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Sodium glucose cotransporter 2 (SGLT2) have proven profound positive effects in heart failure with reduced ejection fraction (HFrEF). These effects are independent from the presence of diabetes. Metabolic effects, antiinflammatory, and antifibrotic properties are discussed as underlying mechanisms. Despite a strong correlation of ventricular arrhythmias with HFrEF, the impact of ertugliflozin on the ventricular arrhythmic burden has not been investigated, yet. Therefore, the Ertugliflozin to Reduce Arrhythmic burden in ICD ± CRT patientS (ERASe) trial was designed to investigate the efficacy and safety of ertugliflozin in patients with reduced and midrange ejection fraction (EF) with or without diabetes. METHODS: Within a multicentre, national, randomized, double-blind, placebo-controlled, phase 3b trial we aim to enrol a total of 402 patients across Austria. Patients with reduced or midrange EF and ICD ± CRT therapy3 months and previous ventricular tachycardia (at least 10 documented VT episodes within the last 12 months) are randomized in a 1:1 ratio to ertugliflozin (5 mg once daily orally administered) or matching placebo. The primary endpoint of the ERASe trial is to investigate the impact of ertugliflozin on total burden of ventricular arrhythmias. Further objectives will include number of therapeutic interventions of implanted devices, atrial fibrillation and heart failure biomarkers. CONCLUSION: The ERASe trial will be the first trial to test ertugliflozin in heart failure patients with nonpreserved ejection fraction and ongoing ICD ± CRT therapy regardless of their diabetic status. The ERASe trial may therefore extend the concept of SGLT2 inhibition to improve cardiac remodelling, including reduced arrhythmic burden. Trial registration Identifier EudraCT Nr. 2020-002581-14 / ClinicalTrials.gov Identifier: NCT04600921.

Aims Catheter ablation (CA) is recommended for patients with atrial fibrillation (AF) after failure of antiarrhythmic drugs (AADs). The role of CA as ‘initial therapy’ for AF is to be determined. Methods and results Following PRISMA guideline an up-to-date pooled analysis of randomized data comparing ablation vs. AADs as first-line therapy for symptomatic AF was performed. The primary outcome was recurrence of atrial tachyarrhythmia. The secondary outcomes were improvement in quality-of-life (QoL) and major adverse events. A total of 997 patients from five randomized trials were enrolled (mean age 57.4 years, 68.6% male patients, 98% paroxysmal AF, mean follow-up 1.4 years). The baseline characteristics were similar between the ablation and AADs group. Overall pooled analysis showed that, as compared with AADs, CA as first-line therapy was associated with significantly higher freedom from arrhythmia recurrence (69% vs. 48%, odds ratio: 0.36, 95% confidence interval: 0.27–0.48, P Conclusions Catheter ablation as ‘initial therapy’ was superior to AADs in maintenance of sinus rhythm and improving QoL for patients with symptomatic paroxysmal AF, without increasing risk of serious adverse events.

Aims Anticoagulation for atrial fibrillation patients with liver disease represents a clinical dilemma. We sought to evaluate the efficacy/safety of different anticoagulation, i.e. vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in such patient group. Methods and results This was a pooled-analysis enrolling up-to-date clinical data. Two subsets: subset A (VKA vs. Non-Anticoagulation) and subset B (NOACs vs. VKA) were pre-specified. The study outcomes were ischaemic stroke (IS)/thromboembolism (TE), major bleeding (MB), intracranial bleeding (ICB), gastrointestinal bleeding (GIB), and all-cause mortality. A total of 20 042 patients’ data were analysed (subset A: N = 10 275, subset B: N = 9767). Overall mean age: 71 ± 11 years, mean CHA2DS2-VASc score: 4.0 ± 1.8, mean HAS-BLED score: 3.6 ± 1.2. The majority of the patients had Child-Pugh category (A-B). As compared with Non-Anticoagulation, VKA seemed to reduce the risk of IS/TE [odds ratio (OR): 0.60, P = 0.05], but heighten the risk of all-bleeding events including MB (OR: 2.81, P = 0.01), ICB (OR: 1.60, P = 0.01), and GIB (OR: 3.32, P = 0.01). When compared with VKA, NOACs had similar efficacy in reducing the risk of IS/TE (OR: 0.82, P = 0.64), significantly lower risk of MB (OR: 0.54, P = 0.0003) and ICB (OR: 0.35, P Conclusions VKA appears to reduce the risk of IS/TE but increase all-bleeding events. NOACs have similar effect in reducing the risk of IS/TE and have significantly lower risk of MB and ICB as compared with VKA. NOACs seem to be associated with better clinical outcome than VKA in patients with mild–moderate liver disease.

AimsCryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). The most frequent complication during CB-based PVI is right-sided phrenic nerve injury (PNI) which is leading to premature abortion of the freeze cycle. Here, we analysed reconnection rates after CB-based PVI and PNI in a large-scale population during repeat procedures.Methods and resultsIn the YETI registry, a total of 17 356 patients underwent CB-based PVI in 33 centres, and 731 (4.2%) patients experienced PNI. A total of 111/731 (15.2%) patients received a repeat procedure for treatment of recurrent AF. In 94/111 (84.7%) patients data on repeat procedures were available. A total of 89/94 (94.7%) index pulmonary veins (PVs) have been isolated during the initial PVI. During repeat procedures, 22 (24.7%) of initially isolated index PVs showed reconnection. The use of a double stop technique did non influence the PV reconnection rate (P = 0.464). The time to PNI was 140.5 ± 45.1 s in patients with persistent PVI and 133.5 ± 53.8 s in patients with reconnection (P = 0.559). No differences were noted between the two populations in terms of CB temperature at the time of PNI (P = 0.362). The only parameter associated with isolation durability was CB temperature after 30 s of freezing. The PV reconnection did not influence the time to AF recurrence.ConclusionIn patients with cryoballon application abortion due to PNI, a high rate of persistent PVI rate was found at repeat procedures. Our data may help to identify the optimal dosing protocol in CB-based PVI procedures.Clinical Trial Registrationhttps://clinicaltrials.gov/ct2/show/NCT03645577?term=YETI&cntry=DE&draw=2&rank=1 ClinicalTrials.gov Identifier: NCT03645577.

