Search

Funding Acknowledgements Type of funding sources: None. Background Left bundle branch area pacing (LBBAP) can be technically challenging and fluoroscopy-intense, particularly in patients with structural heart disease (SHD) and advanced conduction abnormalities. Three-dimensional electroanatomical mapping (EAM) facilitates high-resolution, real-time, and non-fluoroscopic lead navigation, electrogram and pace mapping. Purpose The purpose of the study was to prospectively evaluate the feasibility, safety, and outcomes of routine EAM-guided LBBAP in patients with SHD and advanced conduction abnormalities. Methods Consecutive patients with SHD and advanced conduction abnormalities (defined as second or third-degree atrioventricular (AV) block and/or complete bundle branch block) who underwent an attempt at EAM-guided LBBAP were included. EAM-guided lead implantation was performed in all patients following a standardized protocol irrespective of the pacing indication and type of conduction disturbance. The feasibility, safety, procedural and mid-term outcomes were evaluated. Electrical, echocardiographic, and clinical parameters were assessed at implantation and last follow-up. Results Thirty-two patients (68±18 years; 19% female) were included. The indication for pacing was cardiac resynchronization therapy in 50%, AV block in 44%, and pace-and-ablate in 6% of patients; 24 patients (75%) had an intrinsic QRS >150 ms, 17 (53%) had LBBB. Primary EAM-guided LBBAP was successful in 29 patients (91%). Procedural duration was 95 (70-110) min, total fluoroscopy time 0.93 (0.40-1.73) min, and total fluoroscopy dose 35.4 (20.5-77.2) cGycm2 (Figure 1A). The paced QRS duration during LBBAP was significantly shorter than the baseline intrinsic QRS duration (121.9±10.7 vs. 159.2±34.4 ms; p1.0V/0.4 ms during follow-up. Overall LVEF improved significantly from 44.2±14.3% at baseline to 49.4±13.1% at last follow-up (p=0.009), NYHA functional class from 2.4±0.6 to 1.8±0.6 (p=0.002), respectively (Figure 1C+D). No complications occurred that required intervention. Conclusion Routine near-zero fluoroscopy EAM-guided LBBAP can safely be performed in patients with SHD and advanced conduction abnormalities with high success rates and favourable mid-term outcomes. Further studies are needed to investigate whether the use of EAM improves overall outcome of conduction system pacing, and to identify specific patient populations who benefit the most from EAM-guided lead implantation.

Funding Acknowledgements Type of funding sources: None. Background Central retinal artery occlusion (CRAO) is a devastating event and atrial fibrillation (AF) is a recognized cause that may not be present at the time of the event. Purpose We performed a meta-analysis for the association of CRAO with the risk of new-onset AF and stroke during follow-up. Methods We searched the databases MEDLINE, Embase and SCOPUS from inception to May 2022 for the terms ‘atrial fibrillation’ and ‘retinal artery occlusion’ and identified 205 studies. We excluded duplicates, non-relevant studies and those not reporting new-onset AF after CRAO. We used random effects models to calculate the pooled odds ratio (OR) and 95% confidence intervals (CI) of AF risk in patients with CRAO or stroke in comparison to control groups. Analysis was performed with RevMan 5.4.1 (Cochrane 2020). Results We included 7 studies with 1.476 patients with CRAO compared to a control group without CRAO (n=9.843) and a group with stroke (n=7.058). There were 196 new AF cases (13.4%) in 18 months after CRAO. CRAO was associated with a higher risk for new-onset AF (OR:1.59, CI:1.20-2.11, p=0.001) and stroke (OR:2.46, CI:1.74-3.47, p Conclusions CRAO is associated with a higher risk for new-onset AF and stroke. AF risk after CRAO though is similar to that after stroke. Thus, CRAO should be regarded as cryptogenic stroke and mandate a closer follow-up with screening for AF and evaluation of early anticoagulation.

Funding Acknowledgements Type of funding sources: None. Introduction This study sought to examine the prognostic role of quantifying areas of interest in preinterventional cardiac magnetic resonance (CMR) in patients with structural heart disease (SHD) referred for ablation of ventricular tachycardia (VT). Background The role of preinterventional CMR for the identification of scar areas, borderline zones and reentry channels in the ventricles has been well established. Whether the burden of dense scar or borderline tissue has a prognostic impact on the acute and the long-term ablation outcome in SHD patients is disputed. Methods and results We investigated 185 patients with SHD undergoing preinterventional CMR prior to VT-ablation. 38 patients were excluded because of poor imaging quality, leaving a cohort of 147 patients with positive late enhancement (LGE) imaging (mean age 62 years, 47% non-ischemic cardiomyopathy, mean left ventricle ejection fraction 38%, 96% with implanted ICD). The cohort was divided in ischemic (ICM) and non-ischemic (NICM) cardiomyopathy group and the results regarding burden of overall scar tissue, dense scar, borderline zone, as well as clinical and procedural characteristics, acute and long-term results of the two groups were compared. The ICM patients had more advanced NYHA stadium (p = 0.046), reduced left ventricular ejection fraction (LV-EF, p Conclusion While quantification of the scar tissue and the borderline zone is feasible in ICD patients with SHD, the scar or the borderline zone burden were not predictive of the VT ablation outcome.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): This study was financially supported by Biosense Webster. Introduction Same-day discharge (SDD) protocols following catheter ablation (CA) of atrial fibrillation (AF) were already introduced in selected facilities in Europe but a widespread implementation has not yet succeeded. Data on patients’ perspectives to support early discharge regimens is lacking. Therefore, we conducted a survey to address patients’ beliefs towards SDD and identify variables that are associated with their evaluation. Methods As a part of the prospective, monocentric FAST AFA trial, patients aged ≥20 years undergoing a left atrial CA for AF or atrial flutter were asked to participate in the survey consisting of a study-specific SDD-questionnaire, the AF knowledge scale and pre-defined patient reported outcome measures. The study cohort was stratified based on SDD willingness and a logistic regression analysis was used to identify predictors for patients’ valuation. Results Between 07/26/2021-07/01/2022, 256 of 376 screened patients consented to study participation of whom 248 (median age 61.8 years, 33.9% female) completed the SDD survey. Of them, 50.0% were willing to have SDD concepts integrated into their clinical course with increased patient comfort (27.5%), shorter waiting times (14.6%) and a cost-efficient treatment (14.0%) being imaginable benefits. In contrast, 52.2% of patients saw no advantages in SDD and expressed concerns including uncertainties with occurring complaints (50.6%), as well as the insufficient recognition (47.8%) and treatment (48.9%) of complications. Symptoms at baseline and inpatient treatments within the preceding year were predictors for SDD willingness whereas comorbidity burden or AF knowledge were not. Conclusion We provide a detailed survey expressing patients’ beliefs towards SDD following left atrial CA. Our findings may facilitate adequate patient selection to improve the future implementation of SDD programs in suitable cohorts.

