6 underwent transplantation, 14 had successfully treated VF and 8 had symptomatic sustained VT as... more 6 underwent transplantation, 14 had successfully treated VF and 8 had symptomatic sustained VT as the first major event. In 38 patients, the only presenting CS manifestation was atrioventricular block (AVB) without any arrhythmias or left ventricular dysfunction. In them, the Kaplan-Meier (K-M) estimate of MACE-free survival was 258 months (95% CI, 196-320 months) compared to 204 months (95% CI, 125-283 months) in patients (n=82) with any other disease presentation (Log-rank p=0.015). Measurements of cardiac troponin-T at presentation were available in 95 patients. The K-M survival estimate was 232 months (95% CI, 183-230 months) in 69 patients with cardiac troponin-T (cTnT) ≤30 ng/L vs 127 months (95% CI, 100-154 months) in 26 patients with cTnT >30 ng/L (Logrank p=0.005). In univariate Cox regression analysis, the hazard ratio (95% CI) for MACE was 0.28 (0.13-0.64, p=0.002) for cTnT ≤30 ng/L and 0.32 (0.13-0.84, p=0.021) for lone AVB.
Stereotactic arrhythmia radiotherapy (STAR) is suggested as potentially effective and safe treatm... more Stereotactic arrhythmia radiotherapy (STAR) is suggested as potentially effective and safe treatment for patients with therapy-refractory ventricular tachycardia (VT). However, the current prospective knowledge base and experience with STAR is limited. In this study we aimed to prospectively evaluate the efficacy and safety of STAR. Methods and results The StereoTactic Arrhythmia Radiotherapy in the Netherlands no.1 was a pre-post intervention study to prospectively evaluate efficacy and safety of STAR. In patients with therapy-refractory VT, the pro-arrhythmic region was treated with a 25 Gy single radiotherapy fraction. The main efficacy measure was a reduction in the number of treated VT-episodes by ≥50%, comparing the 12 months before and after treatment (or end of follow-up, excluding a 6-week blanking period). The study was deemed positive when ≥50% of patients would meet this criterion. Safety evaluation included left ventricular ejection fraction, pulmonary function, and adverse events. Six male patients with an ischaemic cardiomyopathy were enrolled, and median age was 73 years (range 54-83). Median left ventricular ejection fraction was 38% (range 24-52). The median planning target volume was 187 mL (range 93-372). Four (67%) patients completed the 12-month follow-up, and two patients died (not STAR related) during follow-up. The main efficacy measure of ≥50% reduction in treated VT-episodes at the end of follow-up was achieved in four patients (67%). The median number of treated VT-episodes was reduced by 87%. No reduction in left ventricular ejection fraction or pulmonary function was observed. No treatment related serious adverse events occurred. Conclusions STAR resulted in a ≥ 50% reduction in treated VT-episodes in 4/6 (67%) patients. No reduction in cardiac and pulmonary function nor treatment-related serious adverse events were observed during follow-up. Clinical trial registration Netherlands Trial Register-NL7510.
Journal of Cardiovascular Electrophysiology, Apr 15, 2022
BackgroundCardiac sarcoidosis (CS) is associated with an increased risk for sudden cardiac death.... more BackgroundCardiac sarcoidosis (CS) is associated with an increased risk for sudden cardiac death. An implantable cardiac defibrillator (ICD) is recommended in a subgroup of CS patients. However, the recommendations for primary prevention differ between guidelines. The purpose of the study was to evaluate the efficacy and safety of ICDs in CS and to identify predictors of appropriate therapy.MethodsA retrospective cohort study was performed in CS patients with an ICD implantation between 2010 and 2019. Primary outcome was appropriate ICD therapy. Independent predictors were calculated using Cox proportional hazard analysis.Results105 patients were included. An ICD was implanted for primary prevention in 79%. During a median follow‐up of 2.8 years, 34 patients (32.4%) received appropriate ICD therapy of whom 24 (22.9%) received an appropriate shock. Three patients (2.9%) received an inappropriate shock due to atrial fibrillation. Independent predictors of appropriate therapy included prior ventricular arrhythmias (hazard ratio [HR]: 10.5 [95% confidence interval (CI): 5.0–21.9]) and right ventricular late gadolinium enhancement (LGE) (HR: 3.6 [95% CI: 1.7–7.6]). Within the primary prevention group, right ventricular LGE (HR: 5.7 [95% CI: 1.6–20.7]) was the only independent predictor of appropriate therapy. Left ventricular ejection fraction did not differ between patients with and without appropriate therapy (44.4% vs. 45.6%, p = .70).ConclusionIn CS patients with an ICD, a high rate of appropriate therapy was observed and a low rate of inappropriate shocks. Prior ventricular arrhythmias and right ventricular LGE were independent predictors of appropriate therapy.
