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Aims Pulmonary vein isolation using radiofrequency ablation is an effective treatment option for patients with symptomatic atrial fibrillation (AF). Application of high power over a short period of time (HPSD) is reported to create more efficient lesions and may prevent collateral thermal oesophageal injury. This study aims to compare efficacy and safety of two different HPSD ablation approaches using different ablation index settings. Methods and results Consecutive patients undergoing AF ablation with HPSD (50 W; ablation index–guided) using the ThermoCool SmartTouch SF catheter were included. Patients were grouped by ablation protocol: ablation with target ablation index (AI) of 400 on the anterior left atrial wall vs. 300 at the posterior left atrial wall (AI 400/300) or AI 450/350 was performed upon the operator’s preference and compared. Peri-procedural parameters and complications were recorded, and incidences of endoscopically detected thermal oesophageal lesions (EDEL) analysed. Recurrence rates after a mean follow-up of 25 ± 7 months and reconnection patterns in patients undergoing redo procedures were investigated. A total of 795 patients (67 ± 10 years; 58% male; 48% paroxysmal AF) underwent a first AF ablation with HPSD (211 in group AI 400/300 and 584 in group 450/350). Median procedure time was 82.9 ± 24.6 min with longer ablation times in patients with target AI 400/300 due to higher intraprocedural reconnection rates, increased box lesions, and additional right atrial isthmus ablations. EDEL rates among target AI 400/300 procedures were significantly lower (3% vs. 7%; P = 0.019). Correspondingly, AI 450/350 was the strongest independent predictor of post-ablation EDEL (OR 4.799, CI 1.427–16.138, P = 0.011). Twelve-month (76% vs. 76%; P = 0.892) and long-term ablation single procedure success (68% vs. 71%; log-rank P = 0.452) after a mean of 25 ± 7 months were comparable among both target AI groups; however, long-term success was significantly higher for paroxysmal AF compared to persistent AF (12 months: 80% vs. 72%; P = 0.010; end of follow-up: 76% vs. 65%; log-rank P = 0.001). One hundred three patients (16%) underwent a redo procedure during follow-up documented comparable pulmonary vein (PV) reconnection among groups. Multivariate predictors of AF recurrence were age, left atrium (LA) size, persistent AF, and extra-PV ablation targets. Conclusion High-power short-duration AF ablation with target AI of 400 for non-posterior wall and 300 for posterior wall lesions resulted in comparable long-term results compared to higher AI (450/350) ablations with significantly lower risk for thermal oesophageal lesions. Older age, larger LA size, persistent AF, and extra-PV ablation targets were identified in a multivariate analysis as independent risk factors for recurrences of atrial arrhythmias.

ZusammenfassungVorhofflimmern (VHF) und eine Herzinsuffizienz begünstigen sich gegenseitig und treten häufig in Kombination auf. Eine effektive Therapie des VHF inklusive der möglicherweise notwendigen Antikoagulation sollte zentraler Baustein bei Patienten mit eingeschränkter systolischer Funktion und VHF sein. Medikamentöse Therapieoptionen sind in der Regel wenig effektiv, sodass zunehmend Katheterablationsverfahren zur Behandlung dieser Patienten in den Vordergrund gestellt werden. Randomisierte Studien bei selektierten Patienten zeigen nicht nur einen symptomatischen Effekt auf die Herzinsuffizienz, sondern neben Verbesserung der LV-Funktion auch einen Letalitätsbenefit der effektiven Ablation von VHF. In der Zukunft gilt es, Patienten sinnvoll für die Katheterablation zu identifizieren. Ob das reine Vorhandensein von VHF oder eher die VHF-Last bei Patienten mit Herzinsuffizienz entscheidend für die Prognose ist, wird aktuell in weiteren Studien untersucht.