Subjective estimation of recurrence after atrial fibrillation ablation is an important tool in clinical use. The aim of this study is to evaluate (1) if the subjective complexity of an atrial fibrillation ablation procedure is correlated with rhythm stability and (2) if the subjective prognosis of the operator has a predictive value. We prospectively enrolled patients admitted for ablation of atrial fibrillation. Two scores were given immediately after the procedure by the operator: the complexity and the prognosis scores. With routine follow-ups, we tried to evaluate the correlation between the subjective scores and measured outcome. The study population included 611 patients (63 ± 10 years, 37% females, 61% persistent AF). During follow-up (FU) (median 24, IQR 7–36 months), recurrences occurred in 44% patients. Both scores (prognosis and complexity) correlated significantly with age, persistent AF, LA diameter, procedural characteristics, and recurrences. On multivariable analysis, complexity (OR 1.304, 95%CI 1.016–1.675, p = 0.037) and prognosis (OR 1.443, 95%CI 1.080–1.982, p = 0.013) scores remained significant predictors for arrhythmia recurrences. On ROC analysis, both scores showed significant predictive value for rhythm outcomes after catheter ablation (AUC 0.599 and 0.613, both p

Funding Acknowledgements Type of funding sources: None. Background Preprocedural contrast-enhanced cardiovascular magnetic resonance (CMR) or computed tomography (CT) imaging of the left atrium (LA) and pulmonary veins (PVs) is usually employed to facilitate catheter mapping and ablation of atrial fibrillation (AF). Incidental findings (IFs) are common on cardiac imaging prior to AF catheter ablation (AFCA). However, previous studies were of small size and have mainly focused on radiological extracardiac IFs detected on preprocedural CT scan. Purpose To assess the prevalence of major cardiac and extracardiac IFs on routine preprocedural CMR in a large cohort of consecutive patients scheduled for first-time AFCA, and to report its impact on clinical decision-making and management. Methods All consecutive patients who underwent routine preprocedural CMR prior to first-time AFCA between April 2015 and March 2019 were considered for analysis. Main exclusion criteria were referral for repeat AFCA; prior cardiac CT or CMR imaging; and general contraindication to CMR or AFCA. All CMR examinations consisted of survey images with full thoracic coverage, cardiac cine and late-gadolinium enhancement imaging, and three-dimensional contrast-enhanced CMR angiography of the LA/PVs. An IF was defined as major when any newly detected finding either resulted in cancellation of the AFCA procedure or intentional deviation from the standard AFCA protocol. In patients with accessory or anomalous PVs the ablation strategy was individually tailored aiming at isolation of all PVs. Results Two thousand consecutive patients (62±10 years; 59% male) with paroxysmal (48%) or persistent (52%) AF were included. Among the entire study cohort 172 patients (8.6%) had a total of 184 cardiac (75%) and extracardiac (25%) major IFs (Fig. A+B). Preprocedural detection of a major IF resulted in cancellation of the scheduled AFCA procedure in 88 patients (4.4%). Forty-two patients (2.1%) have thereupon never been ablated, 46 patients (2.3%) underwent postponed AFCA after a median time from CMR imaging of 83 (32-213) days. The remaining 84 patients with major IF (4.2%) underwent an individualized approach to AFCA (Fig. A). The most common major IFs were accessory or anomalous PVs in 76 (3.8%), extracardiac abnormalities suspicious of malignancy in 29 (1.5%), and positive stress perfusion imaging in 19 (1.0% overall; 7.2% of 261 tested) patients. In 19 patients (1.0%) preprocedural CMR detected a previously unknown intracardiac thrombus or structural cardiac disease. Conclusion Unexpected major IFs on routine preprocedural CMR affected clinical decision-making and therapeutic management in 8.6% of patients scheduled for first-time AFCA at our institution. Whether preprocedural CMR imaging may improve safety and outcome of AFCA needs to be addressed in future research.

Funding Acknowledgements Type of funding sources: None. Background Intramural septal ventricular arrhythmia remains challenging, requiring emergent technologies and experimental approaches. Although conduction system pacing (CSP) has allowed us to reach deep in the septum, ablation though pacing electrodes has not been examined yet. Purpose To evaluate lesion creation by radiofrequency ablation (RFA) through pacing electrodes. Methods A custom ex vivo swine model in a saline bath with an indifferent electrode was used to apply RFA with an 8 mm non-irrigated catheter (SJM, MN, USA) on the proximal end of pacing (CapSureFix 5086) or CSP-electrodes (SelectSecure 3830, Medtronic, MN, USA), screwed in perpendicularly to the slab. A generator (Ampere, SJM, MN, USA) applied RFA at varying settings (1-10 W, 1-20 sec). Lesion depth (D), width (W) and volume (V=3,14*W2*D/4) were assessed and analyzed (SPSS 23). Results A total of 80 lesions were used for analysis. Median RFA with 3 W over 6 sec resulted in an impedance drop from 200 to 140 Ω and a lesion of 2x3 mm or 9.4 mm3 (Figure 1). Higher energy settings caused impedance rise with abort (n=3, 4%) or charring (n=3, 4%). Compared to conventional electrodes, lesions with CSP-electrodes had similar volume (9.3±7 vs. 10.8±9 mm3, p=0.45) and width (2±0.8 vs. 2±0.7, p=0.58), but more depth (2.6±0.5 vs. 3±0.6, p=0.0.01). Regression analysis showed final-impedance (FI), power and duration (WS=W*Sec) as independent predictors of lesion volume (V=4.7WS-4.1WS2+4.5FI-4, p Conclusions Effective ablation through pacing electrodes is possible, but lesion size is limited and low-power settings are necessary. Using CSP-electrodes for effective intramural lesions is possibly a new tool for septal arrhythmias. Further in vivo studies are warranted and bailout use should be considered.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany Introduction A single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (the DX ICD system) can potentially give additive information concerning atrial diagnostics in patients requiring only a single-chamber ICD. We therefore report the real-world experience from large DX registry on implantation, atrial signal quality and detection and the long-term stability of the atrial signal. Methods The prospective, single-arm MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems, NCT01774357) registry study effectively enrolled 2041 patients at 119 sites in 24 countries. All patients had a DX system implanted for a single-chamber ICD indication for primary or secondary prevention of sudden cardiac death. Patients were followed for 24 months including remote monitoring. Implantation and follow-up data are reported for the whole patient set. For the analyses on atrial sensing amplitude values, remotely transmitted device measurements of patients without history of long-standing persistent or permanent AF at baseline were used. Results The mean follow-up period was 677±173 days. Implantation took place at 15±22 days before enrollment. Baseline and implantation data are shown in the table. Implantation procedure and lead insertion were rated as "easy" or "very easy" in 91.0% and 96.3% of assessments, respectively. At implantation, the investigators rated the quality of the atrial sensing amplitude as "sufficient" in 97% of the assessed cases. At enrollment (12-month/24-month follow-up), the atrial signal quality and detection were rated as "good" or "excellent" in 92.3% (89.8%/89.9%) and 92.4% (90.1%/91.3%) of assessments, respectively. For 1841 patients (90.2%), remotely transmitted device information was received. The median (mean ± SD, IQR) transmission rate was 92.5% (85.4±18.2%, 81.4-97.3%). 1746 patients (85.5%) matched the inclusion criteria for the quantitative analyses on atrial sensing. 95.6% of available RA sensing amplitude values were ≥1 mV. Based on each patient’s overall median value, the median (mean ± SD, IQR) RA sensing amplitude was 4.6 mV (4.4±2.0 mV, 2.8-6.2 mV). The time course of patient median values stratified by month is shown in the figure. Conclusion The study followed 2041 patients implanted with the DX ICD system for two years. In the vast majority of cases, investigators rated implantation as (very) easy and the atrial signal over 24 months as good/excellent. According to daily, automatic Home Monitoring data, the overall mean P-wave amplitude remained stable throughout the whole follow-up. The MATRIX study demonstrated functionality and clinical utility of the DX concept in an unselected, real-life setting.

Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is a global health problem with high morbidity and mortality. Catheter ablation (CA) can reduce AF burden and symptoms, but AF recurrence (AFr) remains an issue. Simple AFr predictors like P-wave duration (PWD) could help improve AF therapy. Purpose This updated meta-analysis reviews the increasing evidence for the association of AFr with PWD and offers practical implications. Methods Publication databases were systematically searched and cohort studies reporting PWD and/or morphology at baseline and AFr after CA were included. Complete interatrial block (cIAB) was defined as PWD≥120 ms and biphasic morphology in inferior leads. Random-effects analysis was performed using the Review Manager 5.3 and R programs after study selection, quality assessment and data extraction, to report odds ratio (OR) and confidence intervals (CI). Results Among 4175 patients in 22 studies, 1138 (27%) experienced AFr. Patients with AFr had longer PWD with a mean pooled difference of 7.8 ms (19 studies, p120 ms (13 studies, p=0.01), 2.42 (1.12-5.21) for PWD>140 ms (2 studies, p=0.02), 3.97 (1.79-8.85) for cIAB (6 studies, p150 ms (2 studies, p Conclusion PWD is an independent predictor for AF recurrence after LA ablation. The AFr risk is increasing exponentially with PWD prolongation. This could facilitate risk-stratification by identifying high-risk patients (cIAB, PWD>150 ms) and adjusting follow-up or interventions.

Funding Acknowledgements Type of funding sources: Private hospital(s). Main funding source(s): Heart center of Leipzig Background Cardiac sarcoidosis (CS) is frequently unrecognized cause of non-ischemic cardiomyopathy associated ventricular tachycardia (VT), who eventually require VT ablations because of refractory VTs; however, the reported long-term outcomes after VT ablation are conflicting. Because of the low diagnostic yield of the endomyocardial biopsy (EMB), diagnosis of CS is often based on clinical and imaging criteria, which can lead to misdiagnosing. Purpose and objectives The purpose of this study was to identity whether patients with histologically-proven CS (EMB+) have different patient, procedural characteristics and outcomes after VT ablation as compared to those in whom the diagnosis was based on clinical criteria only (EMB-). Methods Between 2015-2021, 153 patients with suspected CS were evaluated according to a specified protocol including CMR, 18FDG-PET, EMB, bronchoscopy and EBUS biopsy, and serum markers. Those who fulfilled the latest criteria for CS of the Japanese Circulation Society (JCS) were divided into 2 groups: EMB (+) CS proven by myocardial biopsy, and EMB (-) CS fulfilling the clinical criteria for CS. The following endpoints were defined: 1) VT recurrence after ablation; and 2) the composite endpoint of death, heart transplantation or LVAD implantation. Results We identified 76 patients fulfilling the JCS criteria for CS (mean age 50 ± 10.6 years, 38% female, EMB (+) 35.5%). The leading symptoms were as follows: sustained VT in 23 (30%), high-grade AV block in 23 (30%), heart failure in 18 (24%), and other in 12 pts (16%). EMB (+) and the EMB (-) patients had similar clinical characteristics except for the imaging findings. EMB (+) patients exhibit LGE in CMR in 96% vs. 73% in EMB (-); P=0.024, whereas 18FDG-PET showed abnormal myocardial activity in 91% in the EMB (+) vs. 65% in the EMB (-); P=0.028. The primary composite endpoint was reached in 7.4% in EMB (+) group and in 12.2 % in EMB (-) group; P = 0.7. VT ablation was performed in 15 cases: 9 ablations (33%) in EMB (+) vs. 6 ablations (12%) in EMB (-); P=0.037. At the end of the procedure, all inducible VTs were successfully ablated in 100% of the EMB (-) patients vs. 56% in EMB (+) patients; P=0.1. VT recurrence was 78% in EMB (+) group vs. 67% in EMB (-); P = 0.6. The only procedural difference between the groups was the presence of vast RV low-voltage areas in 67% of the EMB (+) vs. 0% in EMB (-); P = 0.028. Conclusions Patients with CS and positive EMB exhibit more often LGE in CMR, abnormal 18FDG-PET activity and required more frequently VT ablation. The procedural characteristics between both groups were similar, except for the frequently observed RV low-voltage areas in most EMB (+) patients, whereas the RV was not affected in any of the EMB (-) patients. In spite of these differences, the VT recurrence rates and the survival seemed not to be affected by the histological evidence of CS in EMB.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany Introduction Device-detected atrial high-rate episodes (AHRE) and their burden progression are associated with an increased risk for thromboembolic events in correlation with CHA2DS2-VASc score and AHRE burden. To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend the monitoring of AHRE progression along pre-specified strata (6min… Methods From the MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems) registry, we analyzed remotely transmitted, and electrogram (IEGM) AHREs in a subset of patients with remote transmissions and without history of long-standing AF at baseline. For each patient, we selected the first occurring episode per duration stratum and the first subsequent occurrence when progressing to a stratum of any longer duration. After episode adjudication by an independent electrophysiologist, we assessed the classification performance of the device (positive predictive value [PPV]) and analyzed AHRE onset and progression pathways. Results Of the MATRIX cohort, 1,746 patients matched the inclusions criteria (see table for patient characteristics) and 1,451 had no AF history. Of the 258 patients with AHREs (14.8%), 450 out of 465 evaluated episodes were correctly classified as AHRE. Reasons for misclassification were artifact (13) and R-wave oversensing (2). PPV was 96.8% (95% confidence interval 94.7%-98.2%). Grouped by stratum, PPV was 93.9%, 99.5% and 100% for 6min… Discussion and Conclusion: The single-chamber ICD with atrial sensing capabilities correctly classified ≈97% of all adjudicated AHREs ≥6min. About 7% of patients had device-detected AHRE onset and/or progression and a mid to high stroke risk. These patients would potentially benefit the most from a guideline-conform AF monitoring strategy to timely initiate anticoagulation medication for stroke prevention.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): The study was partially supported by an investigator initiated grant from Biosense Webster (a Johnson & Johnson company) Background Recurrent sustained ventricular tachycardia (VT) due to nonischemic dilated cardiomyopathy (DCM) is difficult to treat and long-term outcome data are limited. Objective We aimed to identify predictors for mortality or heart transplantation (MHT) and VT recurrence. Methods Consecutive DCM patients accepted for VT catheter ablation (RFCA) in 9 centers were prospectively enrolled and followed. Results Of 281 consecutive patients (age 60±13yrs, 85% men, LVEF 36±12%) 35% had VT storm, 20% incessant VT, and 68% failed amiodarone. During a median follow-up of 21 (IQR 6-30) months after RFCA (epicardial in 58%, no RFCA due to inaccessible target in 6.4%), 67(24%) patients died/underwent HT and 138(49%) had VT recurrence (45 within 30 days defined as early); the cumulative 4-year rate of VT or MHT was 70% and of MHT 38%. In multivariable analysis predictors of MHT were early VT recurrence (HR 2.92 (CI1.37-6.21), p MHT per 100 person-years was 40.4 after early VT recurrence and significantly higher, compared to 14.2 after later VT recurrence and to 8.5 after RFCA with no VT recurrence (both p Patients with early recurrence and LVEF≤32% had a 1-year MHT rate of 55% (figure). VT recurrence was predicted by prior ICD shocks, basal antero-septal VT origin, and procedural failure but not LVEF. Conclusion DCM patients needing RFCA for VT are a high-risk group. Following RFCA half remain free of VT recurrences. Early VT recurrence with LVEF

