Search

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

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

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

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

Summary Background SARS-CoV-2 entry in human cells depends on angiotensin-converting enzyme 2, which can be upregulated by inhibitors of the renin–angiotensin system (RAS). We aimed to test our hypothesis that discontinuation of chronic treatment with ACE-inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) mitigates the course o\f recent-onset COVID-19. Methods ACEI-COVID was a parallel group, randomised, controlled, open-label trial done at 35 centres in Austria and Germany. Patients aged 18 years and older were enrolled if they presented with recent symptomatic SARS-CoV-2 infection and were chronically treated with ACEIs or ARBs. Patients were randomly assigned 1:1 to discontinuation or continuation of RAS inhibition for 30 days. Primary outcome was the maximum sequential organ failure assessment (SOFA) score within 30 days, where death was scored with the maximum achievable SOFA score. Secondary endpoints were area under the death-adjusted SOFA score (AUCSOFA), mean SOFA score, admission to the intensive care unit, mechanical ventilation, and death. Analyses were done on a modified intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT04353596. Findings Between April 20, 2020, and Jan 20, 2021, 204 patients (median age 75 years [IQR 66–80], 37% females) were randomly assigned to discontinue (n=104) or continue (n=100) RAS inhibition. Within 30 days, eight (8%) of 104 died in the discontinuation group and 12 (12%) of 100 patients died in the continuation group (p=0·42). There was no significant difference in the primary endpoint between the discontinuation and continuation group (median [IQR] maximum SOFA score 0·00 (0·00–2·00) vs 1·00 (0·00–3·00); p=0·12). Discontinuation was associated with a significantly lower AUCSOFA (0·00 [0·00–9·25] vs 3·50 [0·00–23·50]; p=0·040), mean SOFA score (0·00 [0·00–0·31] vs 0·12 [0·00–0·78]; p=0·040), and 30-day SOFA score (0·00 [10–90th percentile, 0·00–1·20] vs 0·00 [0·00–24·00]; p=0·023). At 30 days, 11 (11%) in the discontinuation group and 23 (23%) in the continuation group had signs of organ dysfunction (SOFA score ≥1) or were dead (p=0·017). There were no significant differences for mechanical ventilation (10 (10%) vs 8 (8%), p=0·87) and admission to intensive care unit (20 [19%] vs 18 [18%], p=0·96) between the discontinuation and continuation group. Interpretation Discontinuation of RAS-inhibition in COVID-19 had no significant effect on the maximum severity of COVID-19 but may lead to a faster and better recovery. The decision to continue or discontinue should be made on an individual basis, considering the risk profile, the indication for RAS inhibition, and the availability of alternative therapies and outpatient monitoring options. Funding Austrian Science Fund and German Center for Cardiovascular Research.

A universal, mobile protection system for work close to patients suffering from acute infectious diseases with aerosol formation has been developed. It is considered useful by the main medical disciplines involved in the treatment of CoVid patients. In those times, disposable protection gear is scarce, and the robust, reusable protection system might be helpful for medical personnel to work more safely in vulnerable situations.

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

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

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

The second-generation cryoballoon (CBG2) is highly effective for pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF). One-year outcome data are consistent among different research groups. First results suggest that a shortened application time might be equally effective. The objective of the study was to compare procedural and outcome data for a 240 and 180-s protocol. Prospectively, consecutive patients with symptomatic PAF underwent initial PVI with CBG2. In succession, two groups were created: the application time was 240 s in group 1 and 180 s in group 2. In both groups, a bonus application was applied. Periprocedural data, complications, and freedom from atrial fibrillation (AF)/AT/symptoms were compared between the groups. From May 2012 to June 2013, 114 patients (57 per group, 38 % female) were included. The mean left atrial dwelling time decreased by 19 min (−16 %) in group 2 compared to group 1 (p = 0.005). Intraprocedural pulmonary vein (PV) reconduction occurred infrequently (0.4 % in both groups, p = 1.0). One persistent PNP occurred and resolved during the follow-up. Complications were without significant differences. One patient was lost to follow-up. The cumulative rates of freedom from recurrence at 12 months are 76.8 % in group 1 and 83.6 % in group 2. After a mean follow-up of 491 ± 208 days, the rates of freedom from AF/AT/symptoms at last visit were 38/57 (67 %) and 44/56 (78.6 %) in groups 1 and 2 (p = 0.14), respectively. Female sex was identified as a predictor for recurrence. Compared to a protocol with cryoballoon applications of 240 s, a shortened application time to 180 s results in a faster procedure with comparable high rates of freedom from AF at 16 months. Female sex seems to be predictive for recurrences; this finding has to be reconfirmed in a larger population.

A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology.

Hintergrund Die Kryoballonablation ist ein Standardverfahren zur Isolation der Pulmonalvenen bei symptomatischem Vorhofflimmern. Die zweite Generation des Kryoballons wurde 2012 eingefuhrt, eine hohere Effizienz aufgrund mehrerer Verbesserungen des Systems wurde erwartet.