The enormous progress made in recent years in the field of information and communication technology and also in sensor and computer technology has affected numerous fields of medicine and is capable of inducing even radical changes in diagnostic and therapeutic processes. This is particularly true for cardiology, where, for example, telemetric monitoring of cardiac and circulatory functions has been in use for many years. Nevertheless, broad application of newer telemedical processes has not yet been achieved to the extent one would expect from the encouraging results of numerous clinical studies in this field and the state of the art of the underlying technology. In the present paper, the Working Group on Rhythmology of the Austrian Cardiological Society aims to provoke a critical discussion of the digital change in cardiology and to make recommendations for the implementation of those telemedical processes that have been shown to exert positive effects on a wide variety of medical and economic parameters. The greatest benefit of telecardiological applications is certainly to be found in the long-term care of patients with chronic cardiovascular diseases. Accordingly, follow-up care of patients with cardiological rhythm implants, management of chronic heart failure and secondary prevention following an acute cardiac event during rehabilitation are currently the most important fields of application. Telemedicine is intended to enable high-quality and cost-efficient care for an increasing number of patients, whose care poses one of the greatest challenges to our healthcare system. Not least of all, telemedicine should make a decisive contribution to improving the quality of life of this segment of the population by favorably influencing mortality, morbidity and hospitalization as well as the patient's contribution to treatment.

Background Radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) arising from the inaccessible basal region of the left ventricular summit (LVS) is challenging due to proximity to coronary vessels, epicardial fat, and poor radiofrequency (RF) delivery within the distal coronary venous system. Objective The purpose of this study was to describe the outcomes of an anatomic approach to inaccessible LVS-VAs using bipolar radiofrequency (Bi-RFCA) delivered from the anatomically adjacent left pulmonic cusp (LPC) to the opposite left ventricular outflow tract (LVOT). Methods Patients from 3 centers who had undergone Bi-RFCA for inaccessible LVS-VAs refractory to conventional RFCA using an anatomic approach targeting the adjacent LPC (reversed U approach) with catheter tip pointing inferiorly within the LPC and LVOT were reviewed. Results Seven patients (age 59 ± 12 years; 3 women) underwent Bi-RF from the LPC to the LVOT for LVS-VAs after ≥1 failed conventional RFCA. Bi-RFCA (power 36 ± 7 W; duration 333 ± 107 seconds) resulted in VA suppression in 5 of 7 patients. In 2 cases, Bi-RFCA was successfully performed using dextrose 5% in water. No complications occurred. After mean follow-up of 14 ± 6 months, no recurrent VT was documented in 2 of 2 patients with baseline VT. Mean 84% reduction in premature ventricular contraction (PVC) burden (31% ± 13% vs 4% ± 5% PVCs per day; P = .0027) was documented in the other patients. Conclusion In patients with LVS-VAs arising from the inaccessible region and refractory to conventional RFCA, an anatomic approach using Bi-RFCA from the LPC and opposite LVOT is an effective alternative approach.

Within the last decade, implantable cardioverter‐defibrillator (ICD) systems with non‐transvenous leads were developed in order to minimize complications related to the cardiovascular position of transvenous ICD leads. This national expert consensus gives an overview of potential indications for the implantation of non‐transvenous ICD systems, and provides specific recommendations for implantation, follow‐up, and complication management in patients with subcutaneous ICD. Regarding particular issues like the necessity for shock efficacy testing, or the clinical outcome as compared to transvenous ICD, randomized data are expected in the near future.

Aims Atrial fibrillation (AF) is the most prevalent arrhythmia in western countries. It is associated with increased mortality and morbidity and responsible for hospitalization rates of 10–40% per patient per year. Studies from the UK and the USA have shown that AF is responsible for ∼1% of the total healthcare expenditures in these countries. The only potentially curative treatment is pulmonary vein isolation (PVI). Published health economic data on the impact of PVI mainly consist of simulations of expenditures with assumed efficacy taken from ablation studies. Real expenditure data are missing as well as pre-ablation period data and long-term data. Methods and results We analyse true healthcare expenditures based on inpatient and outpatient data from the Upper Austrian Health Insurance Fund social security system of patients undergoing PVI during 2005 to 2015. We identified 1135 patients undergoing PVI with 268 having multiple procedures. Days of hospitalization and days of sick leave started to rise in the year before ablation. PVI was able to lower both parameters to the level of 1 year before ablation. Comparing four quarters before and after a single-index ablation, a highly significant reduction in inpatient healthcare expenditures was documented. There was a significant, but numerically small increase in outpatient expenditures, resulting in a significant reduction in overall healthcare expenditures. Conclusion Analysing a cohort of the Upper Austrian Health Insurance Fund undergoing PVI, we found significant cost-saving effects on post-interventional healthcare expenditures and a reduction in days of sick leave.

Supplemental Digital Content is available in the text., Background: Cryoballoon-based pulmonary vein isolation (PVI) has emerged as an effective treatment for atrial fibrillation. The most frequent complication during cryoballoon-based PVI is phrenic nerve injury (PNI). However, data on PNI are scarce. Methods: The YETI registry is a retrospective, multicenter, and multinational registry evaluating the incidence, characteristics, prognostic factors for PNI recovery and follow-up data of patients with PNI during cryoballoon-based PVI. Experienced electrophysiological centers were invited to participate. All patients with PNI during CB2 or third (CB3) and fourth-generation cryoballoon (CB4)-based PVI were eligible. Results: A total of 17 356 patients underwent cryoballoon-based PVI in 33 centers from 10 countries. A total of 731 (4.2%) patients experienced PNI. The mean time to PNI was 127.7±50.4 seconds, and the mean temperature at the time of PNI was −49±8°C. At the end of the procedure, PNI recovered in 394/731 patients (53.9%). Recovery of PNI at 12 months of follow-up was found in 97.0% of patients (682/703, with 28 patients lost to follow-up). A total of 16/703 (2.3%) reported symptomatic PNI. Only 0.06% of the overall population showed symptomatic and permanent PNI. Prognostic factors improving PNI recovery are immediate stop at PNI by double-stop technique and utilization of a bonus-freeze protocol. Age, cryoballoon temperature at PNI, and compound motor action potential amplitude loss >30% were identified as factors decreasing PNI recovery. Based on these parameters, a score was calculated. The YETI score has a numerical value that will directly represent the probability of a specific patient of recovering from PNI within 12 months. Conclusions: The incidence of PNI during cryoballoon-based PVI was 4.2%. Overall 97% of PNI recovered within 12 months. Symptomatic and permanent PNI is exceedingly rare in patients after cryoballoon-based PVI. The YETI score estimates the prognosis after iatrogenic cryoballoon-derived PNI. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03645577. Graphic Abstract: A graphic abstract is available for this article.

Background A 19-year-old woman with an established diagnosis of long QT syndrome (LQTS) 2 and underlying KCNH2-mutation was referred to our centre for recurrent polymorphic ventricular tachycardia (VT) and ventricular fibrillation (VF) refractory to medical therapy and bilateral thoracic sympathectomy. Case summary Holter monitoring revealed a relevant premature ventricular complex (PVC) burden of two different morphologies. One PVC was originating from the left anterior fascicle, the other from the left posterior fascicle. Radiofrequency ablation resulted in complete suppression of both spontaneous PVC morphologies with a favourable clinical course over the next 2 years. Discussion This case presents two interesting insights: firstly, the consistent bigeminal pattern of the torsade de pointes triggering PVC. These were retrieved from the device interrogation and correlated with the pattern that was seen at the time of the procedure. Secondly, PVC morphologies suggested an origin from both the left ventricular (posterior and anterior) fascicles, which have not been described so far. This was confirmed by the preceding Purkinje potentials seen at the successful ablation sites in sinus rhythm and during PVC. Ablation of triggering PVCs causing recurrent VT/VF in LQTS 2 is feasible and effective over a mid-term follow-up.