Funding Acknowledgements: Type of funding sources: None. Background: Dielectric imaging is used b... more Funding Acknowledgements: Type of funding sources: None. Background: Dielectric imaging is used by the KODEX-EPD system to provide information that can be used to guide catheter ablation of cardiac arrhythmia. This includes assessment of catheter-tissue contact (No touch, Touch, or High touch) and local atrial wall thickness (mm). Additionally, the system can detect changes in local dielectric tissue properties to assess the effect of a radiofrequency energy application. This assessment is used to classify ablation points into low or high dielectric response (LDR or HDR), which was designed to indicate the extent of lesion transmurality. Objectives: To evaluate the relation between dielectric response and other ablation parameters. Methods: The KODEX-EPD system was used to guide ablation in patients with prior pulmonary vein isolation. Ablation included re-isolation of the pulmonary veins and isolation of the superior vena cava if deemed necessary. We downloaded system data from all procedures that were performed with software that provided dielectric response (version 1.5.0, 1.5.0a, 1.5.1 and 1.5.1a) and analyzed the parameters of all individual ablation points. Results: The cohort includes 55 patients, in which 135 pulmonary veins and 19 superior venae cavae were targeted. A total of 860 energy applications were applied, resulting in 1458 ablation points. The system classified 31% of ablation points as HDR and 19% as LDR. The system did not provide a dielectric response in 49%. The system's ability to determine dielectric response was related to the software version(oldest version 71% no DR, newest version 18%) and duration of ablation. High dielectric response (versus LDR or no DR) was multivariably associated with longer energy applications, higher mean ablation power and lower local wall thickness (Table). Mean ablation temperature and impedance drop were not multivariably associated with dielectric response. Conclusion: Dielectric response is independently associated with local wall thickness, ablation power and duration, but not with ablation temperature and impedance drop. Newer software versions have reduced the proportion of ablation points for which no dielectric response was provided. Table
One hundred and eight P referred to a NOACs Anticoagulation Unit from a Tertiary University Hospi... more One hundred and eight P referred to a NOACs Anticoagulation Unit from a Tertiary University Hospital were identified over 12 months. P treated with all NOACs currently available (dabigatran, rivaroxaban, apixaban, edoxaban) were included. Results: Median age of the cohort was 74.9 years and 67.3% were male. Mean glomerular filtration rate was 47.7 mL/min and an impairment was noticed in 35P (32.4%) at the moment of NOAC initiation. Bleeding events occurred in 15P (13,9%), without major haemorrhages, and ischemic episodes in 5P (4,6%) during a mean follow-up of 8 months. Three deaths were reported (one due to a massive stroke). According to renal function, label-discordant dosing was observed in 35% of the P. Lack of renal dose-adjustment was seen in 9.3% and in 25.9% of the P with preserved renal function underdosing was documented. However, when comparing these two groups, there was not a significant increase in bleeding (18.2 vs. 13.4%, p¼ns) or stroke events (0 vs. 6.3%, p¼ns). Finally, 12P (11.1%) reported a temporary interruption of the NOAC mainly attributed to drug-specific side effects and minor bleeding. All the discontinued P proceeded with other types of oral anticoagulants. Conclusions: In routine clinical practice, prescribed NOAC doses are often inconsistent with drug labelling and irregular P medication adherence is not rare. A structured follow-up, with judicious prescribing and regular monitoring of renal function and drug compliance could reduce potential complications.
Background: Atrial tachyarrhythmias, especially atrial fibrillation (AF), are common in patients ... more Background: Atrial tachyarrhythmias, especially atrial fibrillation (AF), are common in patients with cardiac implantable electronic devices (CIEDs). Restoration of sinus rhythm, by means of external electrical cardioversion (ECV), is a frequently used strategy to alleviate symptoms, prevent adverse device reactions and to enable optimal device response. Objectives: To evaluate the safety of external ECV in patients with contemporary CIEDs and to assess the need for immediate device interrogation after ECV. Methods: We conducted a retrospective observational study of patients with a CIED who underwent external ECV between 2008 and 2016 in our centers. Data from device interrogation before ECV, immediately afterwards, and from first follow up interrogation after ECV were collected. CIED related complications and adverse events during and after external ECV were recorded. Results: We analysed 229 elective ECVs in 203 patients (27.9% female, mean age 69610 years). AF was the main reason for ECV (77.3%). One hundred and four ECVs