Although the ectopic foci responsible for initiating atrial fibrillation (AF) are usually located in the pulmonary veins (PVs), non-PV sources may initiate AF in approximately 11% of unselected patients with paroxysmal or persistent AF. The superior vena cava (SVC) is one of the most frequent non-PV origins for initiating AF. This study aims to investigate the effect of empirical SVC isolation in redo AF ablation procedures.Consecutive patients undergoing redo AF ablation procedures using a high-power short-duration protocol (HPSD) (50 W; ablation index guided; target AI 350 for posterior wall ablation, AI 450 for anterior wall ablation; CARTO 3 mapping system) were included. Patients with SVC isolation were compared to patients without SVC isolation. Periprocedural parameters and complications were recorded and analyzed. Short-term endpoints included intrahospital AF recurrence, midterm endpoint AF freedom after 3 months, and long-term endpoint AF freedom after 12 months.A total of 276 patients underwent repeat ablation for recurrent AF (67 ± 10 years; 57% male; 31.5% paroxysmal AF). The patients were divided into two groups: redo procedures with SVC isolation vs redo procedure without SVC isolation. Additional LA substrate modification was done based on intraprocedural voltage maps. Baseline characteristics did not differ significantly between the two groups. Median procedure time was 85.4 ± 27.1 min with ablation times of 14.0 ± 8.5 min. Intrahospital AF recurrence occurred in 32 patients (12%) with no difference among both groups: 17 patients (13%) SVC vs 15 patients (10%) No-SVC; p = 0.416. At 3-month follow-up, 47 (17%) presented an AF recurrence during the blanking period: 25 patients (19%) SVC vs 22 patients (15%) No-SVC; p = 0.304). After 12 months, 202 (73%) of all patients were in stable sinus rhythm with no significant difference between the two groups: 93 patients (73%) SVC vs 109 patients (74%) No-SVC; p = 0.853). No significant differences were noted when dividing the patients in paroxysmal or persistent AF with and without SVC isolation.In our series of repeat AF ablation procedures, the addition of empirical SVC isolation to Re-PVI and LA substrate modification did not influence AF recurrence rates. This strategy can however be safe and useful in patients in whom SVC is identified as a trigger of AF.

Aims Very high-power short-duration (vHPSD) via temperature-controlled ablation (TCA) is a new modality to perform radiofrequency pulmonary vein isolation (PVI), conceivably at the cost of a narrower safety margin towards the oesophagus. In this two-centre trial, we aimed to determine the safety of vHPSD-based PVI with specific emphasis on silent oesophageal injury. Methods and results Ninety consecutive patients with atrial fibrillation (AF) underwent vHPSD-PVI (90 W, 3–4 s, TCA) using the QDOT MICRO catheter, in conjunction with the nGEN (Bad Neustadt, n = 45) or nMARQ generator (Bruges, n = 45). All patients underwent post-ablation oesophageal endoscopy. Procedural parameters and complications were recorded. A subgroup of 21 patients from Bad Neustadt underwent cerebral magnetic resonance imaging (cMRI) to detect silent cerebral events (SCEs). Mean age was 67 ± 9 years, 59% patients were male, and 66% patients had paroxysmal AF. Pulmonary vein isolation was obtained in all cases after 96 ± 29 min. No steam pop, cardiac tamponade, stroke, or fistula was reported. None of the 90 patients demonstrated oesophageal ulceration (0%). Charring was not observed in the nMARQ cohort (0% vs. 11% in the nGEN group). In 5 out of 21 patients (24%), cMRI demonstrated SCE (exclusively nGEN cohort). Conclusion Temperature-controlled vHPSD catheter ablation allows straightforward PVI without evidence of oesophageal ulcerations or symptomatic complications. Catheter tip charring and silent cerebral lesions when using the nGEN generator have led to further modification.

To investigate whether the current standard voltage cut-off of0.5 for dense scar definition on endocardial bipolar voltage mapping (EBVM), using a high-resolution multipoint mapping catheter with microelectrodes (HRMMC), correctly identifies the actual scar area described on CT with myocardial thinning (CT MT).Forty patients (39 men; 67.0 ± 9.0 y/o) with a history of transmural myocardial infarction (mean time interval since MI 15.0 ± 7.9 years) and sustained ventricular tachycardia (VT) were consecutively enrolled. A CT MT was performed in each patient before VT ablation. The CT MT 3D anatomical model, including MT layers, was merged with the 3D electroanatomical and EBVM. Different predefined cut-off settings for scar definition on EBVM were used to identify the optimal ones, which showed the best overlap in terms of scar area with the different MT layers.A cut-off value of0.2 mV demonstrated the best correlation in terms of scar area with the 2 mm thinning on CT MT (p = .04) and a cut-off of1 mV best overlapped with the 5 mm thinning (p = .003). The currently used0.5 mV cut-off for scar definition on EBVM proved to be the best area correlation with 3 mm thinning (p = .0002).In order to better identify the real extent of scar areas after transmural MI as described on preprocedural CT MT, higher cut-off values for scar definition should be applied if the EBVM is performed using a HRMMC.