Funding Acknowledgements Type of funding sources: None. Background Transvenous lead extraction (TLE) is the mainstay therapy for device-related infections. Though TLE procedures are associated with low complication and high success rates, risk factors for major procedure-related complications remain not well defined. Purpose To evaluate the safety and efficacy of TLE in a large single centre cohort and to identify risk factors for major complications. Methods All consecutive patients undergoing TLE in our department between May 2012 and December 2021 were included in a prospective registry. Our protocol for TLE followed a stepwise approach according to lead dwell time and estimated complexity of the procedure: use of simple traction ± locking stylet (LS) ± mechanical and/or powered sheaths ± snare technique via a femoral or jugular access. Patient characteristics, procedural data and complications were gathered and analysed. Logistic regression analysis was applied to identify risk factors for major procedure related complications. Results A total of 2218 leads (25.7% ICD leads) were targeted for TLE in 1060 patients (67.7 ± 14.8 years; 74% male). The mean lead dwell time was 82 ± 62 months. The leading indication for TLE was cardiac device related infection (CDRI) in 695 patients (65.6%), 373 (35.2%) had systemic and 322 (30.4%) localized infection. Leads were extracted by simple traction in 30%, traction with LS in 3.7%, dilator sheaths with LS in 47.7%, and additional use of powered mechanical sheaths in 14.6%. The snare technique was used in 3.9%, with additional venous entry from femoral in 3.5% and jugular in 1.0% of all targeted leads. TLE was completely successful in 92.6%, partially successful with lead fragments Twenty-nine patients (2.7%) experienced minor and 18 patients (1.7%) had major procedure-related complications (cardiac tamponade/perforation) including 2 intraprocedural deaths (0.2%). Presence of abandoned leads (HR 8.41, 95% CI 3.21–22.02; p Conclusion TLE is feasible, effective and safe in our large single centre experience. Overall complication and failure rates are low. Following our TLE protocol, the presence of abandoned leads, a right-sided implantation and dwelling time of the extracted leads were associated with major procedure-related complications.

Cardiac magnetic resonance imaging (cMRI) now rates among the established diagnostic procedures for the clarification of cardiac disease patterns. In modern clinical electrophysiology, apart from providing basic cardiac diagnostics of patients prior to interventional procedures, the imaging method enables the three-dimensional reconstruction of cardiac target structures of the planned ablation procedure, which can significantly improve the safety and efficacy of the intervention. Furthermore, cMRI has a high significance with respect to risk stratification during implantable cardioverter defibrillator (ICD) evaluation. In addition to an exact determination of ventricular function, its capability for detailed tissue characterization enables the visualization and quantification of fibrotic lesions and scar tissue as potential arrhythmogenic triggers. This anatomic assignment also enables an increased accuracy of the ablation of substrate-based arrhythmia. In comparison to this the interventional cMRI as a direct interface between cMRI and invasive electrophysiology represents a comparably new field of application. Initial clinical experiences in the field of ablation of typical atrial fibrillation could not only confirm the feasibility of the concept but also enabled recognition of the clear advantages of an imaging-guided electrophysiological procedure.Die kardiale Magnetresonanztomographie (CMR) zählt mittlerweile zu den etablierten diagnostischen Verfahren in der Abklärung kardialer Krankheitsbilder. In der heutigen klinischen Elektrophysiologie ermöglicht die Bildgebungsmethode abseits der kardialen Basisdiagnostik bei Patienten vor interventionellen Eingriffen die Erstellung von dreidimensionalen Modellen der kardialen Zielstrukturen des geplanten ablativen Verfahrens, was Effizienz und Sicherheit des Eingriffs maßgeblich verbessern kann. Des Weiteren besitzt die CMR einen wesentlichen Stellenwert in der Risikostratifizierung im Rahmen der ICD(implantierbarer Kardioverter-Defibrillator)-Evaluation. Neben einer genauen Bestimmung der Pumpfunktion sind dank der detaillierten Gewebecharakterisierung die Darstellung und Quantifizierung von fibrotischen Arealen bzw. Narben als potenziellen arrhythmogenen Triggern möglich. Diese anatomische Zuordnung erlaubt zudem eine erhöhte Treffsicherheit im Rahmen der Ablation von substratgebundenen Arrhythmien. Im Vergleich hierzu stellt die interventionelle CMR als direkte Schnittstelle zwischen invasiver Elektrophysiologie und CMR-Bildgebung ein noch recht neues Betätigungsfeld dar. Erste klinische Erfahrungen im Bereich der Ablation von typischem Vorhofflattern konnten nicht nur die Machbarkeit des Konzepts belegen, sondern auch die klaren Vorteile einer bildgebungsgesteuerten elektrophysiologischen Prozedur erkennen lassen.

