HM versus conventional: median, 1 versus 5 days; P=0.05). A total of 20 device problems (eg, lead fracture, elective replacement indicators) requiring surgical revision (0.012 per patient-year) were found, 15 in HM and 5 in the conventional groups. Other events were managed nonsurgically (eg, reprogramming, initiation of antiarrhythmics)., Conclusions: ICD lead and generator malfunction was infrequent and often asymptomatic. Only a minority of detected events required surgical intervention. Automatic HM enhanced discovery, permitted prompt detection, and facilitated management decisions. Longitudinal parameter trending, with component function evaluated daily by remote monitoring, may enable long-term performance assessment., Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifier: NCT00336284.

Background: Obstructive sleep apnea (OSA) may be associated with pulmonary vein antrum isolation (PVAI) failure. The aim of the present study was to investigate if treatment with continuous positive airway pressure (CPAP) improved PVAI success rates., Methods and Results: From January 2004 to December 2007, 3000 consecutive patients underwent PVAI. Patients were screened for OSA and CPAP use. Six hundred forty (21.3%) patients had OSA. Patients with OSA had more procedural failures (P=0.024) and hematomas (P<0.001). Eight percent of the non-OSA paroxysmal atrial fibrillation patients had nonpulmonary vein antrum triggers (non-PV triggers) and posterior wall firing versus 20% of the OSA group (P<0.001). Nineteen percent of the non-OSA nonparoxysmal atrial fibrillation population had non-PV triggers versus 31% in the OSA group (P=0.001). At the end of the follow-up period (32±14 months), 79% of the non-CPAP and 68% of the CPAP group were free of atrial fibrillation (P=0.003). Not using CPAP in addition to having non-PV triggers strongly predicted procedural failure (hazard ratio, 8.81; P<0.001)., Conclusions: OSA was an independent predictor for PVAI failure. Treatment with CPAP improved PVAI success rates. Patients not treated with CPAP in addition to having higher prevalence of non-PV triggers were 8 times more likely to fail the procedure.

Introduction: Atrial flutter (AFL) is common after cardiac surgery. However, the types of post-cardiac surgery AFL, its response to catheter-based radiofrequency ablation, and its relationship to atrial fibrillation (AF) are unknown., Methods and Results: We retrospectively studied all patients who underwent mapping and ablation for AFL after cardiac surgery from January 1990 to July 2004. One hundred randomly selected patients without prior cardiac surgery (PCS) who underwent mapping and ablation of AFL served as the control population. A total of 236 patients formed the study population (mean age 62 + 13 years, 22% female) and 100 patients formed the control population (mean age 60 + 13 years, 25% female). The majority of patients without PCS had cavo-tricuspid isthmus (CTI)-dependent AFL when compared to patients with PCS (93% vs 72%, respectively, P < 0.0001). In contrast, scar-related AFL was more common in patients with PCS as compared to patients without PCS (22% vs 3%, P < 0.0001). Predictors of scar related AFL in multivariable regression analysis included PCS and left-sided AFL. Acute success rates and complications were similar between the groups. When compared to patients with AFL ablation without PCS, those that had AFL after PCS had higher rates of recurrence of both AFL (1% vs 12%, P < 0.0001; mean time to recurrence 1.85 years) and AF (16% vs 28%, P = 0.02; mean time to recurrence 2.67 years)., Conclusion: Despite ablation of AFL, patients with PCS have a higher rate of AFL and AF when compared to patients without PCS who underwent ablation of atrial flutter during long-term follow-up.

Introduction: Cerebral thromboembolic event (CTE) is a possible complication of pulmonary vein antrum isolation (PVAI). The objective of this study was to report long-term functional and neurocognitive recovery in patients who had a CTE during or within 48 hours of catheter ablation., Methods and Results: We screened 3,060 patients who underwent PVAI between January 2000 and June 2007. Out the 3,060 patients, 26 patients (0.8%) (61 +/- 8 years, 88% males) had a CTE during or within 48 hours of the procedure. We followed these 26 patients (study group) over time and assessed their functional and neurocognitive recovery status. No preferential vascular territory for the site of obstruction was found; right anterior circulation-5 patients (26%), left anterior circulation-5 patients (26%), posterior circulation-3 patients (16%), and 2 or more territories-6 patients (32%), (P-value = 0.8). The average international normalized ratio at the time of CTE was 1.33 +/- 0.4. Two patients died during the study period. At the end of 38.4 +/- 24 months follow-up, most surviving patients had complete neurocognitive and functional recovery irrespective of the severity of periprocedural stroke., Conclusions: Periprocedural stroke in the setting of catheter ablation for atrial fibrillation is relatively rare. When it occurs, complete functional and neurocognitive recovery over time is the likely outcome for most patients.