Background and aim Sodium glucose cotransporter 2 (SGLT2) have proven profound positive effects in heart failure with reduced ejection fraction (HFrEF). These effects are independent from the presence of diabetes. Since SGLT2 receptors are not expressed in human myocardium, these cardioprotective effects be indirect or pleiotropic. Besides metabolic effects anti-inflammatory anti-fibrotic properties are discussed. Despite a strong correlation of ventricular arrhythmias with HFrEF, the impact of ertugliflozin on the arrhythmic burden has not been investigated, yet. Therefore, the Ertugliflozin to Reduce Arrhythmic burden in ICD/CRT patientS (ERASe) trial was designed to investigate the efficacy and safety of ertugliflozin in diabetic and non-diabetic HFrEF patients. Methods Methods: Within a multicentre, national, randomized, double-blind, placebo-controlled, phase 3b trial we aim to enrol a total of 402 patients across Austria. Patients with HFrEF or HFmrEF and ICD±CRT therapy >3 months and previous ventricular tachycardia (at least 10 documented non-sustained VT episodes within the last 12 months) are randomized in a 1:1 ratio to ertugliflozin (5mg once daily orally administered) or matching placebo. The primary endpoint of the ERASe trial is to investigate the impact of Ertugliflozin on total burden of ventricular arrhythmias. Further objectives will be the number of therapeutic interventions of implanted devices, atrial fibrillation, heart failure biomarker and changes in physical function quality of life, stress and anxiety. Conclusion The ERASe trial will be the first trial to test ertugliflozin in heart failure patients with non-preserved ejection fraction and ongoing ICD/CRT therapy regardless of their diabetic status. The ERASe trial may therefore extend the concept of SGLT2 inhibition to improve cardiac reverse remodelling, including reduced arrhythmic burden. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): unrestricted grant of MSD

Catheter Ablation (CA) is an effective therapeutic option in treating atrial fibrillation (AF). Importantly, recent data show that CA as a rhythm control strategy not only significantly reduces AF burden, but also substantially improves clinical hard endpoints. Since AF is a progressive disease, the time of Diagnosis-to-Intervention appears crucial. Recent evidence shows that earlier rhythm control is associated with a lower risk of adverse cardiovascular outcomes in patients with early AF. Particularly, CA as an initial first line rhythm control strategy is associated with significant reduction of arrhythmia recurrence and rehospitalization in patients with paroxysmal AF. CA is shown to significantly lower the risk of progression from paroxysmal AF to persistent AF. When treating persistent AF, the overall clinical success after ablation remains unsatisfactory, however the ablation outcome in patients with “early” persistent AF appears better than those with “late” persistent AF. “Adjunctive” ablation on top of pulmonary vein isolation (PVI), e.g., ablation of atrial low voltage area, left atrial posterior wall, vein of Marshall, left atrial appendage, etc., may further reduce arrhythmia recurrence in selected patient group. New ablation concepts or new ablation technologies have been developing to optimize therapeutic effects or safety profile and may ultimately improve the clinical outcome.

Background: As a preventive procedure, minimizing periprocedural risk is crucially important during left atrial appendage closure (LAAC). Methods: We included consecutive patients receiving LAAC at nine centres and assessed the relationship between baseline characteristics and the acute procedural outcome. Major procedural complications were defined as all complications requiring immediate invasive intervention or causing irreversible damage. Logistic regression was performed and included age and left-ventricular function. Furthermore, the association between acute complications and long-term outcomes was evaluated. Results: A total of 405 consecutive patients with a median age of 75 years (37% female) were included. 47% had a history of stroke. Median CHA2DS2-VASc score was 4 (interquartile range, 3–5) and the median HAS-BLED score was 3 (2–4). Major procedural complications occurred in 7% of cases. Low haemoglobin (OR 0.8, 95% CI 0.65–0.99 per g/dL, p = 0.040) and end-stage kidney disease (OR 13.0, CI 2.5–68.5, p = 0.002) remained significant in multivariate analysis. Anaemia (haemoglobin < 12 and < 13 g/dL in female and male patients) increased the risk of complications 2.2-fold. Conclusions: The major complication rate was low in this high-risk patient population undergoing LAAC. End-stage kidney disease and low baseline haemoglobin were independently associated with a higher major complication rate.

This study evaluated the role of adjunctive left atrium posterior wall isolation (PWI) in preventing atrial fibrillation (AF) recurrence.The left atrium posterior wall is an arrhythmogenic substrate that contributes to the development of AF.This was an updated pooled analysis that included clinical data regarding PWI plus pulmonary vein isolation (PVI) in treating AF. The primary outcome was recurrence of atrial tachyarrhythmias.A total of 26 studies with 3,287 patients with AF (age 61.7 ± 10.8 years) were included. Mean follow-up was 15.2 ± 8.4 months. Procedural success to achieve PWI was 92.8%. In paroxysmal AF, adjunctive PWI did not reduce the recurrence of all atrial arrhythmias (P = 0.21) or AF (P = 0.37); however, in persistent AF, adjunctive PWI was associated with substantially lower recurrence of all atrial arrhythmias (risk ratio: 0.74; P 0.001) and AF (risk ratio: 0.67; P = 0.01), particularly when randomized data were included. Subgroup analyses based on meta-regression demonstrated that patients with older age, a larger left atrial diameter, and persistent AF benefited more significantly from the adjunctive PWI. Adjunctive PWI using either radiofrequency or a cryoballoon reduced AF recurrence, whereas using radiofrequency seemed to be associated with higher recurrence rate of atrial tachycardias and/or atrial flutter. Non-BOX adjunctive PWI rather than BOX PWI was associated with significantly lower recurrence of AF. The incidence of procedural adverse events between the PVI+PWI (3.2%) and PVI (2.8%) groups was low and similar. PVI+PWI needed longer ablation and/or procedural time but had similar fluoroscopy time.Adjunctive PWI can be achieved in most patients without compromising safety. Patients with persistent AF appear to benefit from this approach. The ablation technology and/or approach may affect the clinical outcome of PWI.

Aims The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints. Methods and results Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P Conclusion Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.

Objectives: This study sought to evaluate the safety and short-term performance of a novel catheter for very high power–short duration (vHPSD) ablation in the treatment of paroxysmal atrial...