Aims Cryoballoon (CB) ablation with the second-generation cryoballoon (CBG2) seems to be more effective than its predecessor [first-generation cryoballoon (CBG1)], but phrenic nerve palsies were observed more frequently. The aim of this study was to compare the safety and efficacy of CBG1 and CBG2 in a substudy of the prospective multicentre, multinational FREEZE Cohort Study. Methods and results Periprocedural data were analysed, and a total of 532 patients with paroxysmal atrial fibrillation (AF) were examined ( n = 224 for CBG1 and n = 308 for CBG2). Procedure time decreased significantly from 149 to 130 min when comparing CBG1 with CBG2 ( P < 0.0001), and pulmonary vein isolation (PVI) was achieved in 97.8 and 97.6% of PVs with CBG1 and CBG2 ( P = 0.77), respectively. The need for dual-balloon usage within a procedure dropped (20.1 vs. 9.0%, P < 0.001), and the fluoroscopy time was reduced when operating the CBG2. Atrial fibrillation recurrence rates until discharge were similar (5.0 vs. 5.8%, P = 0.69). Comparable low rates of major complications were observed with both CBs, and there was a non-significant trend for more phrenic nerve palsies. Conclusion Second-generation cryoballoon demonstrated a high rate of acute PVI in a significant faster procedure, which also utilized less radiation exposure and less dual-balloon usage during an average procedure. The safety profile remains favourable with a non-significant trend for more phrenic nerve palsies. If the enhancements lead to a higher clinical benefit has to be determined. The 1-year outcome data from the ongoing FREEZE Cohort Study comparing radiofrequency and CB ablation will shed some light on that issue. Clinical Trials.gov Identifier: NCT01360008.

Aims: The FREEZE-cohort study (NCT 01360008) is a prospective observational, multicenter and multinational study to evaluate safety and effectiveness of cryoballoon ablation for pulmonary vein isolation as compared to radiofrequency ablation in patients with paroxysmal or persistent atrial fibrillation (lasting < one year) under the conditions of clinical routine. Methods and Results: The study started in 2011 and anticipates inclusion up to 2000 patients in each of the two treatment groups. A total of 37 centers from 8 countries worldwide, all experienced in at least one of the two ablation techniques, participate in the study. The primary outcome parameter of the study is defined as atrial fibrillation recurrence rate during twelve months of follow-up. Secondary outcome parameters include primary success rates, complication rates in general, specific complications with respect to phrenic nerve palsy and pulmonary vein stenosis, radiation exposure, clinical course including death and repeat ablation. Finally specific procedural aspects will be evaluated in a descriptive manner. Preliminary data of the first 1882 patients show that in clinical practice cryoablation is preferentially performed in patients with paroxysmal atrial fibrillation, whereas application of radiofrequency ablation is equally distributed between patients with persistent and paroxysmal atrial fibrillation. Conclusion: Based on multi-center and multi-national data the FREEZE-cohort study will provide important information on long-term efficacy, clinical effectiveness, complication rates and procedural differences between atrial fibrillation patients treated with either cryoablation or radiofrequency ablation.

Background Catheter ablation is used extensively with curative intention in atrial fibrillation. Radiofrequency ablation has long been a standard of care, while cryoballoon technology has emerged as a feasible approach with promising results. Prospective multicenter registry data referring to both ablation technologies in AF ablation therapy are lacking. Methods Between January 2007 and August 2011, a total of 3,775 consecutive patients with symptomatic paroxysmal AF who underwent PV ablation in their respective centers were enrolled. The cohort was divided into 2 groups according to the ablation energy source used: cryoballoon ablation (group 1, n = 905 [24.0%], median age 63 years, 64.3% men) and RF ablation (group 2, n = 2870 [76.0%], median age 63 years, 62.7% men). Comorbidities and baseline clinical characteristics were similar in both groups. Results Acute success rate was similar in both groups (97.5% in cryo vs 97.6% in RF; P = 0.81). Procedure times were similar, ablation and fluoroscopy times were higher in cryoballoon when compared to RF ablation. Overall complication rate was similar in cryo- (4.6%) and RF-ablation (4.6%; P = 1.0). Phrenic nerve palsy was more often in cryo versus RF ablation (2.1% in cryo vs 0.0% in RF; P Conclusion RF ablation is the most widespread ablation method in Germany, but use of cryoballoon increased significantly. Procedure times were similar, but ablation and fluoroscopy times were longer in cryoballoon ablation. No significant differences were found in terms of acute success and overall complication rate.

Complete occlusion of the pulmonary veins (PV) is crucial for successful PV isolation. While two different sizes of cryoballoons (23 and 28 mm) are available, complete occlusion is not always achieved in any given PV. We investigated the role of PV ostial anatomy during cryoballoon PV occlusion grading and atrial fibrillation (AF) recurrence rate.PV ostial diameter was analyzed in 168 consecutive patients (111 men, 61 ± 10 years, 124 paroxysmal (px) and 44 persistent AF) using cardiac computed tomography (CT) prior to procedure. The ovality index at the PV ostial level was calculated in any given PV. During follow-up, 7-day holter monitors were performed at 1, 3, 6, 9, 12, 18 and 24 months post-ablation.The success rate at 12 ± 6 months follow-up was 69% including a 3-month blanking period (px AF: 66%; persistent AF 77%). The ovality index of the left-sided PVs was significantly larger ("more oval") than that of the right-sided PVs (p0.001). An optimized PV occlusion in all individual PVs (complete occlusion, grading 4/4) was achieved during ablation in 49% of patients with AF recurrence and in 73% of patients without AF recurrence (p=0.004). Patients with AF recurrence had "more oval" left-sided PVs compared to patients free from AF recurrence (LSPV 0.40 ± 0.2 vs. 0.33 ± 0.2; p=0.04 and LIPV 0.41 ± 0.3 vs. 0.32 ± 0.2; p=0.03), whereas no significant association was found for right sided PVs.The ostial PV anatomy seems to have an important impact on clinical outcome and should be considered when planning and performing cryoballoon AF ablation procedures.