Data about atrial fibrillation (AF) ablation using high-power short duration (HPSD) radiofrequency ablation in the elderly population is still scarce. The aim of our study was to investigate the efficacy and safety of HPSD ablation in patients over 75 years compared to younger patients.Consecutive patients older than 75 years with paroxysmal or persistent AF undergoing a first-time AF ablation using 50 W HPSD ablation approach were analyzed in this retrospective observational analysis and compared to a control group75 years. Short-term endpoints included intraprocedural reconnection of at least one pulmonary vein (PV) and intrahospital and AF recurrence during 3 months blanking period, as well as a long-term endpoint of freedom from atrial arrhythmias of antiarrhythmic drugs after 12 months.A total of 540 patients underwent a first AF ablation with HPSD (66 ± 10 years; 58% male; 47% paroxysmal AF). Mean age was 78 ± 2.4 and 63 ± 6.3 years (p .001), respectively. Elderly patients were significantly more often women (p .001). The procedure, fluoroscopy, and ablation were comparable. Elderly patients revealed significantly more often extra-PV low-voltage areas requiring additional left atrial ablations (p .001). Overall complication rates were low; however, elderly patients revealed higher major complication rates mainly due to unmasking sick sinus syndrome (p = .003). Freedom from arrhythmia recurrences was comparable (68% vs. 76%, log-rank p = .087). Only in the subgroup of paroxysmal AF, AF recurrences were more common after 12 months (69% vs. 82%; log-rank p = .040; hazard ratio: 1.462, p = .044) in the elderly patients. In multivariable Cox regression analysis of the whole cohort persistent AF, female gender, diabetes mellitus and presence of left atrium low-voltage areas, but not age75 years were associated with AF recurrences.HPSD AF ablation of patients75 years in experienced centers is safe and effective. Therefore, age alone should not be the reason to withhold AF ablation from vital elderly patients due to only a slightly worse outcome and safety profile. In paroxysmal AF, elderly patients have more recurrences compared to the younger control group.

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The arrhythmogenic substrate in patients with Chagas cardiomyopathy, arrhythmogenic dysplasia, postmyocarditis nonischemic dilative cardiomyopathy as well as after extensive posterior or anterior wall myocardial infarction is predominantly located epicardially. This can necessitate epicardial access for an effective, substrate-based catheter ablation of the ventricular tachycardia (VT). Anterior percutaneous epicardial puncture represents the standard approach for epicardial VT ablation. The most important anatomical particularities that must be taken into account when performing an epicardial puncture or epicardial VT ablation are epicardial coronary arteries, left phrenic nerve and epicardial fat. The typical anatomic characteristics of the epicardial structures and resulting considerations for epicardial access are discussed here in detail.Das arrhythmogene Substrat kann bei Patienten mit Chagas-Kardiomyopathie, arrhythmogener Dysplasie, postmyokarditischer dilatativer nichtischämischer Kardiomyopathie sowie nach großem Hinter- oder Vorderwandinfarkt epikardial liegen. Zur effektiven, substratbasierten Katheterablation ventrikulärer Tachykardien (VT) kann dies einen epikardialen Zugang notwendig machen. Die perkutane epikardiale Punktion mit anteriorem Zugang stellt in der Regel den Standard-Zugangsweg für eine epikardiale VT-Ablation dar. Die wichtigsten anatomischen Merkmale, die während der epikardialen Punktion bzw. Katheterablation berücksichtigt werden sollten, sind der Verlauf der epikardialen Koronararterien, der linke N. phrenicus und epikardiales Fettgewebe. Das typische Verteilungsmuster inklusive der daraus resultierenden Spezifikationen des epikardialen Approachs sollten dem Untersucher bekannt sein und werden im Detail diskutiert.

High power short duration (HPSD) ablation proved to be an effective and safe ablation technique for atrial fibrillation (AF). In former case series, a significant amount of postablation coagulation at the catheter tip as well as silent cerebral lesions (SCL) in postprocedural cerebral magnetic resonance (cMRI) have been identified in patients undergoing de-novo AF ablations with very high power 90 W short duration (vHPvSD) ablations using the QDot ablation catheter in combination with a novel RF generator (nGEN, Biosense Webster). Therefore, the RF generator software has been recently modified.Consecutive patients undergoing a first AF ablation including pulmonary vein isolation (PVI) with vHPvSD (90 W, with a predefined ablation time of 3 s at posterior left atrium (LA) wall sites and 4 s at other ablation sites) using the QDOT Micro ablation catheter (Biosense Webster) in conjunction with the technically modified nGEN RF generator (software V1c; Biosense Webster) were included. Procedural characteristics including first-pass isolation per pulmonary vein (PV) pair and early reconnection location within the 30-min waiting period were recorded. In all patients postablation endoscopy to document any thermal esophageal injury (EDEL) and in eligible patients a cMRI to detect silent cerebral events (SCEs)/lesions were performed. All acute procedure-related complications were recorded during the time until hospital discharge. Furthermore, short-term and midterm success after 3 and 6-12 months of follow-up was investigated. In total, 34 consecutive patients (67 ± 9 years; 62% male; 68% paroxysmal AF) were included. First-pass isolation of all PVs was achieved in 6/34 (18%) patients. First-pass isolation was seen in 37/68 (54%) of PV pairs. Early reconnection occurred in 11 (32%) patients (including reconnections at posterior LA wall sites n = 6 and at nonposterior sites n = 5). No patient had an EDEL (0%). In 6/23 (26%) patients undergoing postablation cerebral MRI SCEs were identified. In six patients, coagulation on the catheter tip was detected at the end of the procedure. No further peri- or postprocedural complications were detected. Early AF recurrence before discharge was seen in 1/34 (3%) of the patients included in this study. Within 3 months 10/34 (29%) revealed AF recurrence during blanking period. After a mean follow-up of 7 months, 31/34 (88%) patients revealed sinus rhythm.AF ablation using 90 W vHPvSD with a specialized ablation catheter in conjunction with a recently modified RF generator was associated with no EDEL in the whole study cohort and 26% SCEs in a subgroup of patients undergoing acute postablation cerebral MRI. Accordingly, to our previously published results, a relevant number of catheter tip coagulations was identified in this patient cohort even after modifications of the RF generator. The vHPvSD ablation technique using the present and the previous generator seems to be associated with a very low rate of esophageal injury. However, the recently revised generator software also produced a relevant number of catheter tip coagulum formation and SCEs.