were performed in patients with a pacemaker, 69 in patients with an implantable cardioverter defibrillator (ICD) and 56 in patients with a biventricular devices. The preferred paddle position was anteroposterior (85.8%). No significant differences between right atrial (RA) and right ventricular (RV) sensing values before ECV, immediately afterwards or at follow up (FU) were observed. No significant changes in RA and RV threshold measurements were noted. A small yet significant decrease was observed in RA and RV impedance immediately after ECV (484 vs. 462 ohms, p<0.001 and 536 vs. 514 ohms, p<0.001 respectively). The acutely decreased mean RV impedance did not recover to the baseline value (538 vs. 527 ohms, p¼0.022). Impedance changes were without clinical consequences. No statistically or clinically relevant changes in LV lead threshold or impedance values were measured. No CIED related complications or adverse events were documented following ECV. Conclusion:
Journal of Cardiovascular Electrophysiology, Jan 22, 2020
In patients with a prior myocardial infarction (MI) but preserved LV function, sustained ventricu... more In patients with a prior myocardial infarction (MI) but preserved LV function, sustained ventricular arrhythmias (VA) may arise in the setting of an acute coronary syndrome (ACS). It is unknown whether an Implantable Cardioverter Defibrillator (ICD) is mandatory in these patients as VA might be triggered by a reversible cause. The purpose of this study is to analyse the benefit of ICD therapy in this patient population. Methods: We conducted a retrospective, observational study in ICD recipients implanted from 2008 to 2011. The study group consisted of patients with sustained VA in the setting of an ACS, with a history of MI, but with LVEF>35 (Group A). The two control groups consisted of patients admitted with VA with a history of MI, but without ACS at presentation, either with LVEF >35% (group B) or ≤35% (
Journal of Interventional Cardiac Electrophysiology, May 23, 2022
Purpose The second-generation multi-electrode catheter, PVAC Gold, was designed to improve the sa... more Purpose The second-generation multi-electrode catheter, PVAC Gold, was designed to improve the safe delivery of phased radiofrequency energy using a "single shot" approach for pulmonary vein isolation (PVI), while retaining efficacy. This large registry presents long-term performance in a daily practice setting. Methods A total of 1011 patients undergoing first time ablation for atrial fibrillation (AF) using PVAC Gold were included, 639 patients with PVI for paroxysmal AF (PAF PVI) and 372 patients with persistent or long-standing persistent AF, divided into 175 patients receiving PVI only (PersAF PVI) and 197 patients receiving PVI with additional substrate ablation (PersAF PVI +). Results At 24-month follow-up, single procedure freedom from atrial tachyarrhythmia (ATA) was 58% (368/639) in the PAF PVI group, 44% (77/175) in the PersAF PVI group, and 29% (57/197) in the PersAF PVI + group. Allowing one repeat procedure in 33% of patients, 76%, 65%, and 54% were free from ATA at 24 months, respectively. Pulmonary vein reconnection was observed in 98% of patients with recurrent arrhythmia after PVI. Conclusions Although phased RF ablation with PVAC Gold is quick and safe, the efficacy outcomes are modest compared to current mainstream ablation strategies.
BackgroundThe tissue response viewer (TRV) is a novel marker for ablation lesion quality that aim... more BackgroundThe tissue response viewer (TRV) is a novel marker for ablation lesion quality that aims to classify lesions into transmural or nontransmural lesions (high or low dielectric response, HDR or LDR) using dielectric‐based tissue assessment. The objective of this study was to gain insight in the TRV by relating its outcomes to conventional ablation parameters.MethodsPatients that had repeat ablation for atrial fibrillation with a dielectric imaging‐based mapping system were enrolled. All ablation data were downloaded from the mapping system and analyzed to explore associations between TRV outcomes and other ablation parameters.ResultsThe cohort included 24 patients, in which 58 pulmonary veins and 8 superior vena cavas were targeted. A total of 388 energy applications were applied, resulting in 639 ablation points. The system classified 36% of ablation points as HDR and 44% as LDR. The system did not provide a dielectric response in 20%. The system's ability to provide a dielectric response was related to longer ablation duration and absence of dragging ablation. HDR (versus LDR) was multivariably associated with longer energy applications, higher mean ablation power, and lower wall thickness. Greater impedance drop was univariably associated with HDR.ConclusionOutcomes of the TRV are associated with conventional ablation parameters (e.g., duration and power) but also local wall thickness. Catheter stability seems important for successful lesion assessment with the TRV. Further reduction of missing outcomes and validation of the tool are warranted before widespread use.