Ventricular cardiac rhythm disorders are potentially life-threatening arrhythmias. Ventricular tachycardia (VT) in patients with structural heart disease carries an increased risk of sudden cardiac death. Interventional radiofrequency catheter ablation is increasingly becoming the focus of treatment for ventricular arrhythmias. So far, no randomized study has been able to demonstrate a reduction in mortality; however, depending on the existing cardiomyopathy, interventional VT ablation has proven to be more effective for rhythm stabilization than antiarrhythmic therapy and is subsequently associated with improve quality of life through reduced implantable cardioverter defibrillator (ICD) treatment. The aim of this work is to discuss the pathophysiology, mechanism and treatment of VT with structural heart disease in order to define the role of catheter ablation.Die ventrikuläre Herzrhythmusstörung ist eine potenziell lebensbedrohliche Herzrhythmusstörung. Ventrikuläre Tachykardie (VT) bei Patienten mit struktureller Herzerkrankung birgt ein erhöhtes Risiko für einen plötzlichen Herztod. Die interventionelle Radiofrequenzkatheterablation rückt zunehmend in den Fokus der Therapie, um ventrikuläre Rhythmusstörung zu behandeln. Bisher konnte keine randomisierte Studie eine Mortalitätsreduktion nachweisen, jedoch zeigte sich je nach bestehender Kardiomyopathie, dass die interventionelle VT-Ablation effektiver zur Rhythmusstabilisierung ist als die antiarrhythmische Therapie und konsekutiv mit einer verbesserten Lebensqualität durch reduzierte ICD(implantierbarer Kardioverter-Defibrillator)-Therapien einhergeht. Ziel dieser Arbeit ist es, die Pathophysiologie, den Mechanismus und die Therapie bei VT mit strukturellen Herzerkrankungen zu diskutieren, um die Rolle der Katheterablation zu definieren.

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

A 77-year-old man with ischemic cardiomyopathy, severely reduced left ventricular function, and biventricular defibrillator for primary prevention received catheter ablation for multiple ventricular tachycardia despite amiodarone treatment. A few weeks later, the patient presented with unspecific symptoms such as general malaise and nausea.Ein 77-jähriger Patient mit ischämischer Kardiomyopathie, hochgradig eingeschränkter linksventrikulärer Funktion und primärprophylaktischem biventrikulärem Defibrillator erhält wegen multipler ventrikulärer Tachykardien unter Amiodaron eine Katheterablation. Einige Wochen später stellt sich der Patient mit unspezifischen Symptomen, Unwohlsein und Übelkeit bei durchgehender biventrikulärer Stimulation erneut vor.

Atrial fibrillation is the most common supraventricular arrhythmia with increasing incidence and prevalence. Until now, thermal energy sources such as radiofrequency or cryoablation have been used for pulmonary vein isolation of atrial fibrillation but these have led to indiscriminate tissue destruction in the target area. Pulsed field ablation (PFA) is an energy modality that does not utilize thermal effects. An ultrarapid electric field produces irreversible changes in cell membrane pores (irreversible electroporation) culminating in cell death. The myocardium is very sensitive to PFA compared to the esophagus, the pulmonary veins or the phrenic nerve. Consequently, it is possible to perform effective ablation of the pulmonary veins in a very short time and to make the treatment time more effective without causing relevant collateral damage. The treatment offers a potential paradigm shift from catheter ablation of cardiac arrhythmia.Vorhofflimmern ist die häufigste supraventrikuläre Herzrhythmusstörung mit steigender Inzidenz und Prävalenz. Bisher werden zur interventionellen Behandlung im Rahmen einer Pulmonalvenenisolation thermische Energiequellen, z. B. Radiofrequenz oder Kryoablation, angewandt, die jedoch nicht nur Myozyten, sondern auch benachbartes Gewebe zerstören. PFA („pulsed field ablation“) ist eine Energieform, die sich keine thermischen Effekte zunutze macht. Mittel eines nur Sekunden anhaltenden elektrischen Impulses erfolgt eine irreversible Veränderung der Zellmembranporen (irreversible Elektroporation). Das Myokard reagiert im Vergleich zum Ösophagus, den Pulmonalvenen oder dem Nervus phrenicus sehr sensibel auf diese Form der Energieabgabe. Konsekutiv ist es möglich, in kürzester Zeit eine effektive Ablation der Lungenvenen vorzunehmen, ohne anliegendes Gewebe zu verletzen.

The specification of standard operating procedures (SOPs) is a basic requirement for a successful implementation of telemonitoring with implanted cardiac devices and with external measuring devices in patients with heart failure, cardiac arrhytmia or increased risk of sudden cardiac death. The following article summarizes the possibilities of telemonitoring from a technical and organizational point of view and descibes basic requirements on SOPs. these basic requirements should be further specified and anchored in the organizational structure of the individual telemonitoring concept. Moreover, they should de understood as a basic guideline fpr the actions of telemonitoring center (TMC) employees.

BackgroundThere is discussion evolving around the emergence of different phenotypes of Covid-19-associated thromboembolic disease, i.e. acute pulmonary embolism vs pulmonary thrombosis and different phenotypes of in situ thrombosis. With this study, we wish to provide hospitalization, treatment and in-hospital outcome data for pulmonary embolism during the 2020 Covid-19 pandemic and a corresponding 2016 – 2019 control period.MethodsWe performed a retrospective analysis of claims data of Helios hospitals in Germany. Consecutive cases with a hospital admission between January 1 and December 15, 2020 and pulmonary embolism as primary discharge diagnosis were analyzed and compared to a corresponding period covering the same weeks in 2016 – 2019.ResultsAs previously reported for other emergent medical conditions, there was a hospitalization deficit coinciding with the 1st pandemic wave. Beginning with the 12-week interval May 6 – July 28, there was a stable surplus of hospital admissions in 2020. During this surplus period (May 6 – December 15, 2020), there were 2,449 hospitalizations including 45 PCR-confirmed Covid-19 cases (1.8%) as opposed to 8,717 in 2016 – 2019 (IRR 1.12, 95% CI 1.07 – 1.18, PPP=0.28), the presence of thrombosis (46.1 vs 45.4%, P=0.55) and surgery (3.8 vs. 4.3%, P=0.33) were comparable, coagulopathy (3.3 vs 4.5%, P=0.01) and metastatic cancer (3.0 vs 4.0%, P=0.03) as contributing factors were less frequently observed during the 2020 surplus. Interventional treatments (thrombolytic therapy, thrombectomy or inferior vena cava filter placement) were less frequently used (4.7 vs 6.6%, OR 0.72, 95% CI 0.58 − 0.89, P< 0.01). Similarly, intensive care (35.1 vs 38.8%, OR 0.83, 95% CI 0.75 − 0.92, P< 0.01) and mechanical ventilation utilization (7.2 vs 8.1%, OR 0.88, 95% CI 0.74 – 1.04, P=0.14) as well as in-hospital-mortality rates (7.8 vs 9.8%, OR 0.76, 95% CI 0.64 − 0.90, P< 0.01) were lower in 2020 compared with 2016 – 2019. This was associated with a shorter length of hospital stay (6.4 ±5.4 vs. 7.2 ±5.7 days, P< 0.01) during the 2020 surplus period.ConclusionsOnly a minority of cases were associated with PCR-confirmed Covid-19 but this does not rule out preceding or undetected SARS-CoV-2 infection. Although there is a shift towards milder disease course, the increased incidence of hospitalizations for pulmonary embolism requires immediate attention, close surveillance and further studies.