Aims Pulmonary vein isolation (PVI) using radiofrequency (RF) ablation is an effective treatment option for patients with atrial fibrillation (AF). This study aims to investigate the safety of high-power short duration (HPSD) with emphasis on oesophageal lesions after PVI. Methods and results Consecutive patients undergoing AF ablation with HPSD (50 W; ablation index (AI)-guided; target AI 350 for posterior wall ablation, AI 450 for anterior wall ablation) using the ThermoCool SmartTouch SF catheter were included. Patients underwent post-ablation oesophageal endoscopy to detect and categorize thermal oesophageal injury (EDEL). Occurrence and risk factors of oesophageal lesions and perforating complications were analysed. A total of 1033 patients underwent AF ablation with HPSD. Of them, 953 patients (67.6 ± 9.6 years; 58% male; 43% paroxysmal AF; 68% first PVI) underwent post-procedural oesophageal endoscopy and were included in further analyses. Median procedure time was 82.8 ± 24.4 min with ablation times of 16.1 ± 9.2 min. Thermal oesophageal injury was detected in 58 patients (6%) (n = 29 Category 1 erosion, n = 29 Category 2 ulcerous). One patient developed oesophageal perforation (redo, 4th AF ablation). No patient died. Using multivariable regression models, increased total ablation time [odds ratio (OR) 1.029, P = 0.010] and history of stroke (OR 2.619, P = 0.033) were associated with increased incidence of EDEL after AF ablation, whereas increased body mass index was protective (OR 0.980, P = 0.022). Conclusion Thermal oesophageal lesions occur in 6% of HPSD AF ablations. The risk for development of perforating complications seems to be low. Incidence of atrio-oesophageal fistula (0.1%) is comparable to other reported series about RF ablation approaches.

Introduction Aim of this study was to evaluate efficacy and safety of ventricular tachycardia (VT) catheter ablation in patients with structural heart disease (SHD) in relation to the presence of an intramural septal substrate. Methods Consecutive patients undergoing VT ablation between January 2019 and October 2020 were included. All patients were stratified based on the presence of relevant septal substrate and freedom from VT recurrences were analyzed. Results In total, 199 consecutive patients (64.2 ± 13.0 years; 89% male; 55% ischemic cardiomyopathy (ICM)) undergoing VT ablation were included. 129/199 patients (65%) showed significant septal substrate (55/90 patients (61%) with non-ischemic cardiomyopathy (NICM) compared to 74/109 patients (68%) with ICM; p = 0.37). Acute procedural success with elimination of all inducible VTs was achieved in 66/70 patients (94%) without and in 103/129 patients (80%) with a septal substrate (p = 0.007). In the cohort including patients with a clinical FU, 15/60 patients (25%) without a septal substrate and 48/123 patients (39%) with a septal substrate experienced VT recurrence during a FU of 8.1 ± 5.9 months (p = 0.069). Conclusion Presence of septal VT substrate in patients with a structural heart disease or coronary artery disease is common. Acute success of VT catheter ablation was significantly higher and mid-term success tended to be higher in patients without a septal substrate.

