Alexander Berkowitsch - Academia.edu (original) (raw)

Papers by Alexander Berkowitsch

Research paper thumbnail of Impact of Impaired Renal Function and Metabolic Syndrome on the Recurrence of Atrial Fibrillation after Catheter Ablation: A Long Term Follow-Up

Pacing and Clinical Electrophysiology, 2012

Background: The goal of this study was to analyze impact of metabolic syndrome (MetS) and impaire... more Background: The goal of this study was to analyze impact of metabolic syndrome (MetS) and impaired renal function on long-term follow-up after catheter ablation of atrial fibrillation (AF). Methods and Results: A total of 702 consecutive patients with AF (age = 58 year, history of AF = 5 year, male = 478, paroxysmal atrial fibrillation = 416, coronary artery disease = 62, hypertension = 487) considered for catheter ablation were enrolled in the study. The MetS was diagnosed at admission in 276 patients. The renal function was estimated by glomerular filtration rate (eGFR). Pulmonary vein isolation (PVI) was performed either with cryoballoon technique (n = 260) or circumferential PVI (n = 442) with a 3.5-mm irrigated tip catheter. A 7-day-Holter electrocardiogram was performed at each follow-up visit. Any episode of documented AF after an initial 3-month blanking period was considered as clinical endpoint. Out of 702 patients, 370 (52.7%) were free of AF recurrences at median follow-up of 15 six interquartile range (12.7-42.3) months. The patients with MetS had significantly lower success rate than those without (128/276 (46.4%) vs 242/426 (56.8%), P = 0.006). Among 103 patients with eGFR < 68 mL/min only 35 (34%) were free of recurrences compared with 335/599 (55.9%) in patients with GFR ≥ 68 mL/min (P = 0.001). Both parameters were revealed in multivariate analysis to be independent predictors for outcome after catheter ablation. Conclusion: The results of our study clearly demonstrated that outcome after 1st catheter ablation of AF is poor in patients with MetS and/or impaired renal function. This observation has a potential clinical impact for the follow up management of these patients.

Research paper thumbnail of P6062Predicting outcome with normal-range high-sensitivity troponin i and heart-type fatty acid-binding protein in stable patients with suspected coronary artery disease

European Heart Journal, 2017

Background: Clinical characteristics and prognosis of patients with multi-vessel vasospastic angi... more Background: Clinical characteristics and prognosis of patients with multi-vessel vasospastic angina (VSA) were not fully elucidated. Objectives: To characterize the nature and prognosis of multi-vessel VSA compared with single vessel VAS. Methods: Among 617 patients diagnosed as definite vasospastic angina in the VA-KOREA (Vasospastic Angina in Korea) registry, we identified 201 patients underwent ergonovine provocation test on left and right coronary artery successively. 51 patients were classified into multi-vessel VSA and remaining 150 patients were classified into single vessel VSA. All patients were on optimal medical treatments by attending doctor's discretion. The primary composite endpoint was the 24-months incidences of cardiac death, new onset arrhythmia, and acute coronary syndrome. Emergency room revisits were also reported. Results: The baseline characteristics between multi-vessel VSA and single vessel VSA were similar except total cholesterol level was greater in single vessel VAS (p=0.03). Optimal medical treatments did not differ significantly between 2 groups. The 24-month incidences of cardiac death, new onset arrhythmia, and acute coronary syndrome were greater (3.0%, 6.1%, and 6.1%, respectively, total 15.2%) in the multi-vessel VSA than in single vessel VAS (0%, 1.1%, 0%, respectively, total 1.1%, p=0.001). Multi-vessel VSA showed low primary endpoint free survivor compared with single vessel VSA in Kaplan-Meier survivor curve (Log rank OR 13.90, 95% CI [2.27-85.32], p=0.016, Fig.1). In addition, multi-vessel VSA was an independent predictor for primary composite endpoint on 24 months (HR 36.6, 95% CI [2.04-658.27], p=0.015).

Research paper thumbnail of P355Impact of reduced tricuspid annular plane systolic excursion on outcome after ablation of atrial fibrillation with second-generation cryo-balloon

Europace, 2018

Thirty-nine consecutive patients (79.5% male, mean age 58.867.9 years, 59% paroxysmal AF) were in... more Thirty-nine consecutive patients (79.5% male, mean age 58.867.9 years, 59% paroxysmal AF) were included. Twenty-six patients showed acute PVR in 54/ 546 (9.8%) segments. In each region, segments with acute PVR showed significant lower mean AI compared to segments without PVR (anterior/roof, 411670 vs. 431673 arbitrary unit (au); posterior/inferior/carina, 349663 vs. 373662 au, all p<0.001). Mean minimum AI of reconnected segments was lower than non-reconnected segments (anterior/roof, 310651 vs. 335663 au; posterior/inferior/carina, 273637 vs. 311652 au, all p<0.001). No acute PVR was observed where the minimum AI value was 350 for posterior/inferior/carina segments and 450 for anterior/roof segments. Conclusion: AI values were associated with acute PVR and different target AI values were required by different PV regions for less acute PVR. AI-guided ablation might improve the success rate of point-by-point ablation. P354 Right atrial and coronary sinus complexity parameters predict acute outcome of persistent atrial fibrillation ablation and evolve with ablation steps

Research paper thumbnail of P3865Transformation in rotational atrial activity before and after PVI in patients with persistent AF

European Heart Journal, 2018

Background: Idarucizumab is licensed for dabigatran reversal based on the results of the REVERSE ... more Background: Idarucizumab is licensed for dabigatran reversal based on the results of the REVERSE AD study, which showed rapid and complete reversal of dabigatran anticoagulation in patients presenting with severe bleeding (Group A), or in those requiring urgent surgery (Group B). Enrollment was based solely on the clinical decision to reverse anticoagulation. This analysis focuses on the outcomes in the cohort of trauma patients. Methods: Trauma patients on dabigatran could be enrolled in either group in REVERSE AD , whether for serious bleeding or for reversal prior to urgent surgery. All patients were given 5 grams of idarucizumab intravenously and the primary endpoint was maximum reversal of dabigatran anticoagulation in the first 4 hours, as measured by ecarin clot time or diluted thrombin time. Results: Of the 503 patients enrolled in REVERSE AD, there were 114 trauma victims, 80 enrolled in Group A and 34 in Group B (Table). The most commonly documented mechanism of injury was fall from standing height, resulting in open or closed head injury or pelvic or hip fractures; 6 patients sustained high-impact polytrauma. Other injuries included fractured ribs, broken nose, and severed fingers. No trauma patient received more than one dose of idarucizumab, all patients had 100% reversal, and no drug-related adverse events were reported. Thrombotic events rates were low and consistent with the entire study cohort. Conclusions: Regardless of mechanism of injury, age, comorbidity, renal status, hemodynamic stability, or group assignment, idarucizumab provided prompt, complete, and safe reversal of dabigatran-mediated anticoagulation, allowing treating clinicians to manage the complications of trauma without concern for iatrogenic coagulopathy. Funding Acknowledgements: The study was funded by Boehringer Ingelheim