Background Transvenous lead extraction (TLE) has become the mainstay therapy for device-related infections. Though TLE procedures are associated with low complication and high success rates, risk factors for major procedure-related complications remain not well defined. Purpose To evaluate the safety and efficacy of TLE in a large single centre cohort and to identify risk factors for major complications. Methods All consecutive patients who had undergone TLE in our department between May 2012 and January 2020 were included in a prospective registry. Our protocol for TLE followed a stepwise approach according to lead dwell time and estimated complexity of the procedure: use of simple traction ± locking stylet (LS) ± mechanical and/or powered sheaths ± snare technique. In case of unsuccessful extraction from the venous entry site, femoral or jugular access was approached. Patient characteristics, procedural data and complications were gathered and analysed. Logistic regression analysis was applied to identify risk factors for major procedure-related complications. Results A total of 1717 leads (443 [25.9%] ICD leads) were targeted for TLE in 810 patients (67±15 years; 76% male). The mean lead dwell time was 83±60 months. The leading indication for TLE was cardiac device related infection (CDRI) in 527 patients (65.1%), of whom 273 (51.8%) had systemic and 254 (48.2%) localized infection. Two hundred eighty-three patients (34.9%) underwent TLE for non-CDRI causes. Leads were extracted by simple traction in 28.2%, traction with LS in 4.1%, dilator sheaths with LS in 50.1%, and additional use of powered mechanical sheaths in 13.0%. The snare technique was used in 4.6%. Venous access for TLE was exclusively from the entry site in 94.8%, combined from femoral in 4.0% and jugular in 1.2%. TLE was completely successful in 96.2%, partially successful in 2.1%, and failed in 1.7% of all attempted leads, which translated to a clinical success rate of 96.8%. Eighteen patients (2.2%) experienced minor and 12 patients (1.5%) had major procedure-related complications (cardiac tamponade/perforation) including one intraprocedural death (0.1%) from fulminant pulmonary embolism. Lead-years-per-patient (HR 1.064, 95% CI 1.032–1.096; p Conclusion TLE is feasible, effective and safe in our large single centre experience. Overall complication and failure rates are low. Following our TLE protocol, dwelling time of the extracted leads and low BMI were associated with major procedure-related complications. Funding Acknowledgement Type of funding source: None

Introduction Cardiac device-related infections (CDRI) are associated with increased in-hospital mortality despite effective treatment by transvenous lead extraction (TLE) and antibiotic therapy. Data on mortality and causes of death are scarce and predictors of mortality are not well defined. Purpose To analyse the incidence and causes of mortality in CDRI and identify predictors of mortality in a large single centre experience. Methods All patients undergoing TLE for CDRI in our department between May 2012 and January 2020 were included in a prospective registry. Patient characteristics, procedural and follow-up data were collected and analysed. A Kaplan-Meier analysis was used to analyse the influence of different infection types on mortality. Univariate and multivariate cox regression analysis was applied to identify risk factors for mortality. Results Among 561 consecutive patients (72±12 years; 77% male) treated for CDRI (51.2% systemic and 48.8% localized infection), 61 patients (10.9%) died during the index hospitalization. The most frequent cause of death was severe systemic infection or sepsis in 38 patients (6.8%), followed by end-stage heart failure (9; 1.6%), respiratory insufficiency (3; 0.5%), ventricular arrhythmias (3; 0.5%), asystole (2; 0.4%), pulmonary embolism (2; 0.4%), acute enteric ischemia (2; 0.4%), mechanical ileus (1; 0.2%), and unwitnessed sudden death (1; 0.2%). Patients who died had significantly more often systemic infections (p Conclusion In-hospital mortality in CDRI is particularly high in patients with severe systemic infection and sepsis despite state-of the-art treatment. Delayed TLE is associated with an increased in-hospital mortality. Therefore, TLE should be performed early in the course of CDRI, particularly in patients with severe systemic infection. Funding Acknowledgement Type of funding source: None

The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects.Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions.A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.HINTERGRUND: Diese Leitlinie ( http://leitlinien.net ) fokussiert ausschließlich auf den infarktbedingten kardiogenen Schock (IKS). Beide Strategien, sowohl die kardiologisch/herzchirurgische als auch die intensivmedizinische, sind zur erfolgreichen Behandlung und zum Überleben der Patienten mit IKS essenziell. Dennoch beschäftigen sich sowohl die europäischen als auch die amerikanischen Leitlinien zu Herzinfarkt und Herzinsuffizienz und auch die Positionspapiere zum kardiogenen Schock nahezu ausschließlich mit den kardiologischen Aspekten.In einem nominalen Gruppenprozess der Delegierten der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung (DGK), der Deutschen Gesellschaft für Internistische Intensiv- und Notfallmedizin (DGIIN), der Deutschen Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie (DGTHG), der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), der Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin (ÖGIAIN), der Österreichischen Kardiologischen Gesellschaft (ÖKG), der Deutschen Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen (DGPR) und der Deutschen Interdisziplinären Vereinigung für Intensivmedizin (DIVI) wurden unter Leitung der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) die Evidenzen zur Diagnose, zum Monitoring und zur Therapie des IKS systematisch gesammelt und – darauf aufbauend – Empfehlungen ausgearbeitet. Lag jeweils nur geringe Evidenz zum IKS vor, wurden auch Studienergebnisse generell zu Intensivpatienten gesichtet und dargestellt, um Analogieschlüsse zu erlauben.Es wurden 95 Empfehlungen – inklusive zweier Statements – erarbeitet und darauf basierend 7 Algorithmen mit konkreten Anweisungen zum Handlungsablauf.