Endocardial pacing has experienced a tremendous evolution since the 1960s. A lot of challenges associated with pacemaker and ICD devices have already been successfully targeted. However, a relevant number of problems have not been solved to date. Not all patients with accepted indication for biventricular pacing have benefited from cardiac resynchronisation therapy (CRT) despite extensive efforts to reduce the rate of non-responders. Current strategies to optimize lead position, multipolar left-ventricular (LV) pacing leads, new strategies to gain access to the left-ventricle (atrial transseptal or ventricular transseptal access) or alternative right-ventricular (septal, His bundle pacing) pacing sites, and "leadless" LV pacing have the potential to increase response to device-based heart-failure treatment. The opportunity of pacemaker and ICD remote monitoring led to relevant improvements in therapy management by timely detection of events requiring medical or invasive interventions (e.g., external cardioversion of atrial fibrillation, increasing effective biventricular pacing, catheter ablation of ventricular tachycardias, or changes in heart-failure medication). Two completely endocardial leadless "all-in-one" pacemaker systems recently became available. Besides these innovations, new "synergistic" therapy concepts combining catheter ablation and device therapy proved to affect clinical endpoints (e.g., ATAAC study and CASTLE-AF study).

ZusammenfassungDie neue ESC-Leitlinie zum Management von Patienten mit Vorhofflimmern (VHF) aus 2016 gibt einen Überblick über die aktuelle Datenlage zur Diagnostik und Therapie von Patienten mit VHF. Viele Empfehlungen der Leitlinie beruhen auf Expertenmeinung, und eine Anpassung durch zukünftige Studienergebnisse ist wünschenswert. Insbesondere wird ein multidisziplinärer, kooperativer Ansatz der Prävention, Diagnostik und Therapie von Vorhofflimmern in den Vordergrund gestellt. Ziel ist es, Patienten mit Vorhofflimmern in unterschiedlichen Settings optimal zu behandeln, wobei Lebensqualität und Prognose im Vordergrund stehen. Die Behandlung VHF-begünstigender Faktoren oder Komorbiditäten spielt eine entscheidende Rolle in der Prävention und Therapie von Patienten mit VHF. Neben diesen Empfehlungen zur Prävention und frühzeitigen Erkennung von Vorhofflimmern ist ein großer Teil der Leitlinie auf eine adäquate Schlaganfallprophylaxe und Risikostratifizierung ausgerichtet. Weiterhin wird der klinische CHA2DS2-VASc-Score zur Risikoprädiktion und adäquaten Indikation einer oralen Antikoagulation empfohlen. Insgesamt sind die Empfehlungen bei der Antikoagulation auf ein Vermeiden einer Unter- bzw. Überdosierung von Vitamin-K-Antagonisten zugunsten der neuen direkten Thrombininhibitoren verschoben. Die interventionelle Therapie von Vorhofflimmern wird für symptomatische, medikamentös therapierefraktäre Patienten, aber auch als „First-Line“-Therapie bei Wunsch des Patienten empfohlen. Die Einbindung des Patienten in die Prophylaxe und Entscheidungsfindung zur Therapie wird empfohlen und stellt einen zentralen Kernpunkt der Leitlinienempfehlungen dar, wobei kontrollierte Studien zum Nutzen der Einbindung interdisziplinärer Gremien bisher nicht existieren.

Die Pravalenz einer strukturellen Herzerkrankung steigt mit zunehmendem Lebensalter. Daher treten auch ventrikulare Arrhythmien haufiger auf. Die Katheterablation hat sich bei rezidivierenden Kammertachykardien (VT) als effektive Therapieoption mit hoher Sicherheit und guten Langzeitergebnissen herausgestellt. Daten zur Ablation bei Patienten >75 Jahre sind rar, auch wenn diese Patientengruppe in vielen Untersuchungen als Minoritat eingeschlossen war. Eine generelle Ubertragbarkeit der Daten aus jungeren Patientenkollektiven auf eine altere Population ist aufgrund der unterschiedlichen Patientencharakteristika nicht moglich. Studien zu Patientenkollektiven ≥75 Jahre oder ≥80 Jahre zeigen eine vergleichbare Effektivitat der Katheterablation von VT bei mit zunehmendem Alter steigender Komplikationsrate, die v. a. durch Leistenkomplikationen bedingt ist. Die Katheterablation ischamischer VT erscheint auch bei ≥75-Jahrigen effektiv und sicher, ausgiebige Daten zu anderen kardialen Grundkrankheiten fehlen allerdings. Ein epikardiales Vorgehen erscheint auch bei alteren Patienten (≥80 Jahre) moglich und sicher. Aufgrund der hohen Herausforderungen der VT-Ablation bei alteren Patienten einschlieslich der Berucksichtigung der komplexen Komorbiditat sollten diese in spezialisierten Zentren mit hoher Expertise durchgefuhrt werden. Ziel der Katheterablation bei betagten Patienten ist v. a. die Verbesserung der Lebensqualitat und Morbiditat. Das Langzeituberleben ist aufgrund der „Near end of life“-Situation deutlich geringer als bei jungeren Patienten. Eine sorgfaltige Abwagung der alternativen Therapieoptionen, Erfolgsaussichten der Katheterablation sowie deren Risiken unter Berucksichtigung des Leidensdrucks ist bei diesen Patienten entscheidend.