Aims Cerebral thromboembolic events are well-known complications of pulmonary vein isolation (PVI) and can manifest as stroke or silent cerebral embolic lesions. Over the last years, the preferred oral anticoagulation in atrial fibrillation (AF) shifted from vitamin K antagonists (VKA) to non-vitamin K-dependent oral anticoagulants (NOAC). The aim of this study was to compare the incidence of cerebral embolic lesions after AF ablation in patients on VKA versus patients on NOAC, and to identify corresponding clinical and procedural risk factors. Methods A total of 421 patients undergoing PVI (by radiofrequency catheter or cryoballoon) were prospectively included into the study. Of these, 43.7% were on VKA and 56.3% on NOAC treatment. In the NOAC group 38% of patients had an interruption of anticoagulation for 24-36 hours. All patients underwent pre- and postprocedural cerebral magnetic resonance imaging. Results Periprocedural cerebral lesions occurred in 13.1% overall. Of these, three (0.7%) resulted in symptomatic cerebrovascular accidents. Incidence of cerebral lesions was significantly higher in patients on NOAC compared to VKA (16% vs. 9.2% respectively, p = 0.04), as well as in patients that had intraprocedural cardioversions compared to no cardivoersions (19.5% vs. 10.4% respectively, p = 0.03). In multivariate analysis both parameters were found to be independent risk factors for cerebral embolism. No significant difference between interrupted and uninterrupted NOAC administration could be detected. Conclusions In patients undergoing AF ablation, we identified the use of NOAC and intraprocedural cardioversion as independent risk factors for the occurrence of periprocedural cerebral embolic lesions. Abstract Figure. Incidence of cerebral embolic lesions

Zusammenfassend kann eine ununterbrochene orale Antikoagulation mit unterschiedlichen Empfehlungsklassen und Evidenzlevel sowohl fur die VKA- als auch fur die NOAC-Therapie im Rahmen der Pulmonalvenenisolation empfohlen werden. Selbst bei niedrigen CHA2DS2-VASc-Werten ist 3–4 Wochen vor und 8 Wochen nach dem Eingriff eine OAK indiziert. Eine periinterventionelle Uberbruckung mit Heparinen sollte aufgrund erhohter Blutungsereignisse vermieden werden. Der vorliegende Konsens gibt Empfehlungen zum aktuellen Kenntnisstand und wurde ausschlieslich von Mitgliedern der Arbeitsgruppe Rhythmologie der Osterreichischen Gesellschaft fur Kardiologie erstellt, die uber grose praktische Erfahrungen in der Katheterablation und periinterventionellen OAK bei Patienten mit Vorhofflimmern verfugen. Die Veroffentlichung neuer randomisierter und kontrollierter Studien zu diesem Thema wird in den kommenden Monaten erwartet, so dass es sicherlich Anderungen in den Empfehlungen geben wird. Die Arbeitsgruppe fur Rhythmologie der osterreichischen Kardiologischen Gesellschaft wird sich bemuhen, diese S1-Richtlinie regelmasig auf dem neuesten Stand zu halten. Wir hoffen, dass dieser Konsens dazu genutzt wird, die Sicherheit fur Patienten, die einer Pulmonalvenenisolation unterzogen werden, zu erhohen und den behandelnden Arzten einen homogenen Ansatz in Osterreich zu ermoglichen.

Renal denervation (RDN) has been proposed as a novel interventional antihypertensive technique. However, existing evidence was mainly from patients with severe resistant hypertension. The authors aimed to evaluate the efficacy of RDN in patients with resistant hypertension with mildly elevated blood pressure (BP). Studies of RDN in patients with mild resistant hypertension (systolic office BP 140–160 mm Hg despite treatment with three antihypertensive drugs including one diuretic, or mean systolic BP by 24‐hour ambulatory BP measurement [ABPM] 135–150 mm Hg) were included. Two observational and one randomized cohort were identified (109 patients in the RDN group and 36 patients in the control group). Overall, the mean age of patients was 62±10 years, and 69.7% were male. Before‐after comparison showed that RDN significantly reduced ABPM as compared with the baseline systolic ABPM, from 146.3±13 mm Hg at baseline to 134.6±14.7 mm Hg at 6‐month follow‐up and diastolic ABPM from 80.8±9.4 mm Hg at baseline to 75.5±9.8 mm Hg at 6‐month follow up (both P

Aims Cardiac arrhythmias following acute myocardial infarction (AMI) can be associated with major adverse cardiovascular events. Data on the “real incidence” of post-MI arrhythmias are limited. We aimed to determine the rate and burden of cardiac arrhythmias by the use of insertable cardiac monitors (ICM) in patients with preserved left ventricular ejection fraction (LVEF) after AMI. Methods and results In this prospective observational study, patients with LVEF ≥40% who underwent PCI within 7 days following AMI were enrolled to receive an ICM. Primary outcome was the incidence of new-onset atrial fibrillation (AF) measured by the ICM during a follow-up of 2 years; results: Of 165 consecutive patients with AMI, 50 (30.3%) eligible patients were recruited (mean age 57.8 ± 8.3, 88% male). During follow-up, AF was the most frequently detected arrhythmia. Twenty-nine (58%, 95% CI: 42–70%) patients developed new-onset AF, with a cumulative rate of all detected arrhythmias of 65%. Median time to the first detected AF episode was 4.8 months and the peak cumulative AF burden was detected between 3 and 6 months. Twenty-seven (93%) out of 29 patients with AF were asymptomatic. Cox regression analysis found that baseline troponin level (hazard ratio [HR] for 1 ng/mL increment: 1.03, 95% CI: 1.01–1.06, P = 0.01) and CHA2DS2-VASc score of 4 (HR: 11.42, 95% CI: 1.01–129.06, P = 0.04) were independent risk factors of new-onset AF post-AMI. Conclusion AF is a frequent but largely underestimated cardiac arrhythmia after AMI. More rigorous monitoring strategies resulting in crucial medical interventions (e.g. implementation of oral anti-coagulation) are needed. Clinical Trial Registration . Unique identifier: [NCT02492243][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT02492243&atom=%2Feuropace%2Fearly%2F2017%2F01%2F08%2Feuropace.euw344.atom