Cryoablation for paroxysmal atrial fibrillation (PAF) is well established. The single-big-balloon strategy has been preferred for pulmonary vein isolation (PVI) using the second generation cryoballoon (CBG2). Individual PV-morphologies raise the question if an individualized anatomic approach using the 23-mm or 28-mm CB is reasonable.Consecutive patients were prospectively enrolled in the non-randomized single-center study. Patients were treated with the 28-mm CB, if any PV was21mm, the 23-mm CB, if all PV were ≤21mm, or both sizes, if PVI was difficult. The primary endpoint was arrhythmia-free survival. The secondary endpoint considered procedural results and complications.Overall, 197 patients with symptomatic PAF (64±11 years, 36% female) were included. Acute PVI was achieved in 99.9% of PV. Based on preprocedural imaging, the 28-mm CB was applied as the primary catheter in 47% (92/197 patients), the 23-mm CB in 53% (105/197, p=0.23). The 23-mm CB group included more females, patients with short left atrial (LA)-diameters (each p0.01), and smaller patients (p=0.04). Both CB-sizes were used in 24% (47/197). Additional 23-mm CB usage was necessary in 23% (21/92) of patients, mainly because of insufficient PV-occlusion with the 28-mm CB. Additional 28-mm CB usage was necessary in 25% (26/105, p=0.82), mainly because PV diameters were larger than initially measured. Both CB-sizes were equally safe and effective with a low complication rate and an overall success rate of 86% at 12 and 71% at 18 months (6% on antiarrhythmic drugs). No predictors for AF-recurrence were identified.CB ablation can sometimes be challenging. The 28-mm CB is the preferred catheter in all patients. If balloon positioning is difficult, the 23-mm CB is an option to achieve PVI in small veins. Further studies need to investigate if the 23-mm CB could be beneficial as the primary CB in females with small body height and short LA diameter.

Die kardiale Computertomographie und interventionelle Elektrophysiologie haben sich in den vergangenen Jahren wesentlich weiterentwickelt. Die Computertomographie weist besonders im Hinblick auf die Strahlenreduktion, aber auch durch die Erweiterung der diagnostischen Moglichkeiten Innovationen auf. In vielen elektrophysiologischen Zentren spielt sie eine wichtige Rolle fur die Planung und Durchfuhrung interventioneller Prozeduren. Zudem hat sie eine zentrale Bedeutung in der Erfassung relevanter Komplikationen wie einer Pulmonalvenenstenose oder atrioosophagealen Fistel. Besonders primar anatomisch orientierte Ablationsverfahren wie die Vorhofflimmerablation erfordern eine genaue Kenntnis der relevanten kardialen Strukturen. Gerade die ballonbasierten Verfahren konnen wichtige Detailinformationen aus der prainterventionellen Bildgebung ziehen. Hier ist zu erwarten, dass diese Verfahren mithilfe der exakten anatomischen Information sowohl im Hinblick auf Prozedur- und Durchleuchtungszeiten, aber auch in Bezug auf die Effektivitat und Patientensicherheit weiter verbessert werden konnen. Die Integration anatomischer Bilddaten in dreidimensionale Navigationssysteme ist heute ein fester Bestandteil elektrophysiologischer Untersuchungen. Eine Reduktion der Fluoroskopiezeit, aber auch eine geringere Rezidivrate von Vorhofflimmern nach Pulmonalvenenisolation konnte hierdurch in nicht randomiserten Studien bereits nachgewiesen werden. Die vorliegende Ubersicht fasst aktuelle Entwicklungen im Einsatz der kardialen Computertomographie in der interventionellen Elektrophysiologie mit besonderem Fokus auf die Vorhofflimmerablation zusammen.

Encouraging results of ablation therapy in patients with paroxysmal atrial fibrillation (AF) have prompted changes in professional practice guidelines. The most recent European guidelines have suggested that ablation might be offered as first-line therapy in selected patients. Cryoballoon ablation is a promising technology in interventional AF therapy. Two different sizes of the cryoballoon are currently available: a smaller (23 mm) and a larger (28 mm) balloon relative to the ostial diameter of the pulmonary veins. New tools, the circular mapping catheter and the use of intracardiac echocardiography, provide important periprocedural information. A meta-analysis of previous studies revealed outcome data with an AF-free survival rate of 72.83% at the 1-year follow-up in paroxysmal AF patients undergoing cryoballoon ablation. The most frequent, but reversible complication is phrenic nerve palsy with reported incidences up to 10%. All efforts must be taken to overcome this limitation, since the overall major complication rate tends to be lower in cryoballoon compared to radiofrequency ablation. In persistent AF, reported results in cryoballoon ablation had a limited success rate below 50% after a single procedure. A double balloon approach using both cryoballoon sizes might overcome some of the limitations in persistent AF. Prospective data and randomized studies are required. This article outlines the current status of cryoballoon technology in AF ablation therapy.