Introduction Ablation index (AI), a novel parameter defining energy application at single ablation lesions, calculated by integration of ablation time, energy, catheter stability, and contact force, has been documented to be associated with effective lesions and higher ablation efficacy. Using a prespecified target AI in addition to acute lesion efficacy may affect local collateral damage like esophageal thermal injury when used for guiding radiofrequency (RF) ablation at the posterior left atrial (LA) wall. Methods and results Consecutive patients undergoing first AF ablations using AI were included. Ablation energy was reduced to 25 W when ablating at posterior LA wall. Two different individually defined AI target values were used (300 and 350 for posterior wall ablation). Esophageal endoscopy (EE) was performed 1 to 3 days after ablation procedure to document and categorize endoscopically detected esophageal thermal lesion (EDEL). Two-hundred and eleven consecutive patients with postprocedural EE were included. Incidence of EDEL was 14% (29 of 211 patients; mild category 1 lesions in 22 of 29 patients (76%) and severe category 2 lesions (ulcers > 5 mm) in 7 of 29 patients (24% of EDEL group, 3% of total group). Ablation time at posterior LA wall (9.5 vs 9.0 minutes [P = .67]) was comparable in patients with and without EDEL. Conclusion LA posterior wall RF ablation adopting AI ≤350 was associated with 14% esophageal thermal injury including 3% of severe esophageal thermal ulcers. This incidence is comparable to historic control groups with non AI-guided AF ablation.

Background— Up to 40% of patients demonstrate endoscopically detected asymptomatic esophageal lesions (EDEL) after atrial fibrillation ablation. Methods and Results— Patients undergoing first atrial fibrillation ablation and postinterventional esophageal endoscopy were included in the study. Occurrence of esophageal perforating complications during follow-up was related to documented EDEL (category 1: erythema/erosion; category 2: ulcer). In total, 1802 patients underwent first atrial fibrillation ablation procedure between January 2013 and August 2016 at our institution. Out of this group, 832 patients (506 male patients, 61%; 64.0±10.0 years) with symptomatic paroxysmal (n=345; 42%) or persistent atrial fibrillation underwent postprocedural esophageal endoscopy. Patients were ablated using single-tip ablation with conventional or surround flow irrigation and circular ablation catheters with open irrigation (nMARQ). In 295 of 832 patients (35%), a temperature probe was used. EDEL occurred in 150 patients (18%; n=98 category 1 EDEL, n=52 category 2 EDEL). In 5 of 832 patients (0.6%), an esophageal perforation (n=3) or an esophagopericardial or atrioesophageal fistula (n=2) occurred 15 to 28 days (19±6 days) after ablation. Two patients (1 atrioesophageal fistula and 1 esophagopericardial fistula) died. Esophageal perforation occurred only in patients with category 2 lesions (absolute risk, 9.6%). In a logistic regression analysis, ulcers were identified to be a significant predictor for esophageal perforating complications. Conclusions— Postablation endoscopy seems to identify patients at high risk of esophageal perforating complications only occurring in patients with category 2 EDEL. One out of 10 postablation esophageal ulcers progressed to perforation, and no patient without esophageal thermal ulcers showed the occurrence of perforating esophageal complications.

The prevalence of structural heart disease increases with higher age, and thereby the basis for ventricular arrhythmias is created. Catheter ablation has been shown to be an effective therapy option that is very safe and achieves good long-term results in patients with recurrent ventricular tachycardia (VT). Data regarding ablation in patients older than 75 years is sparse, although this patient group was included as a minority in most published VT ablation studies. Data from younger patient collectives may not be transferable to older patient cohorts due to differences in patient comorbidities and baseline characteristics.Studies with patient collectives ≥75 years or even ≥80 years show comparable efficacy of catheter ablation for VT; however, the complication rate is higher, mainly due to groin complications, increases. Catheter ablation of ischemic VT appears effective and safe even in ≥75 year olds; however, extensive data for other structural heart diseases are lacking. Epicardial procedures are also possible and safe in older patients (≥80 years). Due to the significant challenges of VT ablation in older patients, including the consideration of complex comorbidities, these should be performed in specialized centers with high expertise.The aim of catheter ablation in older patients is, above all, to improve quality of life and morbidity. Long-term survival is significantly lower due to the "near end of life" situation than in younger patients. Careful consideration of alternative therapy options, chances for success of the catheter ablation, and their risks, taking into account specific patient conditions and symptoms, is crucial in these patients.

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. From February 2002–December 2004, 1,000 consecutive patients underwent PVAI or A + DCCV or AVJA. These patients were matched in a nested case-controlled methodology. Survival rates were compared at the end of 7 years. 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. 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 non-randomized treatment selection, and creates a major limitation in making valid generalization of the findings.