Introduction: Around 30% of patients do not respond to cardiac resynchronization therapy (CRT). Nonischemic cardiomyopathy has been identified as an independent predictor of response to CRT, probably due to the absence of compact scar., Methods and Results: The relationship between cardiac scar, ischemia, and hibernation (both at the left-ventricular pacing site and as a total burden) and response to CRT was studied in patients with ischemic cardiomyopathy using the perfusion-viability positron emission tomography (PET) test. Sixty-six patients with ischemic cardiomyopathy and traditional criteria for CRT were included. All patients underwent PET scan prior to CRT. Using PET, the amount and location of scarred, ischemic, and hibernating myocardium were characterized. No revascularization was indicated. Responders were defined by an improvement of left-ventricular ejection fraction (LVEF) >or= 5% and/or New York Heart Association (NYHA) class >or= 1 degree. During a mean follow-up of 26.2 +/- 22.2 months, there was a significant improvement in NYHA class and reverse remodeling in patients with the LV lead inserted remotely from the scar. However, reverse remodeling of a similar degree was present also in patients with extensive scarring including the lateral wall. The presence of ischemia, hibernation, or nontransmural scar at the pacing-site did not significantly modify the outcome of CRT as compared with viable myocardium. There were only 38% of CRT-nonresponders. Neither the extent of scar, ischemia, hibernation, or viability predicted outcome or mortality. Twenty patients died during the follow-up, one patient underwent heart transplant., Conclusions: At follow-up, response to CRT is observed regardless of the presence of extensive scarring. Left ventricular (LV) pacing at sites with ischemia, hibernation, or nontransmural scar does not appear to modify the effect of CRT as compared to viable tissue.

Unlabelled: Intracardiac Echo-Guided Radiofrequency Catheter., Introduction: Patients with atrial septal defect (ASD) are at higher risk for atrial fibrillation (AF) even after repair. Transseptal access in these patients is perceived to be difficult. We describe the feasibility, safety, and efficacy of pulmonary vein antral isolation (PVAI) in these patients., Method: We prospectively compared post-ASD/patent foramen ovale (PFO) repair patients (group I, n = 45) with age-gender-AF type matched controls (group II, n = 45). All the patients underwent PVAI through a double transseptal puncture with a roving circular mapping catheter technique guided by intracardiac echocardiography (ICE). The short-term (3 months) and long-term (12 month) failure rates were assessed., Results: In group I, 23 (51%) had percutaneous closure devices and 22 (49%) had a surgical closure. There was no significant difference between group I and II in the baseline characteristics. Intracardiac echo-guided double transseptal access was obtained in 98% of patients in group I and in 100% of patients in group II. PVAI was performed in all patients, with right atrial flutter ablation in 7 patients in group I and in 4 patients in group II. Over a mean follow-up of 15 +/- 4 months, group I had higher short-term (18% vs 13%, P = 0.77) and long-term recurrence (24% vs 18%, P = 0.6) than group II. There was no significant difference in the perioperative complications between the two groups. Echocardiography at 3 months showed interatrial communication in 2 patients in group I and 1 patient in group II, which resolved at 12 months., Conclusion: Percutaneous AF ablation using double transseptal access is feasible, safe, and efficacious in patients with ASD and PFO repairs.