Research paper thumbnail of P994Five-year outcome and predictors of success after second-generation cryoballoon ablation for treatment of symptomatic atrial fibrillation

European Heart Journal, 2018

Consecutive stepwise forward Cox regression model calculation identified solely VRs (p-value <0.0... more Consecutive stepwise forward Cox regression model calculation identified solely VRs (p-value <0.001, HR 0.116, 95% confidence interval (CI) 0.036-0.367) and male gender (p-value 0.018, HR 0.573, CI 0.360-0.909) as independent predictors for AF-free survival. Conclusion: To the best of our knowledge, we are the first to demonstrate the preeminent impact of VRs during second generation CBA on the outcome of pts suffering from perAF. Thus, our findings may offer new clues for future CBA strategies, targeting for an increased amount of VRs to further improve the outcome of our pts. P994 Five-year outcome and predictors of success after second-generation cryoballoon ablation for treatment of symptomatic atrial fibrillation

Research paper thumbnail of Patients at Intermediate Surgical Risk Undergoing Isolated Interventional or Surgical Aortic Valve Implantation for Severe Symptomatic Aortic Valve Stenosis

Circulation, 2018

Background: Transcatheter aortic valve replacement (TAVR) is increasingly being used for treatmen... more Background: Transcatheter aortic valve replacement (TAVR) is increasingly being used for treatment of severe aortic valve stenosis in patients at intermediate risk for surgical aortic valve replacement (SAVR). Currently, real-world data comparing indications and clinical outcomes of patients at intermediate surgical risk undergoing isolated TAVR with those undergoing SAVR are scarce. Methods: We compared clinical characteristics and outcomes of patients with intermediate surgical risk (Society of Thoracic Surgeons score 4%–8%) who underwent isolated TAVR or conventional SAVR within the prospective, all-comers German Aortic Valve Registry. Results: A total of 7613 patients at intermediate surgical risk underwent isolated TAVR (n=6469) or SAVR (n=1144) at 92 sites in Germany between 2012 and 2014. Patients treated by TAVR were significantly older (82.5±5.0 versus 76.6±6.7 years, P <0.001) and had higher risk scores (logistic EuroSCORE [European System for Cardiac Operative Risk Eva...

Research paper thumbnail of Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation

Europace, 2016

Although the generation of linear lesions by ablation improves success rates in patients with per... more Although the generation of linear lesions by ablation improves success rates in patients with persistent atrial fibrillation (AF), the procedure has been considered unsuitable for cryoablation balloon catheter technologies. We developed a technique for linear ablations, using second-generation cryoballoon technology. Methods and results This was a single-arm, prospective study in 76 patients with persistent AF treated consecutively at our centre. Cryoablation was performed using a 28 mm second-generation cryoballoon. The first cryoenergy application was performed in close proximity to the position during isolation of the left superior pulmonary vein (PV). Sequential overlapping freezes were applied along the left atrial (LA) roof by slight clockwise rotation of the sheath in combination with slight retraction of the sheath and incremental advancement of the cryoballoon, until reaching the original position for right superior PV isolation. The acute endpoint was the creation of a roofline, defined as complete conduction block across the LA roof .120 ms and ascending activation across the posterior LA wall. Acute success in roofline generation was achieved in 88% of patients, applying on average five (median 4-6) freezes with nadir temperature of 2408C (236 to 2448C). In five patients, conduction block could not be achieved. No phrenic nerve injuries occurred during roofline generation. Conclusion Generation of linear roofline lesions is possible with the second-generation cryoballoon. The technique can be used in combination with PV isolation to treat persistent AF with good acute success rates, short procedure times, and acceptable safety concerns. If validated by further studies, the method would be an appealing alternative to radiofrequency ablation techniques.

Research paper thumbnail of Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis

European heart journal. Acute cardiovascular care, Jan 26, 2015

Extracorporeal life support (ECLS) has shown encouraging survival rates in patients with in-hospi... more Extracorporeal life support (ECLS) has shown encouraging survival rates in patients with in-hospital cardiac arrest; however, its routine use is still controversial. We compared the survival of patients with in-hospital cardiac arrest receiving conventional cardiopulmonary resuscitation (CCPR) to that of patients with ECLS as an adjunct to cardiopulmonary resuscitation (ECPR). A total of 353 patients with in-hospital cardiac arrest (272 CCPR and 52 ECPR) were included in this retrospective, propensity score-adjusted (1:1 matched), single-centre study. Primary endpoints were survival at 30 days, long-term survival and neurological outcome defined by the cerebral performance categories score. In the unmatched groups patients undergoing ECPR initially had significantly higher APACHE II scores (P=0.03), increased norepinephrine dosages (P=0.03) and elevated levels of creatine kinase (P<0.0001), creatinine (P=0.04) and lactate (P=0.02) before cardiopulmonary resuscitation compared wit...

Research paper thumbnail of 921 Differential effects on systolic and diastolic function after temporary suspension of long-term cardiac resynchronization therapy

European Journal of Echocardiography, 2006

Background and objective: LV regional dyssynchrony can be well analyzed by Real-time 3D echocardi... more Background and objective: LV regional dyssynchrony can be well analyzed by Real-time 3D echocardiography as well as by Tissue Doppler Imaging (DTI). There is paucity of information concerning comparative dyssynchrony evaluation by both methods. We sought to compare 3D echo and Tissue Doppler dyssynchrony assessment. Methods: We studied 44 patients (28 males, age 47±9 yrs). In the echocardiographic evaluation, the patients underwent 3D real-time echocardiographic quantification of LVEF and LV regional dyssynchrony (LV dyssynchrony index of 6 and 12 segments, relative to basal and basal plus medial segments). By DTI we measured LV QS eletromechanical interval in the basal segment of the mitral valve annulus of the septum, lateral, anterior and inferior walls, as well as DTI dyssinchrony index, defined as the standard deviation of the mean QS eletromechanical interval of the LV basal segments. Also we measured ECG duration; 3D echo and DTI data were compared by correlation coefficient of determination-Spearman (r), 95% CI, p<0.05, linear regression equation and Bland & Altman test. Results: 3D 6 segment dyssynchrony index (DI) ranged from 0.25 to 6.65 (1.15±1.15) %; 3D 12 segment DI ranged from 0.2 to 20.38 (2.04±3.63) %; DTI DI ranged from 0.26 to 4.32 (0.98±0.87) %; ECG duration ranged from 60 to 200 (80+29.5) ms; 3D LVEF ranged from 0.43 to 0.74 (0.59±0.10). Correlation coefficient (r) for DTI DI and 3D 6 DI was 0.7898, p<0.0001; and 0.7271, p<0.0001, for 3D 12 DI. Linear regression equation for DTI DI (y) and 3D 6 DI (x), was: y=0.3230+0.5976 x, p<0.0001; linear regression equation for DTI DI (y) and 3D 12 DI (x), was: y=0.6575+0.1749 x, p<0.0001. Conclusions: In this small series we observed good correlation between 3D echocardiography and DTI LV dyssynchrony assessment. Further studies should be undertaken with larger series of patients with increased ECG duration and decreased LVEF.