Funding Acknowledgement: Type of funding sources: None. Background: Dielectric imaging systems ca... more Funding Acknowledgement: Type of funding sources: None. Background: Dielectric imaging systems can be used to guide catheter ablation for cardiac arrhythmia. Currently, the KODEX-EPD system can be used to acquire high-resolution anatomical data for electroanatomical mapping. Future software versions of this system enable tissue assessment utilizing local dielectric sensing. These dielectric-based tissue assessments (KODEX Vision) enable new features, including wall thickness measurement, catheter-tissue contact assessment, and ablation lesion assessment. Purpose: To gain insight in the dielectric-based tissue assessment features. Methods: The KODEX-EPD system was used to perform repeat ablations in patients with recurrent atrial fibrillation after pulmonary vein isolation. A primary system with the current software version (1.4.8) was used by the operator. Ablation was performed with a non-contact force-sensing irrigated radiofrequency catheter, with power set at 30-35W and aiming for ablation times of 30-60s. A secondary system was blinded for the operator and loaded with beta software (1.5.0) to enable the KODEX Vision features. Only successful local tissue assessments are presented in this abstract. All
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Funding Acknowledgement: Type of funding sources: None. Background: High-density mapping is incre... more Funding Acknowledgement: Type of funding sources: None. Background: High-density mapping is increasingly used in catheter ablation of complex arrhythmias. In atypical atrial flutters (AAFl), high-density mapping can provide a more accurate delineation of the arrhythmic circuit. This promotes acute procedural success, but follow-up data on clinical outcomes are scarce. Purpose: To study procedural characteristics and arrhythmia recurrence of high-density mapping-guided AAFl ablation. Methods: In this monocenter prospective observational cohort study, we included patients that were treated for AAFl using a high-density mapping system with a grid-patterned mapping catheter. We evaluated acute procedural success and atrial flutter recurrence at follow-up. Acute success was defined as non-inducibility of atrial flutters. Arrhythmia recurrence was defined by electrocardiographic documentation of atrial flutter. Results: Between April 2018 and July 2020, 65 patients (69% male; age 65±8yr; 69% prior PVI; 60% prior cardiac surgery) were included in this study. A total of 100 AAFl were observed during the procedures. The flutter
Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This ... more Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This system provides 3D maps of electrical activation across an ultrasound-acquired atrial surface. Methods We evaluated the feasibility and the acute and short-term efficacy and safety of this novel system for ablation of persistent atrial fibrillation (AF) and atypical atrial flutter. Results A total of 21 consecutive patients (age (mean ± standard deviation) 62 ± 8 years, 23% female) underwent catheter ablation with the use of the Ac-QMap System. Fourteen patients (67%) were treated for persistent AF and 7 patients (33%) for atypical atrial flutter. Eighteen patients (86%) had undergone at least one prior ablation procedure. Acute success, defined as sinus rhythm without the ability to provoke the clinical arrhythmia, was achieved in 17 patients (81%). At 12 months, 4 patients treated for persistent AF (29%) and 4 patients treated for atypical flutter (57%) remained in sinus rhythm. Complications included hemiparesis, for which intra-arterial thrombolysis was given with subsequent good clinical outcome (n = 1), and complete atrioventricular block, for which a permanent pacemaker was implanted
It is well known that angiotensin II (Ang II) can facilitate the effects of sympathetic neurotran... more It is well known that angiotensin II (Ang II) can facilitate the effects of sympathetic neurotransmission. In the present study, using various experimental models, we investigated the inhibitory effects of several Ang II subtype 1 receptor (AT1) antagonists on this Ang II-induced facilitation. We compared the sympatho-inhibitory potencies of the AT1 blockers with their respective potencies regarding inhibition of the direct vasoconstrictor effects of Ang II. In the isolated mesenteric artery, we investigated the effects of Ang II in the presence and absence of losartan, irbesartan and telmisartan on stimulation-induced vasoconstrictor responses. In the pithed rat, we studied the effect of AT1 blockade on the sequelae of electrical stimulation of the thoracolumbar sympathetic outflow (presynaptic AT1 blockade) as well as on dose-response curves elicited by exogenous Ang II (postsynaptic AT1 blockade). Additionally, we compared the sympatho-inhibitory of irbesartan in spontaneously hypertensive (SHR) and Wistar-Kyoto (WKY) rats. In the isolated mesenteric artery, Ang II (10 nM) significantly enhanced stimulation-induced vasoconstrictor responses. The enhancement could be antagonized in a concentration-dependent manner by losartan (1 nmol/l to 1 mumol/l), irbesartan (0.1 nmol/l to 0.1 mumol/l) and telmisartan (0.01 nmol/l to 0.01 mumol/l). The sympatho-inhibitory potency was telmisartan > irbesartan > losartan. In the pithed normotensive rat, the stimulation-induced increase in diastolic blood pressure (DBP) as well as the Ang II-elicited DBP response were dose-dependently reduced by all the AT1 receptor blockers investigated. The order of potency with respect to sympatho-inhibition was eprosartan > valsartan = candesartan = embusartan = telmisartan > losartan > irbesartan (comparison of doses which at 2 Hz reduced delta DBP by 20 mmHg, differences significant at P < 0.05). The order of potency regarding inhibition of the Ang II-induced DBP increase was candesartan > embusartan = valsartan = eprosartan = telmisartan > irbesartan > losartan (comparison of the antagonist concentration, in the presence of which twice the agonist concentration, in the presence of which twice the agonist concentration is needed to cause the same effect [pA2 values], differences significant at P < 0.05). In the pithed SHR and the normotensive WKY rat the sympatho-inhibitory potency of irbesartan did not differ significantly between both strains. It can be concluded that all AT1 receptor antagonists appear to possess sympatho-inhibitory properties, which may be of potential interest in the treatment of hypertension and heart failure. Our findings suggest differences in pre- and postsynaptic inhibition between the various compounds, since for eprosartan and losartan the sympatholytic doses and postsynaptic inhibitory doses differed far less than for the other AT1 receptor antagonists.