Emerging evidence indicates combination therapy with anticoagulants and antiplatelet agents for atrial fibrillation (AF) will be increasingly required. Numerous studies compare the efficacy and cost-effectiveness of anticoagulation alone in AF, i. e., non-vitamin K oral anticoagulants (NOACs) vs. warfarin. However, the addition of antiplatelet agents with their potential for decreasing thromboembolic stroke counter-balanced by an increased bleeding risk has received less attention. Thus, we evaluated the cost–utility of this combination therapy. We obtained event estimates from our recent meta-analysis of four randomized clinical trials designed to compare NOACs with warfarin in patients with AF. We examined patient subgroups within each trial that received antiplatelet therapy in addition to anticoagulation. Utilities were derived from the literature and cost estimates from the German health-care system. A decision tree was constructed and populated with these parameters. We used a 1-year time horizon because combination therapy is not recommended beyond this time. We calculated the incremental cost–effectiveness ratio (ICER) per quality-adjusted life-year (QALY). The derived ICER was 13,168.50 € per QALY. NOAC prices exerted considerable influence on the calculation. Nevertheless, there is potential for ICER shifts in favor of warfarin, e.g., if warfarin-mediated anticoagulation control is improved and thereby adverse events decrease. Conversely, if NOAC adherence decreases, adverse events could increase. The derived ICER was 13,168.50 € per QALY, consistent with NOACs being cost-effective vs. warfarin when anticoagulation is used with antiplatelet agents. Nevertheless, country-, practice-, and patient-related factors influence the ICER. Our cost–utility calculation should be used a starting point for decision-making.

Background Based on the assumption of trigger elimination, pulmonary vein isolation (PVI) currently presents the gold standard of atrial fibrillation (AF) ablation. Recently, rapidly spinning rotors or focal impulse formation has been raised as a crucial sustaining mechanism of AF. Ablation of these rotors may potentially obviate the need for trigger elimination with PVI. Purpose This study sought to compare the safety and effectiveness of Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation only with the gold standard of pulmonary vein isolation (PVI) in patients with paroxysmal AF. Methods This was a post-market, prospective, single-blinded, randomized, multi-center trial. Patients were enrolled at three centers and equally (1:1) randomized between those undergoing conventional RF ablation with PVI (PVI group) vs. those treated with FIRM-guided RF ablation without PVI (FIRM group). Data was collected at enrollment, procedure, and at 7-day, 3-month, 6-month, and 12-month follow-up visits. The study was closed early by the sponsor. At the time of study closure, any pending follow-up visits were waived. Results From February 2016 until February 2018, a total of 51 (out of a planned 170) patients (mean age 63±10.6 years, 57% male) were enrolled and randomized. Four patients withdrew from the study prior to treatment, resulting in 23 patients allocated to the FIRM group and 24 in the PVI group. Only 13 patients in the FIRM group and 11 patients in the PVI group completed the 12-month follow-up. Statistical analysis was not completed given the small number of patients. Single-procedure effectiveness (freedom from AF/atrial tachycardia recurrence after blanking period) was 52.9% (9/17) in the FIRM group and 85.7% (12/14) in the PVI group at 6 months; and 31.3% (5/16) in the FIRM group and 80% (8/10) in the PVI group at 12 months. Repeat procedures were performed in 45.8% (11/24) patients in the FIRM group and 7.4% (2/27) in the PVI group. The acute safety endpoint [freedom from procedure-related serious adverse events (SAE)] was achieved in 87% (20/23) of FIRM group patients and 100% (24/24) of PVI group patients. Procedure related SAEs occurred in three patients in the FIRM group: 1 femoral artery aneurysm and 2 injection site hematomas. No additional procedure-related SAEs were reported >7 days post-procedure. Conclusions These partial study effectiveness results reinforce the importance of PVI in paroxysmal atrial fibrillation patients and suggest that FIRM-guided ablation alone (without PVI) is not an effective strategy for treatment of paroxysmal AF in most patients. Further study is needed to understand the effectiveness of adding FIRM-guided ablation as an adjunct to PVI in this patient group. Acknowledgement/Funding Abbot

Background Asymmetric and symmetric dimethylarginine (ADMA and SDMA) are post-translationally modified amino-acids that inhibit nitric oxide (NO) production and have been associated with cardiovascular events and death. Recently, an association of ADMA with atrial fibrillation (AF) incidence and prevalence has been described. In this study we analyzed the association of ADMA and SDMA with the progression and recurrence of AF. Methods In total, 254 patients (64±11 years, 67% males, BMI 29±8 kg/m2, 53% paroxysmal AF, 27% low voltage areas (LVA)) undergoing first AF ablation were included into analyses. LVA were determined using high-density maps and defined as Results While no differences were detected for ADMA, the SDMA plasma concentrations were significantly higher in AF patients with CAF and LVA (n=50, median 0.587 μmol/L; inter quartile range (IQR) 0.514–0.689 μmol/L, p=0.029) compared to PAF without LVA (n=90, 0.532; IQR 0.467–0.640 μmol/L), PAF with LVA (n=12, 0.494; IQR 0.444–0.615 μmol/L) and CAF without LVA (n=86, 0.537; IQR 0.465–0.633) μmol/L. There were 28 patients with available follow-up data and 18 patients (64%) had sinus rhythm. These patients had significantly lower SDMA plasma concentrations (0.458; IQR 0.405–0.517 vs. 0.507; IQR 0.449–0.604 μmol/L; p Conclusion Increased SDMA levels correlated with AF progression phenotypes characterized by persistent AF and the presence of LVA. In patients without arrhythmia recurrences ADMA and SDMA levels decreased.

Background Renin-angiotensin-system inhibitors (RASIs) have been suggested as an upstream therapy for selected AF patients; however, the evidence in surgical setting is limited. Objective We aimed to evaluate the role of preoperative RASIs in prevention of postoperative atrial fibrillation (POAF) and adverse events for patients undergoing cardiac surgery. Methods In this collaborative pooled-analysis, both randomized and nonrandomized controlled trials comparing preoperative RASIs with no preoperative RASIs treatment on the incidence of POAF were identified. Sensitivity and subgroup analyses of RCTs were performed to test the stability of the overall-effect, and meta-regression to explore the potential risk of bias. The primary outcome was POAF, and the secondary outcomes includes rate of stroke, mortality and duration of hospitalization. Results Eleven trials involving 27885 patients (male 74%, median age 65yrs) were included. As compared to the control group, preoperative RASIs did not significantly reduce the risk of POAF (OR: 1.04, 95% CI: 0.91–1.19), stroke (OR: 0.86, 95% CI: 0.62–1.19), death (OR: 1.07, 95% CI: 0.85–1.35), composite adverse cardiac events (OR: 1.04, 95% CI: 0.91–1.18), and hospital stay (WMD: −0.04, 95% CI: −1.05 to 0.98). Pooled-analysis of randomized trials showed consistent results. The primary overall-effect was maintained in sensitivity and subgroup analyses. Meta-regression showed that male-gender was a significant risk-factor of POAF and use of Beta-blockers was associated with a significantly reduced risk in developing POAF. Conclusion and relevance This study demonstrates that preoperative RASIs do not offer additional benefit in reducing the risk of postoperative AF, stroke, death and hospitalization in the setting of cardiac surgery. The results provide no support for use of RASIs for the prevention of POAF and adverse events in patients undergoing cardiac surgery.