Research paper thumbnail of Slope of autocorrelation function of detrended 24-hour RR-intervals independently predicts mortality in postinfarction patients

Computers in Cardiology, 2004

Research paper thumbnail of Release kinetics of inflammatory biomarkers in a clinical model of acute myocardial infarction

Circulation research, Jan 27, 2015

Inflammation in the setting of acute myocardial infarction (MI) has been linked to risk stratific... more Inflammation in the setting of acute myocardial infarction (MI) has been linked to risk stratification; however, the release kinetics of inflammatory biomarkers in patients with acute MI has been difficult to establish. The aim of this study was to determine the kinetics of changes in the levels of several biomarkers specifically linked to inflammation after transcoronary ablation of septal hypertrophy, a procedure that mimics acute MI. We analyzed release kinetics of C-reactive protein, high-sensitivity C-reactive protein, interleukin-6, soluble CD40 ligand, and peripheral blood leukocyte subsets in patients (n=21) undergoing transcoronary ablation of septal hypertrophy. Blood samples were collected before transcoronary ablation of septal hypertrophy and at various times after transcoronary ablation of septal hypertrophy. Serum levels of C-reactive protein were increased at 24 hours (1.0 mg/dL [interquartile range [IQR], 0.7-1.75] versus 0.2 mg/dL [IQR, 0.1-1.05] at baseline [BL]; ...

Research paper thumbnail of Peri-operative results and complications in 15,964 transcatheter aortic valve implantations from the German Aortic valve RegistrY (GARY)

Journal of the American College of Cardiology, Jan 10, 2015

Transcatheter aortic valve implantation (T-AVI) has evolved into a routine procedure with good ou... more Transcatheter aortic valve implantation (T-AVI) has evolved into a routine procedure with good outcomes in high-risk patients. To evaluate the complication rates of T-AVI based on prospective data from the German aortic valve registry (GARY). From 2011 to 2013 a total of 15,964 T-AVI procedures were registered. We evaluated the total cohort for severe vital complications (SVC: death on the day of intervention, conversion to sternotomy, acute PCI, low cardiac output requiring mechanical support, cardiac tamponade requiring treatment, aortic dissection, annular rupture), technical complications of the procedures (TCO: repositioning or retrieval of the valve prosthesis, valve-in-valve implantation, embolization of the prosthesis, closure of a paravalvular leak) and other complications (aortic regurgitation, new-onset pacemaker implantation, stroke, major vascular complications, and major bleeding). The mean patient age was 81±6 years, 54% were female, median-logistic Euroscore I was 18...

Research paper thumbnail of Algorithmic complexity. A new approach of non-linear algorithms for the analysis of atrial signals from multipolar basket catheter

Annali dell'Istituto superiore di sanità, 2001

Symbolic dynamics as a non linear method and computation of the normalized algorithmic complexity... more Symbolic dynamics as a non linear method and computation of the normalized algorithmic complexity (C alpha) was applied to basket-catheter mapping of atrial fibrillation (AF) in the right human atrium. The resulting different degrees of organisation of AF have been compared to conventional classification of Wells. Short time temporal and spatial distribution of the C alpha during AF and effects of propafenone on this distribution have been investigated in 30 patients. C alpha was calculated for a moving window. Generated C alpha was analyzed within 10 minutes before and after administration of propafenone. The inter-regional C alpha distribution was statistically analyzed. Inter-regional C alpha differences were found in all patients (p < 0.001). The right atrium could be divided in high- and low complexity areas according to individual patterns. A significant C alpha increase in cranio-caudal direction was confirmed inter-individually (p < 0.01). The administration of propafe...

Research paper thumbnail of Usefulness of Atrial Fibrillation Burden as a Predictor for Success of Pulmonary Vein Isolation

Pacing and Clinical Electrophysiology, 2005

Background: The definition of symptomatic improvement after pulmonary vein isolation (PVI) is con... more Background: The definition of symptomatic improvement after pulmonary vein isolation (PVI) is controversial. We assessed primarily the usefulness and predictive accuracy (PA) of AF (atrial fibrillation) burden (AFB) within the first 3 months after the procedure as an early predictor for curative success as well as reduction of symptoms. Methods: We studied 100 pts (62 men, mean age: 54 ± 9 years, LVEF: 57 ± 9%, paroxysmal AF, 85, persistent AF, 15) who underwent PVI. RF ablation was used in 63 patients. The combination of cryoablation and RF (Hybrid therapy) was used in the remaining 37 patients, in 19 patients of whom additionally linear lesions were performed. All patients were followed up 3 months after PVI (the blanking period) and every 3 months thereafter. The significance of early recurrence of AF (ERAF) was separately analyzed for RF and for hybrid therapy arm. Quality of life (QoL) was assessed using the physical composite summary score (PCS) and mental composite summary sc...

Research paper thumbnail of Therapy with Renin-Angiotensin System Blockers after Pulmonary Vein Isolation in Patients with Atrial Fibrillation: Who Is a Responder?

Pacing and Clinical Electrophysiology, 2010

The data on anti-arrhythmic effect of renin-angiotensin-aldesteron system blockers (RASB) in pati... more The data on anti-arrhythmic effect of renin-angiotensin-aldesteron system blockers (RASB) in patients with atrial fibrillation (AF) are controversially discussed. The goal of this analysis was to identify cohort of patients with AF and hypertension, who may have benefit from RASB therapy after pulmonary vein isolation (PVI). Methods: A total of 284 patients with AF and hypertension (paroxysmal AF [PAF] = 218, male = 185, age = 61 years, left ventricular ejection fraction = 60%, coronary artery disease = 42) considered for PVI were included. The patients with PAF were stratified according to time spent in AF (AF burden) within 3 months prior to admission (</> 500 hours). Further patients were divided into two groups: (1) lowburden AF; (2) high-burden AF (PAF and persistent AF). In 195 patients, RASB therapy was administered. A 7-day continuous Holter electrocardiogram was performed after discharge, every 3 months thereafter and by symptoms. Results: Preventive effect of RASB was revealed in whole group (112 out of 195 [57%] vs 36 out of 89 [40%]; P = 0.025) and was more pronounced in patients with low-burden AF (79 out of 112 [71%] receiving RASB vs 27 out of 55 [49%] being on other drugs; P = 0.013). However, efficiency of RASB failed in patients with high-burden AF (33 out of 83 on RASB [40%] vs nine out of 34 on other drugs [27%]; P = 0.328). Conclusions: Our data suggest that RASB appears to protect against AF recurrences after PVI in patients with low-burden paroxysmal AF. These results should be tested in a prospective study.