Recent prospective trials of pacing in atrial fibrillation are inconclusive. A substantial suppression of atrial tachyarrhythmias has been observed in patients with brady-tachy-syndrome and high rate of paced vs. intrinsic beats. An improvement in prognosis, incidence of thromboembolism, rehospitalization and improvement in heart failure have been controversally described in different trials. The quality of life improves in most studies in physiologic pacing. This paper presents a short overview on published and ongoing trials in pacing of atrial fibrillation.

Objective: This study was conducted (1) to examine the relationship between left atrial appendage (LAA) flow velocity and pulmonary venous flow (PVF) variables during nonrheumatic atrial fibrillation (AF), and (2) to determine whether a reduction in LAA flow is reflected by the fibrillatory wave amplitude on the surface ECG. Background: Although LAA Doppler echocardiographic signals provide information regarding the velocity and direction of flow only for a localized narrow sample, systolic PVF represents in part the global left atrial function, mainly relaxation. Controversy exists about whether the amplitude of fibrillatory waves recorded on the surface ECG correlates with LAA flow velocity during AF. Measurements and results: Thirty-three patients (20 men, 13 women; mean [6 SD] age, 61 6 11 years) with nonrheumatic AF undergoing transthoracic and transesophageal echocardiography were studied. A correlation between LAA flow velocity and systolic PVF variables (peak systolic velocity, R 5 0.450, p 5 0.009; velocity-time integral of systolic flow, R 5 0.491, p 5 0.004; systolic fraction of PVF, R 5 0.627, p 1 mm) or fine (< 1 mm) in standard ECG lead V1. There was no association between the coarseness of AF and the LAA flow profile. Conclusion: In patients with nonrheumatic AF, a reduction in LAA flow velocity correlates with a reduction in systolic PVF. These hemodynamic changes are not reflected by the ECG fibrillatory wave amplitude. (CHEST 2001; 119:485‐ 492)

Die prospektiven Studien zur Herzschrittmachertherapie bei Patienten mit paroxysmalem Vorhofflimmern zeigten keine ubereinstimmenden Befunde. Eine Suppression der Vorhoftachyarrhythmien gelingt am ehesten bei Patienten mit Bradykardie-Tachykardie-Syndrom und hoher Stimulationsrate. Hinsichtlich einer Verbesserung der Prognose, der Haufigkeit von Thromboembolien, der Rehospitalisierung und einer Verringerung der Herzinsuffizienz sind die Aussagen verschiedener Untersuchungen kontrovers. Die Lebensqualitat ist in einigen Studien bei vorhofbeteiligter Stimulation verbessert. Die vorliegende Arbeit gibt einen Uberblick uber vorliegende und gegenwartig laufende Studien.

Background: While there is agreement that verapamil attenuates the AF- induced refractory period shortening when given before AF induction, controversy exists regarding its effects when given after the onset of persistent AF. This study aimed to compare atrial fibrillatory frequency obtained from the surface ECG in patients with persistent atrial fibrillation (AF) with oral verapamil treatment to those without this treatment. Methods and Results: Surface ECG recordings were performed in 57 patients (34 male, 23 female, mean age 59 ± 11 years) with persistent AF (> 7 days). The frequency content of the fibrillatory baseline was quantified using digital signal processing (filtering, QRST complex averaging and subtraction. Fourier transformation). In 27 patients with verapamil treatment (120 or 240 mg/day for at least 7 days) mean fibrillatory frequency measured 6.4 ± 0.2 Hz, compared to 7.0 ± 0.4 Hz (P = 0.012) in 30 patients without verapamil. In a subset of 20 randomly selected patients (10 with, 10 without verapamil treatment) a 24-hour Holter ECG recording was performed and fibrillatory frequency determined at 4 PM, 10 PM, 4 AM, and 10 AM. While there was a significant frequency reduction in the verapamil treated patients at night (P = 0.011), it remained constant over time in the other patients. Conclusion: In patients with persistent AF, fibrillatory frequency assessed by spectral analysis of the surface ECG is lower in patients taking verapamil. A.N.E. 2002;7(2):92–97