6 underwent transplantation, 14 had successfully treated VF and 8 had symptomatic sustained VT as... more 6 underwent transplantation, 14 had successfully treated VF and 8 had symptomatic sustained VT as the first major event. In 38 patients, the only presenting CS manifestation was atrioventricular block (AVB) without any arrhythmias or left ventricular dysfunction. In them, the Kaplan-Meier (K-M) estimate of MACE-free survival was 258 months (95% CI, 196-320 months) compared to 204 months (95% CI, 125-283 months) in patients (n=82) with any other disease presentation (Log-rank p=0.015). Measurements of cardiac troponin-T at presentation were available in 95 patients. The K-M survival estimate was 232 months (95% CI, 183-230 months) in 69 patients with cardiac troponin-T (cTnT) ≤30 ng/L vs 127 months (95% CI, 100-154 months) in 26 patients with cTnT >30 ng/L (Logrank p=0.005). In univariate Cox regression analysis, the hazard ratio (95% CI) for MACE was 0.28 (0.13-0.64, p=0.002) for cTnT ≤30 ng/L and 0.32 (0.13-0.84, p=0.021) for lone AVB.
Stereotactic arrhythmia radiotherapy (STAR) is suggested as potentially effective and safe treatm... more Stereotactic arrhythmia radiotherapy (STAR) is suggested as potentially effective and safe treatment for patients with therapy-refractory ventricular tachycardia (VT). However, the current prospective knowledge base and experience with STAR is limited. In this study we aimed to prospectively evaluate the efficacy and safety of STAR. Methods and results The StereoTactic Arrhythmia Radiotherapy in the Netherlands no.1 was a pre-post intervention study to prospectively evaluate efficacy and safety of STAR. In patients with therapy-refractory VT, the pro-arrhythmic region was treated with a 25 Gy single radiotherapy fraction. The main efficacy measure was a reduction in the number of treated VT-episodes by ≥50%, comparing the 12 months before and after treatment (or end of follow-up, excluding a 6-week blanking period). The study was deemed positive when ≥50% of patients would meet this criterion. Safety evaluation included left ventricular ejection fraction, pulmonary function, and adverse events. Six male patients with an ischaemic cardiomyopathy were enrolled, and median age was 73 years (range 54-83). Median left ventricular ejection fraction was 38% (range 24-52). The median planning target volume was 187 mL (range 93-372). Four (67%) patients completed the 12-month follow-up, and two patients died (not STAR related) during follow-up. The main efficacy measure of ≥50% reduction in treated VT-episodes at the end of follow-up was achieved in four patients (67%). The median number of treated VT-episodes was reduced by 87%. No reduction in left ventricular ejection fraction or pulmonary function was observed. No treatment related serious adverse events occurred. Conclusions STAR resulted in a ≥ 50% reduction in treated VT-episodes in 4/6 (67%) patients. No reduction in cardiac and pulmonary function nor treatment-related serious adverse events were observed during follow-up. Clinical trial registration Netherlands Trial Register-NL7510.
Journal of Cardiovascular Electrophysiology, Apr 15, 2022
BackgroundCardiac sarcoidosis (CS) is associated with an increased risk for sudden cardiac death.... more BackgroundCardiac sarcoidosis (CS) is associated with an increased risk for sudden cardiac death. An implantable cardiac defibrillator (ICD) is recommended in a subgroup of CS patients. However, the recommendations for primary prevention differ between guidelines. The purpose of the study was to evaluate the efficacy and safety of ICDs in CS and to identify predictors of appropriate therapy.MethodsA retrospective cohort study was performed in CS patients with an ICD implantation between 2010 and 2019. Primary outcome was appropriate ICD therapy. Independent predictors were calculated using Cox proportional hazard analysis.Results105 patients were included. An ICD was implanted for primary prevention in 79%. During a median follow‐up of 2.8 years, 34 patients (32.4%) received appropriate ICD therapy of whom 24 (22.9%) received an appropriate shock. Three patients (2.9%) received an inappropriate shock due to atrial fibrillation. Independent predictors of appropriate therapy included prior ventricular arrhythmias (hazard ratio [HR]: 10.5 [95% confidence interval (CI): 5.0–21.9]) and right ventricular late gadolinium enhancement (LGE) (HR: 3.6 [95% CI: 1.7–7.6]). Within the primary prevention group, right ventricular LGE (HR: 5.7 [95% CI: 1.6–20.7]) was the only independent predictor of appropriate therapy. Left ventricular ejection fraction did not differ between patients with and without appropriate therapy (44.4% vs. 45.6%, p = .70).ConclusionIn CS patients with an ICD, a high rate of appropriate therapy was observed and a low rate of inappropriate shocks. Prior ventricular arrhythmias and right ventricular LGE were independent predictors of appropriate therapy.