Research paper thumbnail of A Decrease in Pulmonary Vein Diameter After Radiofrequency Ablation Predicts the Development of Severe Stenosis

Pacing and Clinical Electrophysiology, 2005

A decrease in ostial pulmonary vein (PV) diameter was observed in patients on the day after radio... more A decrease in ostial pulmonary vein (PV) diameter was observed in patients on the day after radiofrequency ablation of atrial fibrillation (AF). This study examined whether a relative reduction in PV diameter on day 1 (RRPVD1) after the procedure predicts the late development of severe PV stenosis (PVS). The study included 104 consecutive patients (mean age = 55 years, range 46-61, 34 women) with drug refractory AF. Pulmonary vein diameter was measured using MR angiography (MRA) on the day before and on day 1 after the ablation procedure. The MRA was repeated every 3 months after the procedure. Severe PVS was defined as a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;70% diameter reduction from the initial ostial diameter. The cut-off of RRPVD1 was prespecified as 25% decrease in initial diameter. The data are presented as medians and interquartile range. A total of 357 PV were treated. The RRPVD1 was 0.0% (0.0-11.1%). Severe PVS was found in 18 PV during a follow-up of 12 months (range 6-13). The log-rank analysis confirmed a strong association between a RRPVD1 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=25% and the development of PVS (hazard ratio: 7.1; 95% confidence interval 3.8-13.5, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). By multivariate Cox regression model, after adjustment of procedure variables, RRPVD1 was the strongest predictor of development of severe PVS. RRPVD1 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=25% was a strong independent predictor of development of severe PVS.

Research paper thumbnail of Shock Coordinated with High Power of Morphology Electrogram Improves Defibrillation Success in Patients with Implantable Cardioverter Defibrillators

Pacing and Clinical Electrophysiology, 2002

BERKOWITSCH, A., et al.: Shock Coordinated with High Power of Morphology Electrogram Improves Def... more BERKOWITSCH, A., et al.: Shock Coordinated with High Power of Morphology Electrogram Improves Defibrillation Success in Patients with Implantable Cardioverter Defibrillators. Animal studies have suggested that the success of defibrillation may depend on the properties of VF waveform obtained from the morphology electrogram (ME) at the time of the shock. The reliable identification of depolarization events in the fibrillatory signal can be achieved using adaptive estimation of the instantaneous signal power (P). The aim of this study was to investigate if a high P of the ME (PME) was related to ventricular DFT and if the upslope in ME can be associated with the depolarization event. A total of 575 VF (mean duration 10 s) episodes recorded and stored during ICD implantation in 77 patients with ventricular arrhythmias were used for analysis. The DFT was defined using a double step‐down test. The values of PME immediately before pulse delivery (Pshock) and shock outcomes were registered...

Research paper thumbnail of Pulmonary Vein Stenting for the Treatment of Acquired Severe Pulmonary Vein Stenosis after Pulmonary Vein Isolation: Clinical Implications after Long-Term Follow-Up of 4 Years

Journal of Cardiovascular Electrophysiology, 2008

Pulmonary Vein Stenting. Introduction: Severe pulmonary vein stenosis (PVS) after catheter ablati... more Pulmonary Vein Stenting. Introduction: Severe pulmonary vein stenosis (PVS) after catheter ablation of atrial fibrillation (AF) is a well-recognized complication with a further reported incidence of 1.3%. The preferred therapy for symptomatic PVS is pulmonary vein (PV) angioplasty, but this treatment modality is followed by restenosis in 44-70%. Whether there is additional long-term benefit from PVS stenting is uncertain. The aim of this study was the evaluation of the long-term success after PV stenting of severe stenosis. Methods and Results: Ten patients (pts) with 13 PVS were prospectively evaluated. PV stenting was performed with Palmaz Genesis stents. Magnetic resonance imaging (MRI), lung perfusion scans, and CTscans were performed before, directly after, and every 12 months thereafter. Primary endpoint of the study was the occurrence of restenosis after PV stenting. After a median follow-up of 47.7 (IQRs 25/75 47.2-48.5) months, the primary endpoint was achieved in 3 out of 13 PVs (23% of the treated PVs). We observed two in-stent restenosis 2 and 4 years after PV stenting. These pts experienced onset of dyspnea some weeks before. After an additional balloon angioplasty, the in-stent restenosis was resolved. In one asymptomatic patient, we observed an occlusion of the PV stent 13 months poststenting. Normalization of lung perfusion was noted 4 years after PV stenting versus directly poststenting in all pts without in-stent restenosis (n = 7). Conclusion: PVS stenting with stent sizes ≥10 mm seems to be an adequate therapy modality for treatment of severe acquired PVS. Late in-stent restenosis after PVS stenting can occur. The normalization of the initially disturbed lung perfusion scan is possible and remains stable, even 4 years after PVS stenting.

Research paper thumbnail of Cryocatheter Ablation of Right Ventricular Outflow Tract Tachycardia

Journal of Cardiovascular Electrophysiology, 2005

Introduction: Cryocatheter techniques have been successfully applied to treat supraventricular ta... more Introduction: Cryocatheter techniques have been successfully applied to treat supraventricular tachycardia but there are no reports on their value in treating ventricular tachycardia (VT). We present our initial experience with cryocatheter ablation of right ventricular outflow tract (RVOT) tachycardia.Methods and Results: Cryocatheter ablation was attempted in 14 patients (13 females, age 45.9 ± 12.7 years) who were highly symptomatic due to frequent monomorphic ventricular extrasystole (VES) or nonsustained VT originating within the RVOT. A 9‐Fr, 8‐mm‐tip cryocatheter was used for both mapping and ablation. Cryoablation was started after localizing the arrhythmic focus by pace and activation mapping. Ablation success, defined by complete disappearance of target VES/VT acutely and during a follow‐up of 9.3 ± 1.4 weeks, was achieved in 13 of 14 patients. Ablation was successful with local activation times of 35 ± 4 ms, 5.8 ± 3.3 applications, 18.8 ± 7.5 minutes total cryo time, 9.4 ...

Research paper thumbnail of Incidence of pulmonary vein stenosis after pulmonary vein isolation by use of cryoenergy in patients with therapy-refractory atrial fibrillation in the long-term course

Heart Rhythm, 2005

Results: Electrical cardioversion was successful in all 27 subjects. In spite of normal LVEF, NT-... more Results: Electrical cardioversion was successful in all 27 subjects. In spite of normal LVEF, NT-proBNP values before CV were above the reference normal values (Ͻ280 pg/ml) in all but one patient. Nine patients (33%) had an early atrial fibrillation recurrence (within 3 weeks). Persistence of sinus rhythm was associated with a significant reduction in NT-proBNP values (from 672Ϯ280 to 337Ϯ230 pg/ml; pϭ 0.001). No significant differences were instead observed in the subjects with an early recurrence. No correlation was found between NT-proBNP values and, respectively, duration of AF, ejection fraction, left atrial diameter and HRV parameters. A strong correlation was found instead with left appendage emptying velocity (rϭ-0.73; pϭ0.001). Conclusions: These data indicate that in patients with persistent AF, abnormal atrial dynamics are strongly associated with NT-proBNP levels. Recovery of sinus rhythm is accompanied by a rapid reduction of NT-proBNP values likely to be due to the restoration of a more physiological hemodynamic function in the atria.