Background/Introduction The novel catheter with 6 thermocouples for real-time temperature monitoring during irrigated radiofrequency ablation was designed to potentially enhance safety and effectiveness of the Smart Touch Surround Flow (STSF) catheter by incorporating real-time temperature sensing. A supplementary, novel algorithm was developed to modulate power to maintain target temperature during high power/short duration ablation (90W, 4s). Purpose This sub-analysis was performed to examine consistency and reproducibility of the procedural efficiencies and acute success of the novel catheter with optimized temperature control and microelectrodes in treating paroxysmal atrial fibrillation (PAF) across multiple sites from two initial feasibility studies, in standard (QMODE) and high power/short duration (QMODE+) temperature-control ablation modes. Methods The QDOT-MICRO (QMODE, NCT02944968; N=42) and QDOT-FAST (QMODE+, NCT03459196; N=52) studies were both prospective, non-randomized multi-center, clinical investigations completed across 6 and 7 centers, respectively, in Europe. Procedural efficiencies and acute success (PVI via entrance block) was examined across sites within the study. Results In the QDOT-MICRO study, median procedure time (105–155 min), RF ablation time (27.7–39.5 min), and fluoroscopy times (2.2–8 min) during QMODE ablation were similar across the 6 sites. In QMODE+ ablation, median procedure time, RF ablation time, and fluoroscopy times all fall within (84–134 min), (4.8–9.7 min) and (1.1–9.6 min), respectively, across the 7 sites. Fluid delivery by the study catheter was low in both studies: QDOT-MICRO 547±278mL (mean ± SD); QDOT-FAST 382±299. mL (mean ± SD); which is 39.1 and 57.4% lower, respectively, than reported in the SMART SF trial. Esophageal temperature probe was used in the majority of patients (30/42 for QDOT MICRO and 51/52 for QDOT-FAST). Acute PVI was successful in 100% of patients in both studies with no deaths or unanticipated AEs. Conclusion(s) In both feasibility studies, procedural efficiencies were reproducible across study sites in both QMODE and QMODE+, with 100% acute success and good safety outcomes. Efficiencies are likely to improve with further experience. These results need to be confirmed in larger trials. Acknowledgement/Funding Both Studies are Company Sponsored Studies funded by Biosense Webster, Inc.

Background Supraventricular tachycardias induced by dual antegrade conduction via the atrioventricular (AV) node are rare but often misdiagnosed with severe consequences for the affected patients. As long-term follow-up in these patients was not available so far, this study investigates outcomes in patients with dual antegrade conduction in the AV node. Methods and results In this multicentre observational study, patients from six European centres were studied. Catheter ablation was performed in 17 patients (52 ± 16 years) with dual antegrade conduction via both AV nodal pathways between 2012 and 2018. Patients with the final diagnosis of a manifest dual AV nodal non-re-entrant tachycardia had a mean delay of the correct diagnosis of over 1 year (range 2–31 months). Two patients received prescription of non-indicated oral anticoagulation, two further patients suffered from inappropriate shocks of an implantable cardioverter defibrillator. In 12 patients, a co-existence of dual antegrade and re-entry conduction in the AV node was present. Mean fast pathway conduction time was 138 ± 61 ms and mean slow pathway conduction time was 593 ± 134 ms. Successful radiofrequency catheter ablation was performed in all patients. Post-procedurally oral anticoagulation was discontinued, without detection of cerebrovascular events or atrial fibrillation during a long-term follow-up of median 17 months (range 6–72 months). Conclusion This first multicentre study investigating patients with supraventricular tachycardia and dual antegrade conduction in the AV node demonstrates that catheter ablation is safe and effective while long-term patient outcome is good. Autonomic tone dependent changes in ante- vs. retrograde conduction via slow and/or fast pathway can challenge the diagnosis and therapy in some patients. Graphic abstract

The Arrhythmia Working Group of the Austrian Society of Cardiology (OKG) has set the goal of systematically structuring and organizing the acute care of patients with ventricular arrhythmias (VA), i.e. ventricular tachycardia (VT) or ventricular fibrillation (VF) in Austria. Within a consensus paper, national recommendations on the basic diagnostic work-up of VA (12-lead ECG, medical history, family history, laboratory analyses, echocardiography, search for reversible causes, ICD interrogation), as well as further medical treatment and therapeutic measures (indication of coronary angiography, ablation therapy) are established. Since acute ablation of VT is indicated in the current ESC guidelines as a class IB indication for scar-associated incessant VT or electrical storm (ES; ≥ 3 ICD therapies in 24 h) as well as for ischemic cardiomyopathy (iCMP) with recurrent ICD shocks, organizational measures must be taken to ensure that these guidelines can be implemented. Therefore, a VT network will be established covering all areas in Austria, consisting of primary and secondary VT centers. Organizational aspects of an acute VT network are defined and should subsequently be implemented by the participating hospitals. All electrophysiologic centers in Austria that deal with VT ablation are to be integrated into the network in the medium-term. Centers that co-operate in the network are divided into primary and secondary VT centers according to predefined criteria.

In summary, uninterrupted oral antikoagulation can be recommended, with different recommendation classes and levels of evidence, for both, VKA and NOAC therapy, in the framework of PVI. Even with low CHA

Subcutaneous implantable cardioverter-defibrillators (S-ICD) are an innovative and less invasive alternative to transvenous ICD (TV-ICD) in selected patients. We aimed to investigate the underlying diseases and the specific indications for implanting S-ICD in clinical practice, as well as the prevalence of shock delivery and complications.From December 2012, data of 236 patients (30,5% female; age 48,6±16,8years) were gathered from 12 centres in Austria. Follow-up data over a period of 1,7±1,1years were available for 231 patients (in total 359,2 patient-years). Predominant underlying diseases were ischemic cardiomyopathy (iCMP; 32,0%), idiopathic ventricular fibrillation (22,6%) and dilated cardiomyopathy (dCMP; 17,3%). The most frequent indications for implantation were sudden cardiac death survival (27,4%), primary prevention for iCMP (23,9%) and for dCMP (12,8%), and previous explantation of TV-ICD (12,4%). Appropriate shocks were documented in 16 patients (6,9%), iCMP being the predominant underlying disease. Arrhythmia conversion was successful in all patients, efficacy of the first shock was 96%. Inappropriate shock rate was 5,2%, predominantly caused by oversensing of T wave or artefacts. A device upgrade to an ICD system with pacing function was necessary in1%. Clinical complications needing surgical revision occurred in 8 patients (3,5%).S-ICD were mostly implanted for primary prevention, one fourth of our cases were sudden death survivors. Clinical and functional complication rate was relatively low. In conclusion, S-ICD is a safe and efficient alternative in a larger population of ICD candidates, when no cardiac pacing is needed. EC-number: C-136-17.