The specification of standard operating procedures (SOPs) is a basic requirement for a successful implementation of telemonitoring with implanted cardiac devices and with external measuring devices in patients with heart failure, cardiac arrhytmia or increased risk of sudden cardiac death. The following article summarizes the possibilities of telemonitoring from a technical and organizational point of view and descibes basic requirements on SOPs. these basic requirements should be further specified and anchored in the organizational structure of the individual telemonitoring concept. Moreover, they should de understood as a basic guideline fpr the actions of telemonitoring center (TMC) employees.

Atrial fibrillation is the most common form of persistent cardiac arrhythmia with a greatly increasing prevalence due to an aging population and increasing cardiovascular risk factors. Apart from impairment of the quality of life atrial fibrillation is associated with a high morbidity, most importantly stroke and heart failure. The therapy is complex and aims at improving symptoms as well as the prevention of thromboembolic complications, heart failure and aggravating comorbidities. Based on individual patient characteristics and symptoms therapy is mainly based on heart rate control by pharmacological means or therapy for maintaining sinus rhythm. This treatment includes antiarrhythmic drugs and catheter ablation. Current research is aimed at the investigation of the electrophysiological mechanisms of recurrent therapy refractive atrial fibrillation and the question whether the maintenance of sinus rhythm can improve the prognosis of atrial fibrillation.

Syncope is a common problem in clinical practice, which affects approximately 1% of patients admitted to European emergency departments. The clinical practice guidelines for the diagnosis and management of syncope published by the European Society of Cardiology (ESC) are based on the newest scientific data in the field and have provided clinical cardiologists with a structured therapeutic approach for affected patients over many years. The previous ESC guidelines on syncope were published in 2009 and are compared to the most recent edition, which was published in 2018. This review summarizes the most important innovations with respect to the diagnostic principles and treatment of syncope. The initial assessment of the patient and the risk stratification in the emergency department are the focus of the review. Another important topic that is adequately covered in the current guidelines is the rising significance of implantable loop recorders for the evaluation of unexplained syncope and the assessment of potential indications for a definitive treatment with a pacemaker or implantable cardioverter defibrillator (ICD). Additional changes involve the evidence level with respect to the use of other diagnostic (ECG monitoring, tilt testing) and therapeutic measures (indications for pacemaker implantation, catheter ablation of tachycardiac rhythm disorders).

Introduction Atrial natriuretic peptide (ANP) is specifically secreted from the atria in response to tension stress and together with vascular cell adhesion protein-1 (VCAM-1) is associated with AF progression and recurrences. Recently we demonstrated an association between NT-proANP and VCAM1 levels with AF progression phenotypes based on persistent AF and low voltage areas (LVA): paroxysmal AF with/without LVA (PAF−/PAF + ), persistent AF with/without LVA (PersAF ± ). The aim of the current analysis was to investigate NT-proANP and VCAM1 levels in peripheral and cardiac circulation and to analyze potential association with LAA strain. Method The study included 116 patients undergoing first AF catheter ablation. Left atrial appendage (LAA) was analyzed before ablation with mid-esophageal echocardiographic in 2D-speckle tracking imaging. LAA total longitudinal strain (LAA-TLS) was assessed as the absolute difference of the maximal systo-diastolic values in extracted strain-curves. Blood plasma samples from femoral vein and LA were collected before catheter ablation. NT-proANP and VCAM1 were analyzed using commercially available assays. Results There were significant differences between the groups with LAA-TLS ( P 0.001), cardiac NT-proANP ( P = 0.009), and VCAM1 ( P = 0.048). On univariable analysis, age, gender, PersAF, LAA-TLS, renal function, and cardiac NT-proANP and VCAM1 significantly predicted LVA. However, on multivariable analysis, age (OR 1.097, 95%CI 1.009–1.192, P = 0.029), PersAF (OR 4.713, 95%CI 1.131–19.649, P = 0.033), LAA-TLS (OR 0.945, 95%CI 0.898–0.995, P = 0.032) and VCAM1 (OR 1.002, 95%CI 1.000–1.004, P = 0.034) remained significant predictors for LVA. Conclusion Beside age and AF type, LAA-TLS and VCAM1 were significant predictors for LVA. Larger studies analyzing non-invasive predictors for electro-anatomical remodeling in AF patients are needed to prove our results.

Aims The aim was to provide comprehensive information on the use of cardiac implantable electronic device (CIED) and catheter ablation therapy in the European Society of Cardiology (ESC) area. Methods and results The European Heart Rhythm Association (EHRA) has collected data on use of invasive arrhythmia managements since 2008. Fifty-one of the 56 ESC member countries provided data for the EHRA White Book 2015. This analysis is based on the current and previous editions of the EHRA White Book. Up-to-date information on procedure rates for the last 5 years together with information on economic resources, reimbursement systems, and training requirements are presented for each country and the five geographical ESC regions. In 2014, the CIED implantation rates per million population were highest in the Western followed by the Southern and Northern European countries. The catheter ablation activity was largest in the Western followed by the Northern and Southern areas. Altogether the procedure rates were lowest in the Eastern European and in the non-European ESC countries. In the European ESC countries, the procedure rates were 3–10 times higher than in the non-European ESC countries. However, in some countries with a relatively low gross domestic product the procedure rates exceeded the average values indicating that utilization of arrhythmia therapies was not driven merely by the economic factors. Conclusion This analysis indicates that considerable heterogeneity in the availability and utilization of arrhythmia therapies still exist across the ESC area. The data will hopefully aid in directing future activities and promote harmonization of cardiac arrhythmia care in the ESC countries.

In einer prospektiven klinischen Studie mit 155 Patienten mit MADIT–II-Indikation konnte der Nutzen der Technologie des Home-Monitorings (HM) zur Uberwachung von Patienten mit implantierbaren Cardioverter-Defibrillatoren (ICDs) nachgewiesen werden. Die Patienten wurden in eine Gruppe mit 3-monatlicher Vor-Ort-Folgeuntersuchung (3 M) und eine Gruppe mit jahrlicher Vor-Ort-Folgeuntersuchung (12 M) – beide mit kontinuierlichem HM der ICDs – aufgeteilt. Im Ergebnis kam es zu einem leichten Anstieg der ungeplanten Besuche in der 12M-Gruppe (0,64 vs. 0,27 pro Patientenjahr, P = 0,03), aber einer deutlichen Reduktion der gesamten Vor-Ort-Folgeuntersuchungen (1,60 vs. 3,85 pro Patientenjahr, P