Research paper thumbnail of Impact of Impaired Renal Function and Metabolic Syndrome on the Recurrence of Atrial Fibrillation after Catheter Ablation: A Long Term Follow-Up

Pacing and Clinical Electrophysiology, 2012

Background: The goal of this study was to analyze impact of metabolic syndrome (MetS) and impaire... more Background: The goal of this study was to analyze impact of metabolic syndrome (MetS) and impaired renal function on long-term follow-up after catheter ablation of atrial fibrillation (AF). Methods and Results: A total of 702 consecutive patients with AF (age = 58 year, history of AF = 5 year, male = 478, paroxysmal atrial fibrillation = 416, coronary artery disease = 62, hypertension = 487) considered for catheter ablation were enrolled in the study. The MetS was diagnosed at admission in 276 patients. The renal function was estimated by glomerular filtration rate (eGFR). Pulmonary vein isolation (PVI) was performed either with cryoballoon technique (n = 260) or circumferential PVI (n = 442) with a 3.5-mm irrigated tip catheter. A 7-day-Holter electrocardiogram was performed at each follow-up visit. Any episode of documented AF after an initial 3-month blanking period was considered as clinical endpoint. Out of 702 patients, 370 (52.7%) were free of AF recurrences at median follow-up of 15 six interquartile range (12.7-42.3) months. The patients with MetS had significantly lower success rate than those without (128/276 (46.4%) vs 242/426 (56.8%), P = 0.006). Among 103 patients with eGFR < 68 mL/min only 35 (34%) were free of recurrences compared with 335/599 (55.9%) in patients with GFR ≥ 68 mL/min (P = 0.001). Both parameters were revealed in multivariate analysis to be independent predictors for outcome after catheter ablation. Conclusion: The results of our study clearly demonstrated that outcome after 1st catheter ablation of AF is poor in patients with MetS and/or impaired renal function. This observation has a potential clinical impact for the follow up management of these patients.

Research paper thumbnail of P6062Predicting outcome with normal-range high-sensitivity troponin i and heart-type fatty acid-binding protein in stable patients with suspected coronary artery disease

European Heart Journal, 2017

Background: Clinical characteristics and prognosis of patients with multi-vessel vasospastic angi... more Background: Clinical characteristics and prognosis of patients with multi-vessel vasospastic angina (VSA) were not fully elucidated. Objectives: To characterize the nature and prognosis of multi-vessel VSA compared with single vessel VAS. Methods: Among 617 patients diagnosed as definite vasospastic angina in the VA-KOREA (Vasospastic Angina in Korea) registry, we identified 201 patients underwent ergonovine provocation test on left and right coronary artery successively. 51 patients were classified into multi-vessel VSA and remaining 150 patients were classified into single vessel VSA. All patients were on optimal medical treatments by attending doctor's discretion. The primary composite endpoint was the 24-months incidences of cardiac death, new onset arrhythmia, and acute coronary syndrome. Emergency room revisits were also reported. Results: The baseline characteristics between multi-vessel VSA and single vessel VSA were similar except total cholesterol level was greater in single vessel VAS (p=0.03). Optimal medical treatments did not differ significantly between 2 groups. The 24-month incidences of cardiac death, new onset arrhythmia, and acute coronary syndrome were greater (3.0%, 6.1%, and 6.1%, respectively, total 15.2%) in the multi-vessel VSA than in single vessel VAS (0%, 1.1%, 0%, respectively, total 1.1%, p=0.001). Multi-vessel VSA showed low primary endpoint free survivor compared with single vessel VSA in Kaplan-Meier survivor curve (Log rank OR 13.90, 95% CI [2.27-85.32], p=0.016, Fig.1). In addition, multi-vessel VSA was an independent predictor for primary composite endpoint on 24 months (HR 36.6, 95% CI [2.04-658.27], p=0.015).

Research paper thumbnail of P355Impact of reduced tricuspid annular plane systolic excursion on outcome after ablation of atrial fibrillation with second-generation cryo-balloon

Europace, 2018

Thirty-nine consecutive patients (79.5% male, mean age 58.867.9 years, 59% paroxysmal AF) were in... more Thirty-nine consecutive patients (79.5% male, mean age 58.867.9 years, 59% paroxysmal AF) were included. Twenty-six patients showed acute PVR in 54/ 546 (9.8%) segments. In each region, segments with acute PVR showed significant lower mean AI compared to segments without PVR (anterior/roof, 411670 vs. 431673 arbitrary unit (au); posterior/inferior/carina, 349663 vs. 373662 au, all p<0.001). Mean minimum AI of reconnected segments was lower than non-reconnected segments (anterior/roof, 310651 vs. 335663 au; posterior/inferior/carina, 273637 vs. 311652 au, all p<0.001). No acute PVR was observed where the minimum AI value was 350 for posterior/inferior/carina segments and 450 for anterior/roof segments. Conclusion: AI values were associated with acute PVR and different target AI values were required by different PV regions for less acute PVR. AI-guided ablation might improve the success rate of point-by-point ablation. P354 Right atrial and coronary sinus complexity parameters predict acute outcome of persistent atrial fibrillation ablation and evolve with ablation steps

Research paper thumbnail of P3865Transformation in rotational atrial activity before and after PVI in patients with persistent AF

European Heart Journal, 2018

Background: Idarucizumab is licensed for dabigatran reversal based on the results of the REVERSE ... more Background: Idarucizumab is licensed for dabigatran reversal based on the results of the REVERSE AD study, which showed rapid and complete reversal of dabigatran anticoagulation in patients presenting with severe bleeding (Group A), or in those requiring urgent surgery (Group B). Enrollment was based solely on the clinical decision to reverse anticoagulation. This analysis focuses on the outcomes in the cohort of trauma patients. Methods: Trauma patients on dabigatran could be enrolled in either group in REVERSE AD , whether for serious bleeding or for reversal prior to urgent surgery. All patients were given 5 grams of idarucizumab intravenously and the primary endpoint was maximum reversal of dabigatran anticoagulation in the first 4 hours, as measured by ecarin clot time or diluted thrombin time. Results: Of the 503 patients enrolled in REVERSE AD, there were 114 trauma victims, 80 enrolled in Group A and 34 in Group B (Table). The most commonly documented mechanism of injury was fall from standing height, resulting in open or closed head injury or pelvic or hip fractures; 6 patients sustained high-impact polytrauma. Other injuries included fractured ribs, broken nose, and severed fingers. No trauma patient received more than one dose of idarucizumab, all patients had 100% reversal, and no drug-related adverse events were reported. Thrombotic events rates were low and consistent with the entire study cohort. Conclusions: Regardless of mechanism of injury, age, comorbidity, renal status, hemodynamic stability, or group assignment, idarucizumab provided prompt, complete, and safe reversal of dabigatran-mediated anticoagulation, allowing treating clinicians to manage the complications of trauma without concern for iatrogenic coagulopathy. Funding Acknowledgements: The study was funded by Boehringer Ingelheim