The aim of this study was to evaluate the rate of bleeding, thromboembolic complications, and the rate of stent thrombosis or restenosis in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). In this retrospective analysis, we included patients with AF who underwent PCI with stent implantation from 2003 to 2006. Combinations of aspirin, clopidogrel, and oral anticoagulation with phenprocoumon (OAC) were used for antithrombotic management. Follow-up was performed by telephone interview. Adverse events (AEs) were defined as major bleedings, stroke/transient ischaemic attack, peripheral embolism, stent thrombosis, or restenosis. One hundred and seventeen patients (85 men, mean age 72.0 +/- 8.2 years) were included in the study. Fifty-five patients (47%) received drug-eluting stents, 62 patients (53%) bare-metal stents. After coronary intervention, 53 patients (45.3%) received a combination of aspirin, clopidogrel, and OAC, 64 (54.7%) patients received other antithrombotic regimens. Eighteen patients died during follow-up, 11 patients presumably of cardiac and 7 patients of non-cardiac causes. In total, 26 AEs occurred in 24 of 113 patients (21.2%) during follow-up: 13 major bleedings, 6 cardioembolic complications, 3 stent thromboses, and 4 restenoses. The present study demonstrates an 11.5% rate of major bleedings, a 5.3% rate of thromboembolic events, and a 2.7% rate of stent thromboses in the high-risk group of patients with AF and coronary stent implantation. The decision on different antithrombotic treatment regimens needs to be based on the patients' individual risk until further prospective studies have evaluated the risk-benefit profile of a standardized approach of triple therapy in this high-risk patient group.

Atrial fibrillation and congestive heart failure are frequently associated with complex interactions. Patients with both diseases bear a sophisticated therapeutic challenge for the attending physician. The approach to treat atrial fibrillation differs for patients with and without heart failure in several aspects. Basic requirements are the treatment of the underlying diseases and prophylaxis of thromboembolic complications. Rate and rhythm control are the two main therapeutic strategies for atrial fibrillation according to the current guidelines. Large trials including the recently published AF-CHF study (Atrial Fibrillation - Congestive Heart Failure) failed to demonstrate a difference in mortality for both strategies. Thus, the therapeutic decision is mainly based on the patient's symptoms to improve quality of life. Rate control should be applied to asymptomatic patients or if rhythm control has already failed. If beta-blockers and digoxin have failed to control heart rate, His ablation with pacemaker implantation can be considered. In patients without heart disease, class I antiarrhythmic drugs and, in case of ineffectiveness, amiodarone or catheter ablation are recommended for rhythm control. First data concerning catheter ablation of atrial fibrillation in heart failure are promising and randomized studies are on the way. Rhythm control remains first-line therapy in recent-onset or highly symptomatic paroxysmal or persistent atrial fibrillation patients with and without heart failure.

Patients with frequent premature ventricular contractions (PVCs) are often highly symptomatic with significantly reduced quality-of-life. We evaluated the outcome and success of PVC ablation in patients in the German Ablation Registry. The German Ablation Registry is a nationwide prospective multicenter database of patients who underwent an ablation procedure, initiated by the “Stiftung Institut fur Herzinfarktforschung” (IHF), Ludwigshafen, Germany. Data were acquired from March 2007 to May 2011. Patients underwent PVC ablation in the enrolling ablation centers. A total of 408 patients (age 53.5 ± 15 years, 55 % female) undergoing ablation for PVCs were included. 32 % of patients showed a co-existing structural heart disease. Acute ablation success of the procedure was 82 % in the overall patient group. In patients without structural heart disease, acute success was significantly higher compared with patients with structural heart disease (86 vs. 74 %, p = 0.002). All patients were discharged alive after a median of 3 days. No patient suffered an acute myocardial infarction, stroke, or major bleeding. After 12 months’ follow-up, 99 % of patients were still alive showing a significant different mortality between patients with structural heart disease compared with those without (2.3 vs. 0 %, p = 0.012). In addition, 76 % of patients showed significantly improved symptoms after 12 months of follow-up. Based on the data from this registry, ablation of PVCs is a safe and efficient procedure with an excellent outcome and improved symptoms after 12 months.

Herausgegeben vom Vorstand der Deutschen Gesellschaftfur Kardiologie – Herz- und Kreislaufforschung e.V.Bearbeitet im Auftrag der Kommission fur Klinische KardiologieM. Borggrefe, M. Bohm, J. Brachmann, H.-R. Figulla, G. Hasenfus,A. Osterspey, K. Rybak, U. Sechtem, S. Silberauserdem H.M. HoffmeisterOnline publiziert: 26. Oktober 2007Prof. Dr. med. Karl-Heinz Kuck (

Aims First-line ablation prior to antiarrhythmic drug (AAD) therapy is an option for symptomatic paroxysmal atrial fibrillation (PAF); however, the optimal ablation technique, radiofrequency (RF), or cryoballoon (CB) has to be determined. Methods and results The FREEZE Cohort Study compares RF and CB ablation. Treatment-naive patients were documented in the FREEZEplus Registry. Periprocedural data and outcome were analysed. From 2011 to 2014, a total of 373/4184 (8.9%) patients with PAF naive to AAD were identified. Pulmonary vein isolation (PVI) was performed with RF ( n = 180) or CB ( n = 193). In the RF group, patients were older (65 vs. 61 years, P < 0.01) compared with the CB group. The procedure time was significantly shorter and radiation exposure higher in the CB group. Major adverse events occurred in 1.6% (CB) and 3.7% (RF) of patients ( P = 0.22). AF/atrial tachycardia (AT) recurrence until discharge was 4.5% (RF) and 8.5% (CB, P = 0.2). Follow-up (FU) ≥12 months was available in 99 (RF) and 107 (CB) patients. After 1.4 years of FU, freedom from AF/atrial tachycardia (AT) was 61% (RF) and 71% (CB, P = 0.11). In the RF group, more patients underwent cardioversion, and a trend for more repeat ablations was observed. Persistent phrenic nerve palsy was observed in one patient treated by CB. Conclusion First-line ablation for PAF is safe and effective with either RF or CB. The procedure was faster with the CB, but the radiation exposure was higher. Although there was a trend for more recurrences and complications in the RF group, a more favourable risk profile in patients undergoing CB ablation might have biased the results. ClinicalTrials.gov identifier NCT01360008.