Background Sufficient electrode-tissue contact is crucial for adequate lesion formation in radiofrequency catheter ablation (RFCA). Objective We assessed the impact of direct catheter force measurement on acute procedural parameters and outcome of RFCA for paroxysmal and persistent atrial fibrillation (AF). Methods Ninety-nine consecutive patients (70% men) with paroxysmal (63.6%) or persistent AF underwent left atrial RFCA using a 3.5-mm open-irrigated-tip (OIT) catheter with contact force measurement capabilities (group 1). For comparison a case-matched cohort with standard OIT catheters was used (99 patients; group 2). Case matching included gender, type of AF, number or RFCA procedures, and type of procedure. Results Procedural data showed a significant decline in radiofrequency ablation time from 52 ± 20 to 44 ± 16 minutes (P = 0.003) with a remarkable mean reduction in overall procedure time of 34 minutes (P = 0.0001; 225.8 ± 53.1 vs 191.9 ± 53.3 minutes). In parallel, the total fluoroscopy time could be significantly reduced from 28.5 ± 11.0 to 19.9 ± 9.3 minutes (P = 0.0001) as well as fluoroscopy dose from 74.1 ± 58.0 to 56.7 ± 38.9 Gy/cm2 (P = 0.016). Periprocedural complications were similar in both groups. Conclusions The use of contact force sensing technology is able to significantly reduce ablation, procedure, and fluoroscopy times as well as dose in RFCA of AF in a mixed case-matched group of paroxysmal and persistent AF. Energy delivery is substantially reduced by avoiding radiofrequency ablation in positions with insufficient surface contact. Additionally 12-month outcome data showed increased efficacy. Such time saving and equally safe technology may have a relevant impact on laboratory management and increased cost effectiveness.

Importance Postoperative atrial fibrillation (POAF) is a well-known complication after cardiac surgery. Renin-angiotensin system inhibitors (RASIs) have been suggested as an upstream therapy for selected patients with AF; however, evidence in the surgical setting is limited. Objective To evaluate the role of preoperative RASIs in prevention of POAF and adverse events for patients undergoing cardiac surgery. Data Sources The PubMed database and the Cochrane Library from inception until December 31, 2018, were searched by using the keywordsrenin-angiotensin system inhibitorsORangiotensin-converting enzyme inhibitorsORangiotensin receptor blockerORaldosterone antagonistANDcardiac surgery. ClinicalTrials.gov was searched from inception until December 31, 2018, by using the keywordspostoperative atrial fibrillation. Study Selection Randomized clinical trials (RCTs) and observational studies comparing the association between preoperative RASI treatment vs no preoperative RASI treatment (control group) and the incidence of POAF were identified. Eleven unique studies met the selection criteria. Data Extraction and Synthesis Pooled analysis was performed using a random-effects model. Sensitivity and subgroup analyses of RCTs were performed to test the stability of the overall effect. Metaregression was conducted to explore potential risk of bias. Main Outcomes and Measures The primary outcome was POAF, and the secondary outcomes included rates of stroke and mortality and duration of hospitalization. Results Eleven unique studies involving 27 885 unique patients (74.4% male; median age, 65 years [range, 58.5-74.5 years]) were included. Compared with the control group, the RASI group did not have a significantly reduced risk of POAF (odds ratio [OR], 1.04; 95% CI, 0.91-1.19;P = .55;z = 0.60), stroke (OR, 0.86; 95% CI, 0.62-1.19;P = .37;z = 0.90; without significant heterogeneity,P = .11), death (OR, 1.07; 95% CI, 0.85-1.35;P = .56;z = 0.59; without significant heterogeneity,P = .12), composite adverse cardiac events (OR, 1.04; 95% CI, 0.91-1.18;P = .58;z = 0.56), or a reduced hospital stay (weighted mean difference, −0.04; 95% CI, −1.05 to 0.98;P = .94;z = 0.07) using a random-effects model. Pooled analysis focusing on RCTs showed consistent results. The primary overall effect was maintained in sensitivity and subgroup analyses. Metaregression showed that male sex was significantly associated with POAF (τ2 = 0.0065;z = 3.47;Q = 12.047;P Conclusions and Relevance The findings from this study suggest that preoperative RASI treatment does not offer additional benefit in reducing the risk of POAF, stroke, death, and hospitalization in the setting of cardiac surgery. The results provide no support for conventional use of RASIs for the possible prevention of POAF and adverse events in patients undergoing cardiac surgery; further randomized data, particularly among those patients with heart failure, are needed.

Aims Currently, fluoroscopy-based catheter visualization is the standard modality in invasive electrophysiological procedures. Recently a new technology for non-fluoroscopic visualization of diagnostic (since 2010) and ablation catheters (since May 2012) has been introduced. The MediGuide™-Technology (MediGuide) projects catheter tips on prerecorded cine loops in a high time resolution. Methods and results We report on MediGuide-based supraventricular tachycardia (SVT) cases [atrioventricular nodal reentry tachycardia (AVNRT), atrioventricular reentry tachycardia (AVRT), Wolff–Parkinson–White syndrome (WPW), ectopic atrial tachycardia (EAT) and typical atrial flutter) from two European centres. In all patients, diagnostic and/or ablation catheters with a special sensor were used to perform the ablation procedures. All procedural data such as acute success, duration of the procedure, fluoroscopy time, and dose and patients' characteristics were analyzed and compared with conventionally ablated patients ( n = 1865). Procedure-related complications during the hospital stay were recorded. A total of 24 consecutive patients were analyzed: no significant difference to the control group was seen in the baseline characteristics. The MediGuide patients were predominantly male (66%), aged 58 ± 14 years and were ablated for 6 AVNRT (25%), 4 AVRT/WPW (17%), 1 EAT (4%), and 13 typical atrial flutter (54%). The acute success rate was 100% (98% in the control group, n.s.). The median fluoroscopy time was 0.5 ± 1.4 min (10.2 ± 9.6 in the control group, P < 0.001), the median fluoroscopy dose was 187 ± 554 cGy cm2 (996 ± 2593 cGy cm2, P < 0.05). Mean procedure time was 70 ± 25 min (60 ± 36 min, n.s.). No complications during the hospital stay were recorded. Conclusion In several different forms of supraventricular tachycardias the MediGuide-Technology contributed to a dramatic reduction in irradiation exposure. With a median fluoroscopy time of 30 s all SVT cases were effectively performed with no complications; the fluoroscopy burden can be significantly reduced not only for the patient but also for the nurses and the physicians performing the case. The overall procedure times are not prolonged due to the use of MediGuide Technology compared with a control group of >1800 patients undergoing conventional ablation procedures.