Funding Acknowledgements: Type of funding sources: None. Background: Dielectric imaging is used b... more Funding Acknowledgements: Type of funding sources: None. Background: Dielectric imaging is used by the KODEX-EPD system to provide information that can be used to guide catheter ablation of cardiac arrhythmia. This includes assessment of catheter-tissue contact (No touch, Touch, or High touch) and local atrial wall thickness (mm). Additionally, the system can detect changes in local dielectric tissue properties to assess the effect of a radiofrequency energy application. This assessment is used to classify ablation points into low or high dielectric response (LDR or HDR), which was designed to indicate the extent of lesion transmurality. Objectives: To evaluate the relation between dielectric response and other ablation parameters. Methods: The KODEX-EPD system was used to guide ablation in patients with prior pulmonary vein isolation. Ablation included re-isolation of the pulmonary veins and isolation of the superior vena cava if deemed necessary. We downloaded system data from all procedures that were performed with software that provided dielectric response (version 1.5.0, 1.5.0a, 1.5.1 and 1.5.1a) and analyzed the parameters of all individual ablation points. Results: The cohort includes 55 patients, in which 135 pulmonary veins and 19 superior venae cavae were targeted. A total of 860 energy applications were applied, resulting in 1458 ablation points. The system classified 31% of ablation points as HDR and 19% as LDR. The system did not provide a dielectric response in 49%. The system's ability to determine dielectric response was related to the software version(oldest version 71% no DR, newest version 18%) and duration of ablation. High dielectric response (versus LDR or no DR) was multivariably associated with longer energy applications, higher mean ablation power and lower local wall thickness (Table). Mean ablation temperature and impedance drop were not multivariably associated with dielectric response. Conclusion: Dielectric response is independently associated with local wall thickness, ablation power and duration, but not with ablation temperature and impedance drop. Newer software versions have reduced the proportion of ablation points for which no dielectric response was provided. Table
One hundred and eight P referred to a NOACs Anticoagulation Unit from a Tertiary University Hospi... more One hundred and eight P referred to a NOACs Anticoagulation Unit from a Tertiary University Hospital were identified over 12 months. P treated with all NOACs currently available (dabigatran, rivaroxaban, apixaban, edoxaban) were included. Results: Median age of the cohort was 74.9 years and 67.3% were male. Mean glomerular filtration rate was 47.7 mL/min and an impairment was noticed in 35P (32.4%) at the moment of NOAC initiation. Bleeding events occurred in 15P (13,9%), without major haemorrhages, and ischemic episodes in 5P (4,6%) during a mean follow-up of 8 months. Three deaths were reported (one due to a massive stroke). According to renal function, label-discordant dosing was observed in 35% of the P. Lack of renal dose-adjustment was seen in 9.3% and in 25.9% of the P with preserved renal function underdosing was documented. However, when comparing these two groups, there was not a significant increase in bleeding (18.2 vs. 13.4%, p¼ns) or stroke events (0 vs. 6.3%, p¼ns). Finally, 12P (11.1%) reported a temporary interruption of the NOAC mainly attributed to drug-specific side effects and minor bleeding. All the discontinued P proceeded with other types of oral anticoagulants. Conclusions: In routine clinical practice, prescribed NOAC doses are often inconsistent with drug labelling and irregular P medication adherence is not rare. A structured follow-up, with judicious prescribing and regular monitoring of renal function and drug compliance could reduce potential complications.
Background: Atrial tachyarrhythmias, especially atrial fibrillation (AF), are common in patients ... more Background: Atrial tachyarrhythmias, especially atrial fibrillation (AF), are common in patients with cardiac implantable electronic devices (CIEDs). Restoration of sinus rhythm, by means of external electrical cardioversion (ECV), is a frequently used strategy to alleviate symptoms, prevent adverse device reactions and to enable optimal device response. Objectives: To evaluate the safety of external ECV in patients with contemporary CIEDs and to assess the need for immediate device interrogation after ECV. Methods: We conducted a retrospective observational study of patients with a CIED who underwent external ECV between 2008 and 2016 in our centers. Data from device interrogation before ECV, immediately afterwards, and from first follow up interrogation after ECV were collected. CIED related complications and adverse events during and after external ECV were recorded. Results: We analysed 229 elective ECVs in 203 patients (27.9% female, mean age 69610 years). AF was the main reason for ECV (77.3%). One hundred and four ECVs