Objectives: The aim of this study was to determine the long-term results of ablation for sustained focal atrial tachycardia in patients with and without a history of atrial fibrillation. Methods: A history of atrial fibrillation was documented in 25 of 111 patients (23%) with focal atrial tachycardias. We studied the results of focal ablation during a follow-up of 27 ± 22 months. Results: Enlargement of left atrium (Odds ratio 2.99) and septal origin of the atrial focus (Odds ratio 5.68) were independent predictors of coexisting atrial fibrillation. Patients with a septal origin of the focal atrial tachycardia were older (62 vs. 54 years) and had a higher rate of structural heart disease than patients with a non-septal site of origin (51 vs. 29%). A higher rate of atrial fibrillation was found in patients with anteroseptal (56%), midseptal (50%) and posteroseptal (36%) atrial tachycardias than in patients with focal atrial tachycardias arising from the crista terminalis (9%), the tricuspid (12%) and mitral annulus (0%), the ostia of thoracic veins (17%) and other right atrial (27%) and left atrial free wall sites (10%). During the follow-up, atrial fibrillation was documented in 3% of patients without preexisting atrial fibrillation. In patients with focal atrial tachycardia and a history of atrial fibrillation, at least one episode of atrial fibrillation was documented during follow-up in 64% of patients, but 60% of patients reported marked symptomatic improvement. Conclusion: An increased rate of coexisting atrial fibrillation was found in patients with a septal origin of focal atrial tachycardia. Ablation of the focal atrial tachycardia may eliminate both arrhythmias, but patients with a history of atrial fibrillation may still be prone to recurrences of atrial fibrillation after focal ablation.

During surgical and interventional procedures, interference may occur between ICDs and electrical cautery or with the application of RF energy. This may lead to the false induction of ICD therapies or could even result in device malfunction, which represents a potential perioperative hazard for the patient. This study analyzed the intraoperative interactions in 45 consecutive ICD patients in reference to different surgical and interventional procedures. A total of 33 surgical operations (general surgery [n = 14], urologic [n = 5], abdominal [n = 10], gynecological [n = 2], thoracic [n = 1], neurosurgical [n = 1]) and 12 interventional therapies (RF catheter ablation [n = 10], endoscopic papillotomy [n = 2]) were performed. The ICD devices were all located in left pectoral position and consisted of 25 single and 20 dual chamber defibrillators. During the procedure, tachyarrhythmia detection (VF 296 +/- 20 ms, VT 376 +/- 49 ms) of the devices was maintained active (monitoring mode), only ICD therapies were inactivated. The indifferent electrode of the electrical cauter/RF generator was placed in standard positions (right/left mid-femoral position [n = 27/8], thoracic spine area [n = 10]). After the procedure, the ICD memory was checked for detections and for changes in the programming. There was no oversensing, reprogramming, or damage of any defibrillator caused by RF energy. Despite the lack of undesired interactions, ICDs should be inactivated preoperatively to assure maximum patient safety. However, should inactivation not be possible, or the achievement uncertain, electromagnetic interference is highly unlikely.

AIMS Catheter ablation of the inferior vena cava-tricuspid annulus isthmus and continuation of antiarrhythmic drug therapy have been shown to be an effective hybrid therapy for atrial flutter which results from antiarrhythmic drug treatment of atrial fibrillation. The aim of this study was to determine the risk factors for recurrence of atrial fibrillation in patients undergoing hybrid therapy for antiarrhythmic drug-induced atrial flutter. METHODS AND RESULTS 90 patients with paroxysmal (n=46) or persistent atrial fibrillation (n=44) developed atrial flutter due to the administration of amiodarone (n=48), flecainide (n=22), propafenone (n=14) or sotalol (n=6). Recurrence of atrial fibrillation after ablation was assessed during follow-up on continued antiarrhythmic drug therapy and during long-term follow-up, irrespective of the initial antiarrhythmic medication. During the follow-up on continued antiarrhythmic drug therapy (16+/-13 months), recurrence of atrial fibrillation was documented in 24 of 90 patients (27%). The presence of accompanying pre-ablation episodes of atrial fibrillation on antiarrhythmic treatment (Odds ratio 7.1, 95% confidence interval 2.3 to 25, p=0.001) and decreased left ventricular ejection fraction (Odds ratio 3.7, 95% confidence interval 1.01 to 12.5, p=0.048) were significant and independent predictors of post-ablation atrial fibrillation. Antiarrhythmic medication was discontinued during long-term follow-up due to adverse drug effects (amiodarone, n=12; flecainide, n=1) in 13 patients (14%). During the long-term follow-up, irrespective of the initial antiarrhythmic medication (21+/-15 months), stable sinus rhythm was maintained in 60 of 90 patients (67%). CONCLUSION Hybrid therapy can be considered as the first line therapy for patients with antiarrhythmic drug-induced atrial flutter but patients should be carefully evaluated for accompanying pre-ablation episodes of atrial fibrillation and possible adverse drug effects before initiation of hybrid therapy.