Aims Left atrial radiofrequency ablation has been shown to carry a risk of asymptomatic cerebral lesions. No data exist in patients under continued oral anticoagulation during the ablation procedure. The aim of this study was to quantify the amount of silent cerebral lesions assessed by pre-procedural and post-procedural magnetic resonance imaging (MRI) in patients under therapeutic international normalized ratio (INR) and to identify clinical or procedural parameters that correlate with cerebral embolism. Methods and results A total of 131 consecutive patients undergoing catheter ablation for paroxysmal ( n = 80, 61.1%) or persistent ( n = 51, 38.9%) atrial fibrillation were included in the study. Pulmonary vein antrum isolation (PVI), roofline, mitral isthmus line, and complex fractionated atrial electrogram (CFAE) ablation using 3.5 mm open-irrigated tip catheters were performed, as needed. All patients underwent pre-procedural and post-procedural cerebral MRI. Post-procedural MRI revealed new embolic lesions in 16 patients (12.2%), all of them asymptomatic. Clinical parameters showing a significant correlation with cerebral embolism in univariate analysis were age ( P = 0.027), persistent atrial fibrillation (vs. paroxysmal; P = 0.039), and spontaneous echo contrast in transesophageal echocardiography ( P = 0.029). Significant procedural parameters were electric cardioversion ( P = 0.041), PVI only ( P = 0.008), and ablation of complex atrial electrograms ( P = 0.005). Independent risk factors in multivariate analysis were age ( P = 0.009), spontaneous echo contrast ( P = 0.029) and CFAE ablation ( P = 0.006). Conclusion Radiofrequency ablation in patients under continued oral therapeutic anticoagulation is associated with a substantial risk of silent embolism detected by cerebral MRI. Therefore, continuation of oral anticoagulation is not able to prevent cerebral embolism. A variety of different clinical and procedural factors seem to contribute to the risk of cerebral lesions.

Background: Electrode-tissue contact is crucial for adequate lesion formation in radiofrequency catheter ablation (RFCA). Objective: We assessed the impact of direct catheter force measurement on acute procedural parameters during RFCA of atrial fibrillation (AF). Methods: Fifty consecutive patients (28 male) with paroxysmal AF who underwent their first procedure of circumferential pulmonary vein (PV) isolation (PVI) were assigned to either RFCA using (1) a standard 3.5-mm open-irrigated-tip catheter or (2) a catheter with contact force measurement capabilities. Using the endpoint of PVI with entry and exit block, acute procedural parameters were assessed. Results: Procedural data showed a remarkable decline in ablation time (radiofrequency time needed for PVI) from 50.5 ± 15.9 to 39.0 ± 11.0 minutes (P = 0.007) with a reduction in overall procedure duration from 185 ± 46 to 154 ± 39 minutes (P = 0.022). In parallel, the total energy delivered could be significantly reduced from 70,926 ± 19,470 to 58,511 ± 14,655 Ws (P = 0.019). The number of acute PV reconnections declined from 36% to 12% (P = 0.095). Conclusions: The use of contact force sensing technology is able to significantly reduce ablation and procedure times in PVI. In addition, energy delivery is substantially reduced by avoiding radiofrequency ablation in positions with insufficient surface contact. Procedural efficacy and safety of this new feature have to be evaluated in larger cohorts. (PACE 2012; 35:1312–1318)

Criteria for Epicardial Origin in Ischemic VT. Objectives: We tested proposed algorithms for idiopathic and nonischemic tachycardias for their ability to identify epicardial LV-VT origins. Backgroud: Several ECG features have been reported to identify epicardial origins for left ventricular tachycardias (LV-VTs) in the absence of myocardial infarction. Only limited data exist in postinfarction patients. Methods: The QRS features of 24 VTs that were ablated from the epicardium and 39 left ventricular VTs ablated from the endocardium were retrospectively analyzed for various 12-lead ECG features previously reported. Results: No ECG feature consistently predicted an epicardial LV-VT origin in infarct-related tachycardias, with epicardial VTs showing slightly longer QRS durations (189 ± 32 ms in epicardial vs 179 ± 37 ms in endocardial, P = 0.28). Pseudo-delta duration was 38 ± 27 versus 47 ± 27 ms (P = 0.2), intrinsicoid deflection time 93 ± 35 versus 86 ± 32 ms (P = 0.4), shortest RS 97 ± 38 versus 99 ± 32 ms (P = 0.77), and median deflection index 0.82 ± 0.25 versus 0.87 ± 0.22 (P = 0.43). The finding of a Q wave in lead I and the absence of a Q wave in the inferior leads failed to predict an epicardial origin in superior LV-VT sites. Q waves in any inferior lead and aVR/aVL-ratio

Ventricular preexcitation caused by right-sided accessory pathways can lead to abnormal septal motion patterns and may be associated with left ventricular (LV) dysfunction and heart failure, despite the lack of a clinical arrhythmia. Hence successful ablation of the accessory pathway abolishes not only preexcitation but also ventricular dyssynchrony in these patients. We describe a case of an asymptomatic 20-year-old male presenting with ventricular Type-B preexcitation combined with LV dysfunction. The individual risk of arrhythmic events was enhanced due to competitive sport activities of the patient and a short antegrade refractory period of the accessory pathway. Hence standard radiofrequency ablation of the right anterolateral accessory pathway was performed, despite no history of tachycardia. After successful accessory pathway ablation, normalization of LV size and function was demonstrated by echocardiography with a long-term follow-up of 4 years.

Ischemic heart disease is characterized by hemodynamic adaptations and an increased risk of ventricular arrhythmias. Frequent premature ventricular complexes (PVCs) have been associated with ventricular reentry arrhythmias and can promote the worsening of left ventricular function. This case report discusses the beneficial effects of catheter ablation of frequent premature ventricular complexes originating remote from the healed myocardial infarction scar in the treatment of progressive heart failure.

Ventrikulare Tachykardien (VTs) sind aufgrund ihrer hamodynamischen Auswirkungen sowie fehlender Induzierbarkeit mittels konventioneller Katheterablationstechniken teilweise nur schwer zu behandeln. Neue elektroanatomische Mappingverfahren ermoglichen die Behandlung betroffener Patienten im Sinusrhythmus. Ziel dieser Untersuchung war es, unsere eigene Erfahrung in der Modifikation des arrhythmogenen Substrats von VTs mittels endo- und epikardialer Techniken zu charakterisieren. Ausgewertet wurden die Daten von 40 konsekutiven Patienten mit Indikation zu einer katheterinterventionellen Behandlung ventrikularer Tachyarrhythmien. Die Lokalisation der Zielregion erfolgte in Abhangigkeit der Induzierbarkeit der VTs mittels Pace-, Aktivierungs-, Entrainment- bzw. Substratmapping. Bei 38 der 40 Patienten konnten im Rahmen von 43 Prozeduren alle klinisch relevanten der insgesamt 56 dokumentierten VT-Morphologien abladiert werden. Es handelte sich bei 20 Patienten um rechtsventrikulare (RV) Tachykardien und bei 20 Patienten um linksventrikulare (LV) Tachykardien. Bei 3 Patienten war eine transthorakale epikardiale Ablation notwendig (n = 1:RVVT; n = 2:LVVT). Bei 4 der 14 Patienten mit implantierbarem Cardioverter-Defibrillator mit mehrfachen Schockabgaben in der Vorgeschichte kam es wahrend der Nachbebachtungszeit erneut zu antitachykarden Therapien des Aggregates (n = 2:Schock; n = 2:Antitachykardes Pacing). Die systematische Kombination verschiedener Mappingverfahren ermoglicht die erfolgreiche Behandlung ventrikularer Tachykardien mittels Katheterablation.