BOLLMANN, A., et al.: Electrocardiographic Characteristics in Patients with Nonrheumatic Atrial Fibrillation and their Relation to Echocardiographic Parameters. The aim of this study was to determine the relation between (1) ECG fibrillatory wave amplitude and left atrial diameter and left atrial appendage (LAA) flow velocity using different ECG recording techniques, and (2) ECG fibrillatory frequency and frequency of LAA contractions in patients with nonrheumatic AF. In 36 patients (22 men, 14 women, mean age 61 ± 11 years) with persistent AF, ECG recordings were performed using a standard 12-lead ECG and an orthogonal ECG lead system using a high gain, high resolution ECG. AF was classified as coarse (fibrillatory amplitude ≥ 1 mm) or fine (fibrillatory amplitude < 1 mm) in leads I, aVF, V1 and corresponding leads X, Y, and Z. Fibrillatory frequency from the ECG was determined by subtracting averaged QRST complexes and applying a Fourier analysis to the resulting signal. Doppler flow was obtained from LAA during transesophageal echocardiography and LAA emptying velocity was determined. Fourier analysis was also applied to the Doppler signal generating the frequency of LAA contractions. Coarse AF was observed in 0, 9, and 18 patients in leads I, aVF, and V, respectively. It was more often (P < 0.05) detected in corresponding leads X (n = 13), Y (n = 31), and Z (n = 23). Fine AF in lead X was associated with a reduced LAA velocity (33 ± 16 cm/s in coarse AF vs 22 ± 13 cm/s in fine AF, P = 0.05). There was neither a relation between AF coarseness in any other ECG lead and LAA flow velocity, left atrial diameter, or echo contrast. In 25 patients with an active LAA flow, the mean frequency of LAA contractions was 6.8 ± 0.8 Hz. The corresponding mean frequency obtained from the ECG was 6.7 ± 0.7 Hz (r = 0.85, P < 0.001). The mean difference between these two measures was 0.04 Hz, and the 95% confidence limits were 0.90 and – 0.82 Hz using the Bland-Altman method. In conclusion, AF coarseness and its relation to LAA flow velocity depend on the ECG recording technique used. LAA contractions represent one mechanical correlate of the electrical fibrillatory activity in AF.

Atrial fibrillatory frequency reflects the atrial refractory period during AF. This study was conducted to investigate noninvasively the diurnal fluctuations of fibrillatory frequency in persistent human atrial fibrillation and to determine the relationship between changes in ventricular rate and fibrillatory frequency. Ambulatory ECGs were recorded in 30 patients (18 men, 12 women, mean age 60 +/- 11 years) with persistent AF (> 24 hours). AF frequency was measured in 1-minute ECG segments by subtracting averaged QRST complexes and applying Fourier analysis to the resulting signals at 4 PM, 10 PM, 4 AM, and 10 AM. Peak frequency was determined in the 3-12 Hz frequency band. Mean fibrillatory frequency measured 6.6 +/- 0.6 Hz (range 5.0-7.8 Hz). Two different frequency patterns were distinguished comparing maximal diurnal versus nocturnal fibrillatory frequency. In six (20%) patients an increase (P = 0.045) in nocturnal fibrillatory frequency (type I) was found. In the remaining 24 (80%) patients a decrease (P < 0.001) in fibrillatory frequency occurred (type II). Type I AF showed a strong inverse correlation between relative changes (percent) in ventricular rate and fibrillatory frequency obtained from two consecutive measurement points (r = -0.88 to -.97, P < 0.01), whereas in type II AF a moderate positive correlation (r = 0.36 to 0.41, P < 0.05) was detected. These data indicate a circadian pattern in AF frequency that concurs with ventricular rate changes suggesting a modulating influence of the autonomic nervous system on atrial electrophysiology in persistent human AF.

Objective: Automatic analysis of the frequency content of the fibrillatory baseline on the surface ECG accurately reflects the average rate of atrial fibrillation (AF). This frequency measurement correlates with the behavior of AF and predicts the response to administration of ibutilide, a new antiarrhythmic drug. Neither the temporal pattern of fibrillatory frequency in spontaneous paroxysmal or persistent AF, nor its response to chronic antiarrhythmic medication has been studied so far. Methods and Results: Holter ECG recordings were made in 20 patients during AF. One minute ECG segments were selected for analysis. The frequency content of the fibrillatory baseline was then quantified using digital signal processing. After high-pass filtering, the QRST complexes were subtracted using a template matching algorithm. The resulting fibrillatory baseline signal was subjected to Fourier transformation, displayed as a frequency power spectrum and the peak frequency (f) was determined. In 11 patients (7 male, 4 female, age 62±10 years) 31 paroxysmal AF episodes were analyzed. Duration ranged from 1 min to 665 min (115±175 min). Initial mean peak f measured 5.1±0.7 Hz (range 3.9 to 6.9 Hz). There was a positive correlation between f and AF duration ( R =0.53, p =0.002). AF of less than 15 min duration ( n =13) showed a lower f (4.8±0.6 Hz) when compared with longer lasting episodes ( n =18, 5.3±0.7 Hz, p =0.03). In short AF episodes f was constant, whereas in longer-lasting episodes f increased to 5.8±0.5 Hz ( p