Background: Catheter ablation of atrial fibrillation (AF) is an increasingly popular therapeutic option for symptomatic patients who have failed multiple antiarrhythmic drugs (AADs). Patients of higher body mass index often fail direct current cardioversion. The role of body mass index (BMI) on the success of AF ablation is not well understood. Methods: We prospectively studied 511 patients who underwent AF ablation at the Cleveland Clinic Foundation between 2002 and 2005. Patients were divided into four classes based on their BMI: Class I ( 25); Class II (25.1-30); Class III (30.1-35) and Class IV (>35). These groups were compared for baseline demographic and clinical characteristics. Any recurrence of AF after 3 months of ablation was considered as failure. All classes were followed for at least 12 months and rates of failure were compared. Results: Based on their BMI, 25% of patients were assigned to class I, 37% in class II, 21% in class III and 16% in class IV. Patients of higher classification (class III or IV) were more likely to be male (p<0.001), diabetic (p<0.001), smokers (p=0.002), with coronary artery disease (=0.018), left atrial enlargement (p=0.015) and longstanding AF (p=0.007). Severity of obesity as measured by BMI had a direct correlation to early (p=0.05) and late (p=0.01) recurrence of AF. Conclusion: Obesity is significantly associated with long-term AF recurrence after catheter ablation. Higher incidence of smoking & left atrial enlargement may possibly contribute to higher failure rates in this sub-group of patients.

Introduction: The incidence of left atrial appendage (LAA) thrombus in patients with paroxysmal atrial fibrillation (PAF) who present for pulmonary vein antrum isolation procedure (PVAI) is unknown., Methods and Results: All consecutive patients from January 2000 to June 2004 who underwent a PVAI received a computed tomography (CT) to evaluate LAA thrombus before the procedure and 3 months post-PVAI. All patients were followed prospectively. One thousand two hundred twenty-one patients received a PVAI during the study dates. All patients received a CT pre-PVAI at 3 months, and 601 (49%) received a transesophageal echocardiography (TEE) pre-PVAI. Per protocol, all patients who had CT scans that were positive for LAA thrombus received a TEE. There were 9 patients who had LAA thrombus on CT scan, but only 3 had LAA thrombus on TEE. Using TEE as the gold standard, only 3 patients had an LAA thrombus before PVAI; of these patients, 2 had chronic AF with average ejection fraction (EF) of 48% and 1 patient had PAF with EF 25%. No patients with PAF and normal EF had LAA thrombus. Patients with LAA thrombus pre-PVAI had lower EF than patients without LAA thrombus (40% vs. 53%, P = 0.007) but had similar LA size (5.0 vs. 4.5 cm, P = 0.77). No other differences in baseline characteristics were noted., Conclusions: In this registry of 1,221 patients, we did not observe LA thrombus in PAF patients with normal EF who present for PVAI. Prescreening CT alone is likely to be sufficient in paroxysmal AF patients with normal EF, and the use of TEE may not be needed.

Unlabelled: PV isolation at the antrum (PVAI) has improved safety and efficacy of ablation procedures for atrial fibrillation (AF). AF triggers from the superior vena cava (SVC) may compromise the outcome of PVAI., Purpose: We evaluated the (1) incidence of SVC triggers, (2) feasibility of empiric SVC electrical isolation (SVCI) as an adjunct to PVAI, and (3) SVCI safety., Methods and Results: Of 190 patients (group I), 24 (12%) showed SVC triggers. Following PVAI, seven patients had AT originating from the SVC and three had AF. After SVCI, all 24 patients were arrhythmia-free 450 +/- 180 days post procedure. In the subsequent 217 patients (group II), empirical SVCI was performed following PVAI. Sixty-six of all 407 patients (16%) experienced recurrence of AF. A repeat procedure in 25 of the 66 patients showed that five (20%) had AF recurrence initiated by SVC triggers, of whom four were among group I patients (4/190; 2%) and one was from group II (1/217; 0.4%), (P < 0.05). Transient diaphragmatic paralysis can be avoided by pacing at the lateral aspect of the SVC using high output (30 mA). There was no SVC stenosis on CT scans before or 3 months after the procedure. There was no sinus node injury., Conclusions: The SVC harbors the majority of non-PV triggers of AF. SVCI is feasible, safe, and may be considered as an adjunctive strategy to PVAI for ablation of AF. The long-term favorable outcome of this hybrid approach remains to be evaluated in a larger series of patients.