Systems Induce Specific Lesion Geometries and Adverse Effect Profiles. The success and safety of standard catheter radiofrequency ablation may be limited for ablation of atrial fibrillation and ventricular tachycardia. The aim of this study was to characterize and compare different cooled and noncooled catheter systems in terms of their specific lesion geometry, incidence of impedance rise, and crater and coagulum formation to facilitate appropriate catheter selection for special indications. The study investigated myocardial lesion generation of three cooled catheter systems (7 Fr, 4-mm tip): two saline irrigation catheters with a showerhead-type electrode tip (sprinkler) and a porous metal tip and an internally cooled catheter. Noncooled catheters (7 Fr) had a large tip electrode (8 mm) and a standard tip electrode (4 mm). RF energy was delivered on isolated porcine myocardium su perfused with heparinized pig blood (37°C) at power settings of 10-40 W Both irrigated systems were characterized by a large lesion depth (8.1 ′ 1.6 mm) and a large lesion diameter (13.8 ′ 1.6 mm). In comparison, internally cooled lesions showed a similar lesion depth (8.0 ′ 1.0 mm), but a significantly smaller lesion diameter (12.3 ′ 1.2 mm, P = 0.04). Large tip lesions had a similar lesion diameter (14.5 ′ 1.6 mm), but a significantly smaller lesion depth (6.3 ′ 1.0 mm, P = 0.002>) compared to irrigated lesions. However, lesion volume was not significantly different between the three cooled and the large tip catheter. To induce maximum lesion size, power requirements were three times higher for the irrigation systems and two times higher for the internally cooled and the large tip catheter compared to the standard catheter. Impedance rise was rarest with irrigated and large tip ablation. In case of impedance rise crater formation was a frequent observation (61-93%). Irrigated catheters prevented coagulum formation most effectively. Irrigated rather than internally cooled ablation appears to be most adequate for the induction of deep and long lesions at a low rate of impedance rise and thrombus formation. Large tip ablation may be feasible for the creation of long linear lesions, however, with an increased risk of thrombus formation.

Im Rahmen operativer oder interventioneller Eingriffe konnen Interferenzen zwischen implantierbaren Cardioverter/Defibrillatoren (ICD) und Elektrokautern bzw. der Radiofrequenz-Katheterablation auftreten. Daraus konnen die Fehlabgabe von Stimulations- und Schocktherapien bzw. die Inaktivierung des ICDs resultieren und eine Gefahrdung des Patienten darstellen. Methodik Wir untersuchten deshalb die intraoperativen Interaktionen bei 23 konsekutiven Patienten mit einem ICD (KHK n=15, DCM n=5, sonstige n=3, Alter 67±13Jahre) im Rahmen unterschiedlicher operativer und interventioneller Eingriffe. Es wurden 16 operative Eingriffe (allgemeinchirurgische OP n=7, urologische OP n=5, abdominelle OP n=2, gynakologische OP n=1, Thorax-OP n=1) sowie 7 interventionelle Therapieverfahren (RF-Katheterablation n=5, ERCP mit Papillotomie n=2) durchgefuhrt. Die ausschlieslich pektoral implantierten ICD-Systeme (Medtronic n=16, Guidant CPI n=7) bestanden aus 15 Einkammer- sowie 8 Zweikammer-Defibrillatoren. Praoperativ erfolgte eine Inaktivierung der ICD-Therapien, die Tachyarrhythmie-Detektion (VF 295±21ms, VT 370±55ms) der Aggregate wurde aktiv belassen (Uberwachungsmodus). Die Position der intraoperativen, indifferenten Elektrode des Elektrokauters/RF-Generators wurde ermittelt (med. Oberschenkel rechts n=18, mittlere BWS dorsal n=5). Nach durchgefuhrtem Eingriff wurden der ICD-Speicher auf Detektionen bzw. die Programmierung auf Veranderungen uberpruft sowie eine Funktionskontrolle durchgefuhrt. Ergebnis In keinem Fall kam es durch den Einsatz eines Elektrokauters oder durch eine RF-Ablation zu einer Fehldetektion durch den ICD oder zu einer Umprogrammierung. Schlussfolgerung Trotz der nicht nachweisbaren Interaktionen zwischen dem Einsatz von Radiofrequenzstrom und implantierbaren Defibrillatoren sollten ICDs prainterventionell inaktiviert werden, um eine maximale Patientensicherheit zu gewahrleisten. Sollte sich jedoch diese Inaktivierung als ineffektiv oder als nicht kontrollierbar erweisen, so sind mit hoher Wahrscheinlichkeit keine Interferenzen zu befurchten. Auf jeden Fall sollte aber postinterventionell eine Funktionskontrolle des ICDs mit Uberprufung der Stimulations- und Sensingfunktion durchgefuhrt werden.

Pulmonary vein bigeminy is the pair of a second, late and ectopic pulmonary vein potential following atrial far-field activation and a first passive pulmonary vein potential during sinus rhythm. The aim of this study was to determine the electrophysiological characteristics of pulmonary vein bigeminy and to evaluate its relevance as a trigger for paroxysmal atrial fibrillation.