were performed in patients with a pacemaker, 69 in patients with an implantable cardioverter defibrillator (ICD) and 56 in patients with a biventricular devices. The preferred paddle position was anteroposterior (85.8%). No significant differences between right atrial (RA) and right ventricular (RV) sensing values before ECV, immediately afterwards or at follow up (FU) were observed. No significant changes in RA and RV threshold measurements were noted. A small yet significant decrease was observed in RA and RV impedance immediately after ECV (484 vs. 462 ohms, p<0.001 and 536 vs. 514 ohms, p<0.001 respectively). The acutely decreased mean RV impedance did not recover to the baseline value (538 vs. 527 ohms, p¼0.022). Impedance changes were without clinical consequences. No statistically or clinically relevant changes in LV lead threshold or impedance values were measured. No CIED related complications or adverse events were documented following ECV. Conclusion:
Journal of Cardiovascular Electrophysiology, Jan 22, 2020
In patients with a prior myocardial infarction (MI) but preserved LV function, sustained ventricu... more In patients with a prior myocardial infarction (MI) but preserved LV function, sustained ventricular arrhythmias (VA) may arise in the setting of an acute coronary syndrome (ACS). It is unknown whether an Implantable Cardioverter Defibrillator (ICD) is mandatory in these patients as VA might be triggered by a reversible cause. The purpose of this study is to analyse the benefit of ICD therapy in this patient population. Methods: We conducted a retrospective, observational study in ICD recipients implanted from 2008 to 2011. The study group consisted of patients with sustained VA in the setting of an ACS, with a history of MI, but with LVEF>35 (Group A). The two control groups consisted of patients admitted with VA with a history of MI, but without ACS at presentation, either with LVEF >35% (group B) or ≤35% (
Journal of Interventional Cardiac Electrophysiology, May 23, 2022
Purpose The second-generation multi-electrode catheter, PVAC Gold, was designed to improve the sa... more Purpose The second-generation multi-electrode catheter, PVAC Gold, was designed to improve the safe delivery of phased radiofrequency energy using a "single shot" approach for pulmonary vein isolation (PVI), while retaining efficacy. This large registry presents long-term performance in a daily practice setting. Methods A total of 1011 patients undergoing first time ablation for atrial fibrillation (AF) using PVAC Gold were included, 639 patients with PVI for paroxysmal AF (PAF PVI) and 372 patients with persistent or long-standing persistent AF, divided into 175 patients receiving PVI only (PersAF PVI) and 197 patients receiving PVI with additional substrate ablation (PersAF PVI +). Results At 24-month follow-up, single procedure freedom from atrial tachyarrhythmia (ATA) was 58% (368/639) in the PAF PVI group, 44% (77/175) in the PersAF PVI group, and 29% (57/197) in the PersAF PVI + group. Allowing one repeat procedure in 33% of patients, 76%, 65%, and 54% were free from ATA at 24 months, respectively. Pulmonary vein reconnection was observed in 98% of patients with recurrent arrhythmia after PVI. Conclusions Although phased RF ablation with PVAC Gold is quick and safe, the efficacy outcomes are modest compared to current mainstream ablation strategies.
BackgroundThe tissue response viewer (TRV) is a novel marker for ablation lesion quality that aim... more BackgroundThe tissue response viewer (TRV) is a novel marker for ablation lesion quality that aims to classify lesions into transmural or nontransmural lesions (high or low dielectric response, HDR or LDR) using dielectric‐based tissue assessment. The objective of this study was to gain insight in the TRV by relating its outcomes to conventional ablation parameters.MethodsPatients that had repeat ablation for atrial fibrillation with a dielectric imaging‐based mapping system were enrolled. All ablation data were downloaded from the mapping system and analyzed to explore associations between TRV outcomes and other ablation parameters.ResultsThe cohort included 24 patients, in which 58 pulmonary veins and 8 superior vena cavas were targeted. A total of 388 energy applications were applied, resulting in 639 ablation points. The system classified 36% of ablation points as HDR and 44% as LDR. The system did not provide a dielectric response in 20%. The system's ability to provide a dielectric response was related to longer ablation duration and absence of dragging ablation. HDR (versus LDR) was multivariably associated with longer energy applications, higher mean ablation power, and lower wall thickness. Greater impedance drop was univariably associated with HDR.ConclusionOutcomes of the TRV are associated with conventional ablation parameters (e.g., duration and power) but also local wall thickness. Catheter stability seems important for successful lesion assessment with the TRV. Further reduction of missing outcomes and validation of the tool are warranted before widespread use.