This case study shows a young male presenting a mixture of two disease entities: (1) Brugada syndrome with a nearly-normal baseline electrocardiogram and positive Ajmaline drug challenge as well as (2) idiopathic ventricular fibrillation including extremely short-coupled monomorphic ventricular premature beats (VPB) triggering ventricular fibrillation (coupling interval 318 ± 21 ms). In this phenotypic patient group—more suggestive of idiopathic ventricular fibrillation due to the ultra-short coupling interval of the VPBs—drug treatment with a class IA agent such as Quinidine might be an important option to implantable cardioverter-defibrillator and ablation therapy. (PACE 2010; 33:e84–e87)

Background Induction of gastroesophageal reflux after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) may have an impact on the progression of esophageal injury. Objective The purpose of this study was to assess the acute effect of RFCA on distal esophageal acidity using leadless pH-metry capsules. Methods A total of 31 patients (27 male and 4 female; 25 with paroxysmal AF) who underwent RFCA and esophagoscopy 24 hours before and after ablation were assessed for reflux and esophageal lesions. A leadless pH-metry capsule was inserted into the lower esophagus to screen for pH changes, number and duration of refluxes, and the DeMeester score (a standardized measure of acidity and reflux). No patient had a history of reflux or was taking proton pump inhibitors within 4 weeks before and 24 hours after ablation. Results Five patients (16.1%) who presented with asymptomatic reflux prior to ablation were excluded from further examination. Of the remaining 26 patients, 5 (19.2%) demonstrated a significant pathologic increase in DeMeester score after ablation. No statistical differences in baseline parameters, method of sedation, ablation approach, and total energy delivered on the posterior wall were observed between patients with and those without a pathologic DeMeester score. One patient with asymptomatic reflux prior to ablation developed esophageal ulceration. Conclusion A significant number of patients undergoing RFCA of AF develop pathologic acid reflux after ablation. In addition, a subgroup of patients has a preexisting condition of asymptomatic reflux prior to ablation. This finding may explain a potential mechanism for progression of esophageal injury to atrio-esophageal fistulas in patients undergoing RFCA.

Die Radiofrequenzablation etabliert sich zusehends als kurative Therapieoption fur medikamentos therapierefraktares Vorhofflimmern. Speziell die Ablationstherapie bei Vorhofflimmern ist jedoch mit einem signifikanten Prozedurrisiko verbunden, da diese Prozedur eine der komplexesten elektrophysiologischen Interventionen darstellt. Die Kenntnis haufiger sowie seltener prozedurbezogener Komplikationen, deren Inzidenz, Athiologie und die Nutzung von Praventionsmoglichkeiten sollte die Risiken minimieren und gleichzeitig zu einer Verbesserung des Ablationserfolges beitragen. Unter Zuhilfenahme rezenter internationaler Erhebungen oder Konsensusdokumente und Vergleich mit den Daten unserer Elektrophysiologieeinheit soll eine praxisorientierte Ubersicht uber relevante Komplikationen gegeben werden. Groses Augenmerk soll dabei auf die rechtzeitige Erkennung und die technischen sowie prozedurbezogenen Moglichkeiten zur Vermeidung von Komplikationen gelegt werden.

Purpose of review This review provides an update on the mechanisms, incidence, and current management of significant pulmonary vein stenosis following catheter ablation of atrial fibrillation. Recent findings Catheter ablation involving the pulmonary veins and the surrounding left atrial tissue is increasingly used to treat atrial fibrillation. In parallel with the fact that these procedures may cure a substantial proportion of patients, severe complications have been observed. Pulmonary vein stenosis is a new clinical entity produced by radiofrequency energy delivery mainly within or at the orifice of the pulmonary veins. The exact incidence is currently unknown because the diagnosis is dependent on the imaging modality and on the rigor with which patients are followed up. The optimal method for screening patients has not been determined. Stenosis of a pulmonary vein may be assessed by combining anatomic and functional imaging using computed tomographic or magnetic resonance imaging, transesophageal echocardiography, and lung scanning. Symptoms vary considerably and may be misdiagnosed, leading to severe clinical consequences. Current treatment strategies involve pulmonary vein dilatation or stenting; however, the restenosis rate remains high. The long-term outcome in patients with pulmonary vein stenosis is unclear. Strategies under development to prevent pulmonary vein stenosis include alternate energy sources and modified ablation techniques. Summary Pulmonary vein stenosis following catheter ablation is a new clinical entity that has been described in various reports recently. There is much uncertainty with respect to causative factors, incidence, diagnosis, and treatment, and long-term sequelae are unclear.

Long-term efficacy of pulmonary vein (PV) ostial isolation for paroxysmal atrial fibrillation is difficult to assess. We evaluated the net duration of atrial tachyarrhythmia episodes (burden), atrial tachyarrhythmia episode frequency, and quality-of-life (QOL) before and after PV isolation in patients with an existing pacemaker featuring extensive diagnostic capabilities. Due to frequent recurrences of paroxysmal atrial fibrillation, PV isolation was performed 21 +/- 10 months following pacemaker implantation on 12 patients (57 +/- 5 years) with normal left ventricular function. Atrial tachyarrhythmia burden (ATB) and episode frequency were monitored daily by the device both pre- and postablation. QOL questionnaires were collected at ablation and 1, 3, and 6 months thereafter. Patients were followed for 20 +/- 9 and 11 +/- 9 months pre- and postablation, respectively. Membrane-active antiarrhythmic medications were discontinued after ablation in 8 of 12 patients. PV isolation resulted in a significant reduction of ATB from a median of 3.2 hours/day (preablation) to 0.2 hours/day (postablation, P < 0.01, Wilcoxon signed-rank test). The median tachyarrhythmia frequency was 6.4 episodes/day (preablation) and 0.3 episodes/day (postablation, P = 0.09). QOL measures significantly improved over the data collection intervals (P < 0.05). Tachyarrhythmia burden was positively associated with Symptom Checklist frequency and severity (P < 0.01). Significant long-term reductions in total ATB (symptomatic and asymptomatic) were observed. Furthermore, reductions in ATB were associated with improvements in QOL measures. Extensive monitoring capabilities in implantable devices help provide complete disclosure on the effect of PV isolation in paroxysmal atrial fibrillation patients.

This study summarizes our results in diagnosing and treating pulmonary vein stenosis complicating ablation for atrial fibrillation in 6 of 92 patients. Patients with significant pulmonary vein narrowing underwent either dilatation or dilatation plus stenting. Pulmonary vein intervention produced a favorable clinical course over the following 7 +/- 2 months despite significant restenosis in 2 patients.