Background— Cryoballoon (CB) ablation results in >70% freedom from atrial fibrillation at 1 year. Single-center data of the first (CBG1) and second (CBG2) cryoballoon, recently introduced, were analyzed to compare safety and efficacy. Methods and Results— From March 2011 to December 2012, CB ablation with spiral mapping was performed consecutively in 484 patients with symptomatic atrial fibrillation. CBG1 was used in 364 of 484 (75%) and CBG2 in 120 of 484 (25%) patients. Periprocedural data were analyzed. Acute pulmonary vein (PV) isolation with CB only was achieved in 99.86% and 100% of veins with CBG1 and CBG2, respectively ( P =0.43). Number of applications until PV isolation decreased significantly with CBG2 (1.45±0.81 versus 1.28±0.64; P =0.001). Procedural, left atrial, and fluoroscopy time were reduced by −5%, −11%, and −15% ( P P P P =0.0023). In-hospital atrial fibrillation recurrence rates were similar. Balloon temperatures were significantly warmer with 23-mm CBG2 and a trend for colder balloon temperature with 28-mm CBG2 were observed compared with their predecessors. Comparable low rates of phrenic nerve palsy were recorded (1.1% versus 1.7%; P =0.64). Esophageal temperatures were similar. Major complication rates were low (3.3% versus 3.33%; P =1.0). Conclusions— CBG2 attains high rates of acute PV isolation within a significant faster and less complex procedure. Time to isolation is shorter, and PV isolation is achieved with fewer applications using CBG2. These enhancements were not at the cost of complications. Long-term success rates remain to be demonstrated.

Aims Incisional atrial tachycardias in patients following surgery for congenital heart disease are based on complex structural abnormalities in these hearts. The aim of this study was to evaluate the use of the electroanatomical mapping system, CARTO, in consecutive patients with different forms of incisional atrial tachycardia. Methods and Results The electroanatomical mapping system combines electrophysiological and spatial information and allows visualization of atrial activation in a three-dimensional anatomical reconstruction of the atria. Electroanatomical mapping of right atrial activation was performed in 10 patients after surgery for congenital heart disease, surgery for Wolff–Parkinson–White syndrome, or heart transplantation presenting with 13 incisional atrial tachycardias. The three-dimensional mapping allowed a rapid distinction between focal (n=3) and reentrant mechanisms (n=10) and visualization of the activation wavefronts along anatomical and surgically created barriers. Electroanatomical activation maps (mean right atrial activation time 213±107ms) were constructed with 89±60 catheter positions during an average mapping time of 48±33 min. Reentrant tachycardias propagating through the tricuspid annulus–vena cava inferior isthmus (n=6) or along periatriotomy loops (n=4) were identified in eight patients. Ectopic atrial foci near surgical scars could be localized in three patients. Catheter ablation by creation of a lesion in a critical isthmus of conduction or by targeting the arrhythmogenic focus eliminated 11 of 13 incisional atrial tachycardias. Conclusion Visualization of atrial activation in a three-dimensional reconstruction of the right atrium using the electroanatomical mapping system CARTO facilitates understanding of the mechanism and defines the reentrant circuits of incisional atrial tachycardias. This new method may improve the success rate of electrophysiologically guided and anatomically guided catheter ablation of incisional atrial tachycardias.

Early reinitiation of atrial fibrillation (ERAF) following external or internal electrical cardioversion is one of the factors determining unsuccessful electrical cardioversion. Prevention of ERAF has not been studied systematically in patients on amiodarone therapy.

Aims Antiarrhythmic drug treatment for atrial fibrillation can cause atrial flutter-like arrhythmias. The aim of this study was to clarify the effect of catheter ablation of the tricuspid annulus-vena cava inferior isthmus on amiodarone-induced atrial flutter and to determine the incidence of atrial fibrillation after catheter ablation of amiodarone-induced atrial flutter in comparison to regular typical flutter. Methods and Results Among 92 consecutive patients with typical atrial flutter who underwent isthmus ablation 28 patients had atrial flutter without a history of previous atrial fibrillation (group I), 10 patients had atrial flutter following the initiation of amiodarone therapy for paroxysmal atrial fibrillation (group II) and 54 patients had atrial flutter and atrial fibrillation (group III). Atrial cycle length during atrial flutter in amiodarone-treated patients (group II) (27724 ms) was significantly longer as compared to the cycle length of atrial flutter in group I (24733 ms) and group III patients (23528 ms). The rate of successful transient entrainment and overdrive stimulation to sinus rhythm was not different between patients with (60%) or without amiodarone therapy (group I: 71%, group III: 53%). Successful isthmus ablation with bidirectional conduction block eliminating right atrial flutter was achieved in 90% of amiodarone-treated patients and 93% of patients without amiodarone therapy. In the amiodarone-treated patient group atrial conduction times during pacing in sinus rhythm were significantly prolonged by 20–30% before and after ablation in all regions of the reentrant circuit. During a mean follow-up of 83 months post-ablation, atrial fibrillation recurred in two of 10 patients on continued amiodarone therapy after successful isthmus ablation. Thus, successful catheter ablation of atrial flutter due to amiodarone therapy was associated with a markedly lower recurrence rate of paroxysmal atrial fibrillation (20%) as compared to patients with atrial flutter plus preexisting paroxysmal atrial fibrillation (76%) and was similar to the outcome of patients with successful atrial flutter ablation without preexisting atrial fibrillation (25%). Conclusion These data suggest that isthmus ablation with bidirectional block and continuation of amiodarone therapy is an effective therapy for the treatment of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation. (Eur Heart J 2000; 21: 565–572)