Research paper thumbnail of P994Five-year outcome and predictors of success after second-generation cryoballoon ablation for treatment of symptomatic atrial fibrillation

European Heart Journal, 2018

Consecutive stepwise forward Cox regression model calculation identified solely VRs (p-value <0.0... more Consecutive stepwise forward Cox regression model calculation identified solely VRs (p-value <0.001, HR 0.116, 95% confidence interval (CI) 0.036-0.367) and male gender (p-value 0.018, HR 0.573, CI 0.360-0.909) as independent predictors for AF-free survival. Conclusion: To the best of our knowledge, we are the first to demonstrate the preeminent impact of VRs during second generation CBA on the outcome of pts suffering from perAF. Thus, our findings may offer new clues for future CBA strategies, targeting for an increased amount of VRs to further improve the outcome of our pts. P994 Five-year outcome and predictors of success after second-generation cryoballoon ablation for treatment of symptomatic atrial fibrillation

Research paper thumbnail of Patients at Intermediate Surgical Risk Undergoing Isolated Interventional or Surgical Aortic Valve Implantation for Severe Symptomatic Aortic Valve Stenosis

Circulation, 2018

Background: Transcatheter aortic valve replacement (TAVR) is increasingly being used for treatmen... more Background: Transcatheter aortic valve replacement (TAVR) is increasingly being used for treatment of severe aortic valve stenosis in patients at intermediate risk for surgical aortic valve replacement (SAVR). Currently, real-world data comparing indications and clinical outcomes of patients at intermediate surgical risk undergoing isolated TAVR with those undergoing SAVR are scarce. Methods: We compared clinical characteristics and outcomes of patients with intermediate surgical risk (Society of Thoracic Surgeons score 4%–8%) who underwent isolated TAVR or conventional SAVR within the prospective, all-comers German Aortic Valve Registry. Results: A total of 7613 patients at intermediate surgical risk underwent isolated TAVR (n=6469) or SAVR (n=1144) at 92 sites in Germany between 2012 and 2014. Patients treated by TAVR were significantly older (82.5±5.0 versus 76.6±6.7 years, P <0.001) and had higher risk scores (logistic EuroSCORE [European System for Cardiac Operative Risk Eva...

Research paper thumbnail of Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation

Europace, 2016

Although the generation of linear lesions by ablation improves success rates in patients with per... more Although the generation of linear lesions by ablation improves success rates in patients with persistent atrial fibrillation (AF), the procedure has been considered unsuitable for cryoablation balloon catheter technologies. We developed a technique for linear ablations, using second-generation cryoballoon technology. Methods and results This was a single-arm, prospective study in 76 patients with persistent AF treated consecutively at our centre. Cryoablation was performed using a 28 mm second-generation cryoballoon. The first cryoenergy application was performed in close proximity to the position during isolation of the left superior pulmonary vein (PV). Sequential overlapping freezes were applied along the left atrial (LA) roof by slight clockwise rotation of the sheath in combination with slight retraction of the sheath and incremental advancement of the cryoballoon, until reaching the original position for right superior PV isolation. The acute endpoint was the creation of a roofline, defined as complete conduction block across the LA roof .120 ms and ascending activation across the posterior LA wall. Acute success in roofline generation was achieved in 88% of patients, applying on average five (median 4-6) freezes with nadir temperature of 2408C (236 to 2448C). In five patients, conduction block could not be achieved. No phrenic nerve injuries occurred during roofline generation. Conclusion Generation of linear roofline lesions is possible with the second-generation cryoballoon. The technique can be used in combination with PV isolation to treat persistent AF with good acute success rates, short procedure times, and acceptable safety concerns. If validated by further studies, the method would be an appealing alternative to radiofrequency ablation techniques.

Research paper thumbnail of Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis

European heart journal. Acute cardiovascular care, Jan 26, 2015

Extracorporeal life support (ECLS) has shown encouraging survival rates in patients with in-hospi... more Extracorporeal life support (ECLS) has shown encouraging survival rates in patients with in-hospital cardiac arrest; however, its routine use is still controversial. We compared the survival of patients with in-hospital cardiac arrest receiving conventional cardiopulmonary resuscitation (CCPR) to that of patients with ECLS as an adjunct to cardiopulmonary resuscitation (ECPR). A total of 353 patients with in-hospital cardiac arrest (272 CCPR and 52 ECPR) were included in this retrospective, propensity score-adjusted (1:1 matched), single-centre study. Primary endpoints were survival at 30 days, long-term survival and neurological outcome defined by the cerebral performance categories score. In the unmatched groups patients undergoing ECPR initially had significantly higher APACHE II scores (P=0.03), increased norepinephrine dosages (P=0.03) and elevated levels of creatine kinase (P<0.0001), creatinine (P=0.04) and lactate (P=0.02) before cardiopulmonary resuscitation compared wit...

Research paper thumbnail of 921 Differential effects on systolic and diastolic function after temporary suspension of long-term cardiac resynchronization therapy

European Journal of Echocardiography, 2006

Background and objective: LV regional dyssynchrony can be well analyzed by Real-time 3D echocardi... more Background and objective: LV regional dyssynchrony can be well analyzed by Real-time 3D echocardiography as well as by Tissue Doppler Imaging (DTI). There is paucity of information concerning comparative dyssynchrony evaluation by both methods. We sought to compare 3D echo and Tissue Doppler dyssynchrony assessment. Methods: We studied 44 patients (28 males, age 47±9 yrs). In the echocardiographic evaluation, the patients underwent 3D real-time echocardiographic quantification of LVEF and LV regional dyssynchrony (LV dyssynchrony index of 6 and 12 segments, relative to basal and basal plus medial segments). By DTI we measured LV QS eletromechanical interval in the basal segment of the mitral valve annulus of the septum, lateral, anterior and inferior walls, as well as DTI dyssinchrony index, defined as the standard deviation of the mean QS eletromechanical interval of the LV basal segments. Also we measured ECG duration; 3D echo and DTI data were compared by correlation coefficient of determination-Spearman (r), 95% CI, p<0.05, linear regression equation and Bland & Altman test. Results: 3D 6 segment dyssynchrony index (DI) ranged from 0.25 to 6.65 (1.15±1.15) %; 3D 12 segment DI ranged from 0.2 to 20.38 (2.04±3.63) %; DTI DI ranged from 0.26 to 4.32 (0.98±0.87) %; ECG duration ranged from 60 to 200 (80+29.5) ms; 3D LVEF ranged from 0.43 to 0.74 (0.59±0.10). Correlation coefficient (r) for DTI DI and 3D 6 DI was 0.7898, p<0.0001; and 0.7271, p<0.0001, for 3D 12 DI. Linear regression equation for DTI DI (y) and 3D 6 DI (x), was: y=0.3230+0.5976 x, p<0.0001; linear regression equation for DTI DI (y) and 3D 12 DI (x), was: y=0.6575+0.1749 x, p<0.0001. Conclusions: In this small series we observed good correlation between 3D echocardiography and DTI LV dyssynchrony assessment. Further studies should be undertaken with larger series of patients with increased ECG duration and decreased LVEF.