Review of available data suggests that serial drug testing in patients with a history of sustained ventricular tachyarrhythmias using various antiarrhythmic drugs including amiodarone is able to identify subgroups with favorable and unfavorable outcome (patient groups with suppression vs. no suppression of inducibility of VT/VF). These results more likely reflect patient selection rather than drug effects, thus limiting the role of electrophysiologically guided antiarrhythmic therapy to actively modify outcome. All major and actual antiarrhythmic drug trials including an amiodarone arm, have chosen to deliver this drug empirically in both patients with asymptomatic as well as severely symptomatic life-threatening sustained ventricular tachyarrhythmias instead of a guided approach. The empiric approach is therefore adequate until new valid data comparing the empiric with the guided—or the invasive with the non invasive—approach tell us otherwise.

Vorhofflimmern stellt die haufigste anhaltende Rhythmusstorung in der klinischen Praxis dar. Die Therapie des paroxysmalen Vorhofflimmerns, richtet sich heute hauptsachlich auf die Pravention rekurrenter Flimmerepisoden. Strategie der Wahl ist hierbei zunachst die pharmakologische Therapie; haufige Ineffektivitat, Nebenwirkungen und die Gefahr von Proarrhythmien stimuliert auch hier, wie bei der Behandlung aller anderen supraventrikularen Tachykardien, die Entwicklung nichtmedikamentoser alternativer Therapieverfahren.

Bei Patienten mit Herzinsuffizienz konnen aufgrung struktureller und funktioneller Veranderungen auf Vorhofebene supraventrikulare Herzrhythmusstorungen wie Vorhofflattern und Vorhofflimmern auftreten. Wahrend sich beim Vorhofflattern die Radiofrequenz-Katheterablation als nichtmedikamentose kurative Therapie bereits mit sehr guten Erfolgsquoten etabliert hat, werden bei medikamentos therapierefraktarem Vorhofflimmern zur Zeit verschiedene, potentiell auch kurative Therapieformen im Rahmen koutrollierter Studien wissenschaftlich untersucht. Die Induktionsmechanismen und die Erfolgsraten der verschiedenen Therapieverfahren sowie Akut- und Spatkomplikationen abgewartet werden, um in der Zukunft fur jeden Patienten eine individuell optimierte alternative Therapie einsetzen zu konnen.

Das Prinzip der antitachykarden Stimulation (ATS) ventrikularer Tachykardien bei Patienten mit implantierbarem Cardioverter/Defibrillator (ICD) hat sich als effektive Option zur schmerzlosen Therapie monomorpher ventrikularer Tachykardien (VT) etabliert. Ziel dieser Analyse war es, die Effizienz und Sicherheit dieser Therapieform an einem groseren Patientenkollektiv mit einer grosen Anzahl spontaner VTs zu ermitteln, sowie Pradiktoren, die mit einer erfolgreichen Uberstimulation assoziiert sind, zu identifizieren. Wir untersuchten 2926 Episoden spontaner monomorpher VTs mit einer mittleren Zykluslange von 349 ± 51 ms (240–520 ms). Das Beobachtungskollektiv bestand aus 80 Patienten (KHK n = 50, dilatative Kardiomyopathie n = 18, sonstige n = 12), Alter 59 ± 12 Jahre, mittlere Nachbeobachtungszeit 26 ± 17 Monate. 64 Patienten (80%) erfuhren 2629 Episoden einer VT, die Erfolgsquote der ATS lag bei 89,9%. Der Erfolg war nicht mit einer effizienten Testung des Modus an induzierten Tachykardien, der Auswurffraktion, dem Grad der Herzinsuffizienz (NYHA) oder kardialen Aneurysmen assoziiert. Ebenso beeinflusten weder die Grunderkrankung noch Antiarrhythmika die ATS-Erfolgsrate. Als Pradiktoren fur den Therapieerfolg konnten kurze VT-Zykluslangen (VTCL, ≤ 300 ms vs. > 300 ms, p 300 ms, p < 0,04) und kurzen Kopplungsintervallen (≥ 81% vs. ≥ 81%, p < 0,01). Schlusfolgerungen: 1. Die antitachykarde Stimulation ist eine hocheffiziente Therapieoption, weitgehend unabhangig von Patientencharakteristika. 2. Als positive Pradiktoren fur eine erfolgreiche Uberstimulation konnten ein langes Ankopplungsintervall der Stimulationstherapien und eine niedrige Zykluslange der VT bestimmt werden, so das mit Intervallen zwischen 90–97% der Therapieerfolg maximiert werden kann und auch schnelle VTs (Zykluslange < 300 ms) mit hoher Effizient terminierbar sind. 3. Eine Testung des ATS-Modus an induzierten Tachykardien erbrachte keine Verbesserung der Therapieeffizienz, so das mit einer empirischen Programmierung der Therapien eine gleich hohe Erfolgsrate erzielt werden kann. 4. Das Akzelerationsrisiko steigt mit abnehmender VTCL und bei Verwendung kurzer Kopplungsintervalle, somit sollten aggressive Therapien bei schnellen VTs (Zykluslange < 300 ms) nicht angewendet werden.