Research paper thumbnail of Slope of autocorrelation function of detrended 24-hour RR-intervals independently predicts mortality in postinfarction patients

Computers in Cardiology, 2004

Research paper thumbnail of Release kinetics of inflammatory biomarkers in a clinical model of acute myocardial infarction

Circulation research, Jan 27, 2015

Inflammation in the setting of acute myocardial infarction (MI) has been linked to risk stratific... more Inflammation in the setting of acute myocardial infarction (MI) has been linked to risk stratification; however, the release kinetics of inflammatory biomarkers in patients with acute MI has been difficult to establish. The aim of this study was to determine the kinetics of changes in the levels of several biomarkers specifically linked to inflammation after transcoronary ablation of septal hypertrophy, a procedure that mimics acute MI. We analyzed release kinetics of C-reactive protein, high-sensitivity C-reactive protein, interleukin-6, soluble CD40 ligand, and peripheral blood leukocyte subsets in patients (n=21) undergoing transcoronary ablation of septal hypertrophy. Blood samples were collected before transcoronary ablation of septal hypertrophy and at various times after transcoronary ablation of septal hypertrophy. Serum levels of C-reactive protein were increased at 24 hours (1.0 mg/dL [interquartile range [IQR], 0.7-1.75] versus 0.2 mg/dL [IQR, 0.1-1.05] at baseline [BL]; ...

Research paper thumbnail of Peri-operative results and complications in 15,964 transcatheter aortic valve implantations from the German Aortic valve RegistrY (GARY)

Journal of the American College of Cardiology, Jan 10, 2015

Transcatheter aortic valve implantation (T-AVI) has evolved into a routine procedure with good ou... more Transcatheter aortic valve implantation (T-AVI) has evolved into a routine procedure with good outcomes in high-risk patients. To evaluate the complication rates of T-AVI based on prospective data from the German aortic valve registry (GARY). From 2011 to 2013 a total of 15,964 T-AVI procedures were registered. We evaluated the total cohort for severe vital complications (SVC: death on the day of intervention, conversion to sternotomy, acute PCI, low cardiac output requiring mechanical support, cardiac tamponade requiring treatment, aortic dissection, annular rupture), technical complications of the procedures (TCO: repositioning or retrieval of the valve prosthesis, valve-in-valve implantation, embolization of the prosthesis, closure of a paravalvular leak) and other complications (aortic regurgitation, new-onset pacemaker implantation, stroke, major vascular complications, and major bleeding). The mean patient age was 81±6 years, 54% were female, median-logistic Euroscore I was 18...

Research paper thumbnail of Algorithmic complexity. A new approach of non-linear algorithms for the analysis of atrial signals from multipolar basket catheter

Annali dell'Istituto superiore di sanità, 2001

Symbolic dynamics as a non linear method and computation of the normalized algorithmic complexity... more Symbolic dynamics as a non linear method and computation of the normalized algorithmic complexity (C alpha) was applied to basket-catheter mapping of atrial fibrillation (AF) in the right human atrium. The resulting different degrees of organisation of AF have been compared to conventional classification of Wells. Short time temporal and spatial distribution of the C alpha during AF and effects of propafenone on this distribution have been investigated in 30 patients. C alpha was calculated for a moving window. Generated C alpha was analyzed within 10 minutes before and after administration of propafenone. The inter-regional C alpha distribution was statistically analyzed. Inter-regional C alpha differences were found in all patients (p < 0.001). The right atrium could be divided in high- and low complexity areas according to individual patterns. A significant C alpha increase in cranio-caudal direction was confirmed inter-individually (p < 0.01). The administration of propafe...

Research paper thumbnail of Usefulness of Atrial Fibrillation Burden as a Predictor for Success of Pulmonary Vein Isolation

Pacing and Clinical Electrophysiology, 2005

Background: The definition of symptomatic improvement after pulmonary vein isolation (PVI) is con... more Background: The definition of symptomatic improvement after pulmonary vein isolation (PVI) is controversial. We assessed primarily the usefulness and predictive accuracy (PA) of AF (atrial fibrillation) burden (AFB) within the first 3 months after the procedure as an early predictor for curative success as well as reduction of symptoms. Methods: We studied 100 pts (62 men, mean age: 54 ± 9 years, LVEF: 57 ± 9%, paroxysmal AF, 85, persistent AF, 15) who underwent PVI. RF ablation was used in 63 patients. The combination of cryoablation and RF (Hybrid therapy) was used in the remaining 37 patients, in 19 patients of whom additionally linear lesions were performed. All patients were followed up 3 months after PVI (the blanking period) and every 3 months thereafter. The significance of early recurrence of AF (ERAF) was separately analyzed for RF and for hybrid therapy arm. Quality of life (QoL) was assessed using the physical composite summary score (PCS) and mental composite summary sc...

Research paper thumbnail of Therapy with Renin-Angiotensin System Blockers after Pulmonary Vein Isolation in Patients with Atrial Fibrillation: Who Is a Responder?

Pacing and Clinical Electrophysiology, 2010

The data on anti-arrhythmic effect of renin-angiotensin-aldesteron system blockers (RASB) in pati... more The data on anti-arrhythmic effect of renin-angiotensin-aldesteron system blockers (RASB) in patients with atrial fibrillation (AF) are controversially discussed. The goal of this analysis was to identify cohort of patients with AF and hypertension, who may have benefit from RASB therapy after pulmonary vein isolation (PVI). Methods: A total of 284 patients with AF and hypertension (paroxysmal AF [PAF] = 218, male = 185, age = 61 years, left ventricular ejection fraction = 60%, coronary artery disease = 42) considered for PVI were included. The patients with PAF were stratified according to time spent in AF (AF burden) within 3 months prior to admission (</> 500 hours). Further patients were divided into two groups: (1) lowburden AF; (2) high-burden AF (PAF and persistent AF). In 195 patients, RASB therapy was administered. A 7-day continuous Holter electrocardiogram was performed after discharge, every 3 months thereafter and by symptoms. Results: Preventive effect of RASB was revealed in whole group (112 out of 195 [57%] vs 36 out of 89 [40%]; P = 0.025) and was more pronounced in patients with low-burden AF (79 out of 112 [71%] receiving RASB vs 27 out of 55 [49%] being on other drugs; P = 0.013). However, efficiency of RASB failed in patients with high-burden AF (33 out of 83 on RASB [40%] vs nine out of 34 on other drugs [27%]; P = 0.328). Conclusions: Our data suggest that RASB appears to protect against AF recurrences after PVI in patients with low-burden paroxysmal AF. These results should be tested in a prospective study.

Research paper thumbnail of A Decrease in Pulmonary Vein Diameter After Radiofrequency Ablation Predicts the Development of Severe Stenosis

Pacing and Clinical Electrophysiology, 2005

A decrease in ostial pulmonary vein (PV) diameter was observed in patients on the day after radio... more A decrease in ostial pulmonary vein (PV) diameter was observed in patients on the day after radiofrequency ablation of atrial fibrillation (AF). This study examined whether a relative reduction in PV diameter on day 1 (RRPVD1) after the procedure predicts the late development of severe PV stenosis (PVS). The study included 104 consecutive patients (mean age = 55 years, range 46-61, 34 women) with drug refractory AF. Pulmonary vein diameter was measured using MR angiography (MRA) on the day before and on day 1 after the ablation procedure. The MRA was repeated every 3 months after the procedure. Severe PVS was defined as a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;70% diameter reduction from the initial ostial diameter. The cut-off of RRPVD1 was prespecified as 25% decrease in initial diameter. The data are presented as medians and interquartile range. A total of 357 PV were treated. The RRPVD1 was 0.0% (0.0-11.1%). Severe PVS was found in 18 PV during a follow-up of 12 months (range 6-13). The log-rank analysis confirmed a strong association between a RRPVD1 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=25% and the development of PVS (hazard ratio: 7.1; 95% confidence interval 3.8-13.5, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). By multivariate Cox regression model, after adjustment of procedure variables, RRPVD1 was the strongest predictor of development of severe PVS. RRPVD1 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=25% was a strong independent predictor of development of severe PVS.

Research paper thumbnail of Shock Coordinated with High Power of Morphology Electrogram Improves Defibrillation Success in Patients with Implantable Cardioverter Defibrillators

Pacing and Clinical Electrophysiology, 2002

BERKOWITSCH, A., et al.: Shock Coordinated with High Power of Morphology Electrogram Improves Def... more BERKOWITSCH, A., et al.: Shock Coordinated with High Power of Morphology Electrogram Improves Defibrillation Success in Patients with Implantable Cardioverter Defibrillators. Animal studies have suggested that the success of defibrillation may depend on the properties of VF waveform obtained from the morphology electrogram (ME) at the time of the shock. The reliable identification of depolarization events in the fibrillatory signal can be achieved using adaptive estimation of the instantaneous signal power (P). The aim of this study was to investigate if a high P of the ME (PME) was related to ventricular DFT and if the upslope in ME can be associated with the depolarization event. A total of 575 VF (mean duration 10 s) episodes recorded and stored during ICD implantation in 77 patients with ventricular arrhythmias were used for analysis. The DFT was defined using a double step‐down test. The values of PME immediately before pulse delivery (Pshock) and shock outcomes were registered...

Research paper thumbnail of Pulmonary Vein Stenting for the Treatment of Acquired Severe Pulmonary Vein Stenosis after Pulmonary Vein Isolation: Clinical Implications after Long-Term Follow-Up of 4 Years

Journal of Cardiovascular Electrophysiology, 2008

Pulmonary Vein Stenting. Introduction: Severe pulmonary vein stenosis (PVS) after catheter ablati... more Pulmonary Vein Stenting. Introduction: Severe pulmonary vein stenosis (PVS) after catheter ablation of atrial fibrillation (AF) is a well-recognized complication with a further reported incidence of 1.3%. The preferred therapy for symptomatic PVS is pulmonary vein (PV) angioplasty, but this treatment modality is followed by restenosis in 44-70%. Whether there is additional long-term benefit from PVS stenting is uncertain. The aim of this study was the evaluation of the long-term success after PV stenting of severe stenosis. Methods and Results: Ten patients (pts) with 13 PVS were prospectively evaluated. PV stenting was performed with Palmaz Genesis stents. Magnetic resonance imaging (MRI), lung perfusion scans, and CTscans were performed before, directly after, and every 12 months thereafter. Primary endpoint of the study was the occurrence of restenosis after PV stenting. After a median follow-up of 47.7 (IQRs 25/75 47.2-48.5) months, the primary endpoint was achieved in 3 out of 13 PVs (23% of the treated PVs). We observed two in-stent restenosis 2 and 4 years after PV stenting. These pts experienced onset of dyspnea some weeks before. After an additional balloon angioplasty, the in-stent restenosis was resolved. In one asymptomatic patient, we observed an occlusion of the PV stent 13 months poststenting. Normalization of lung perfusion was noted 4 years after PV stenting versus directly poststenting in all pts without in-stent restenosis (n = 7). Conclusion: PVS stenting with stent sizes ≥10 mm seems to be an adequate therapy modality for treatment of severe acquired PVS. Late in-stent restenosis after PVS stenting can occur. The normalization of the initially disturbed lung perfusion scan is possible and remains stable, even 4 years after PVS stenting.

Research paper thumbnail of Cryocatheter Ablation of Right Ventricular Outflow Tract Tachycardia

Journal of Cardiovascular Electrophysiology, 2005

Introduction: Cryocatheter techniques have been successfully applied to treat supraventricular ta... more Introduction: Cryocatheter techniques have been successfully applied to treat supraventricular tachycardia but there are no reports on their value in treating ventricular tachycardia (VT). We present our initial experience with cryocatheter ablation of right ventricular outflow tract (RVOT) tachycardia.Methods and Results: Cryocatheter ablation was attempted in 14 patients (13 females, age 45.9 ± 12.7 years) who were highly symptomatic due to frequent monomorphic ventricular extrasystole (VES) or nonsustained VT originating within the RVOT. A 9‐Fr, 8‐mm‐tip cryocatheter was used for both mapping and ablation. Cryoablation was started after localizing the arrhythmic focus by pace and activation mapping. Ablation success, defined by complete disappearance of target VES/VT acutely and during a follow‐up of 9.3 ± 1.4 weeks, was achieved in 13 of 14 patients. Ablation was successful with local activation times of 35 ± 4 ms, 5.8 ± 3.3 applications, 18.8 ± 7.5 minutes total cryo time, 9.4 ...

Research paper thumbnail of Incidence of pulmonary vein stenosis after pulmonary vein isolation by use of cryoenergy in patients with therapy-refractory atrial fibrillation in the long-term course

Heart Rhythm, 2005

Results: Electrical cardioversion was successful in all 27 subjects. In spite of normal LVEF, NT-... more Results: Electrical cardioversion was successful in all 27 subjects. In spite of normal LVEF, NT-proBNP values before CV were above the reference normal values (Ͻ280 pg/ml) in all but one patient. Nine patients (33%) had an early atrial fibrillation recurrence (within 3 weeks). Persistence of sinus rhythm was associated with a significant reduction in NT-proBNP values (from 672Ϯ280 to 337Ϯ230 pg/ml; pϭ 0.001). No significant differences were instead observed in the subjects with an early recurrence. No correlation was found between NT-proBNP values and, respectively, duration of AF, ejection fraction, left atrial diameter and HRV parameters. A strong correlation was found instead with left appendage emptying velocity (rϭ-0.73; pϭ0.001). Conclusions: These data indicate that in patients with persistent AF, abnormal atrial dynamics are strongly associated with NT-proBNP levels. Recovery of sinus rhythm is accompanied by a rapid reduction of NT-proBNP values likely to be due to the restoration of a more physiological hemodynamic function in the atria.