Funding Acknowledgement: Type of funding sources: None. Background: Dielectric imaging systems ca... more Funding Acknowledgement: Type of funding sources: None. Background: Dielectric imaging systems can be used to guide catheter ablation for cardiac arrhythmia. Currently, the KODEX-EPD system can be used to acquire high-resolution anatomical data for electroanatomical mapping. Future software versions of this system enable tissue assessment utilizing local dielectric sensing. These dielectric-based tissue assessments (KODEX Vision) enable new features, including wall thickness measurement, catheter-tissue contact assessment, and ablation lesion assessment. Purpose: To gain insight in the dielectric-based tissue assessment features. Methods: The KODEX-EPD system was used to perform repeat ablations in patients with recurrent atrial fibrillation after pulmonary vein isolation. A primary system with the current software version (1.4.8) was used by the operator. Ablation was performed with a non-contact force-sensing irrigated radiofrequency catheter, with power set at 30-35W and aiming for ablation times of 30-60s. A secondary system was blinded for the operator and loaded with beta software (1.5.0) to enable the KODEX Vision features. Only successful local tissue assessments are presented in this abstract. All
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Funding Acknowledgement: Type of funding sources: None. Background: High-density mapping is incre... more Funding Acknowledgement: Type of funding sources: None. Background: High-density mapping is increasingly used in catheter ablation of complex arrhythmias. In atypical atrial flutters (AAFl), high-density mapping can provide a more accurate delineation of the arrhythmic circuit. This promotes acute procedural success, but follow-up data on clinical outcomes are scarce. Purpose: To study procedural characteristics and arrhythmia recurrence of high-density mapping-guided AAFl ablation. Methods: In this monocenter prospective observational cohort study, we included patients that were treated for AAFl using a high-density mapping system with a grid-patterned mapping catheter. We evaluated acute procedural success and atrial flutter recurrence at follow-up. Acute success was defined as non-inducibility of atrial flutters. Arrhythmia recurrence was defined by electrocardiographic documentation of atrial flutter. Results: Between April 2018 and July 2020, 65 patients (69% male; age 65±8yr; 69% prior PVI; 60% prior cardiac surgery) were included in this study. A total of 100 AAFl were observed during the procedures. The flutter
Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This ... more Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This system provides 3D maps of electrical activation across an ultrasound-acquired atrial surface. Methods We evaluated the feasibility and the acute and short-term efficacy and safety of this novel system for ablation of persistent atrial fibrillation (AF) and atypical atrial flutter. Results A total of 21 consecutive patients (age (mean ± standard deviation) 62 ± 8 years, 23% female) underwent catheter ablation with the use of the Ac-QMap System. Fourteen patients (67%) were treated for persistent AF and 7 patients (33%) for atypical atrial flutter. Eighteen patients (86%) had undergone at least one prior ablation procedure. Acute success, defined as sinus rhythm without the ability to provoke the clinical arrhythmia, was achieved in 17 patients (81%). At 12 months, 4 patients treated for persistent AF (29%) and 4 patients treated for atypical flutter (57%) remained in sinus rhythm. Complications included hemiparesis, for which intra-arterial thrombolysis was given with subsequent good clinical outcome (n = 1), and complete atrioventricular block, for which a permanent pacemaker was implanted
It is well known that angiotensin II (Ang II) can facilitate the effects of sympathetic neurotran... more It is well known that angiotensin II (Ang II) can facilitate the effects of sympathetic neurotransmission. In the present study, using various experimental models, we investigated the inhibitory effects of several Ang II subtype 1 receptor (AT1) antagonists on this Ang II-induced facilitation. We compared the sympatho-inhibitory potencies of the AT1 blockers with their respective potencies regarding inhibition of the direct vasoconstrictor effects of Ang II. In the isolated mesenteric artery, we investigated the effects of Ang II in the presence and absence of losartan, irbesartan and telmisartan on stimulation-induced vasoconstrictor responses. In the pithed rat, we studied the effect of AT1 blockade on the sequelae of electrical stimulation of the thoracolumbar sympathetic outflow (presynaptic AT1 blockade) as well as on dose-response curves elicited by exogenous Ang II (postsynaptic AT1 blockade). Additionally, we compared the sympatho-inhibitory of irbesartan in spontaneously hypertensive (SHR) and Wistar-Kyoto (WKY) rats. In the isolated mesenteric artery, Ang II (10 nM) significantly enhanced stimulation-induced vasoconstrictor responses. The enhancement could be antagonized in a concentration-dependent manner by losartan (1 nmol/l to 1 mumol/l), irbesartan (0.1 nmol/l to 0.1 mumol/l) and telmisartan (0.01 nmol/l to 0.01 mumol/l). The sympatho-inhibitory potency was telmisartan > irbesartan > losartan. In the pithed normotensive rat, the stimulation-induced increase in diastolic blood pressure (DBP) as well as the Ang II-elicited DBP response were dose-dependently reduced by all the AT1 receptor blockers investigated. The order of potency with respect to sympatho-inhibition was eprosartan > valsartan = candesartan = embusartan = telmisartan > losartan > irbesartan (comparison of doses which at 2 Hz reduced delta DBP by 20 mmHg, differences significant at P < 0.05). The order of potency regarding inhibition of the Ang II-induced DBP increase was candesartan > embusartan = valsartan = eprosartan = telmisartan > irbesartan > losartan (comparison of the antagonist concentration, in the presence of which twice the agonist concentration, in the presence of which twice the agonist concentration is needed to cause the same effect [pA2 values], differences significant at P < 0.05). In the pithed SHR and the normotensive WKY rat the sympatho-inhibitory potency of irbesartan did not differ significantly between both strains. It can be concluded that all AT1 receptor antagonists appear to possess sympatho-inhibitory properties, which may be of potential interest in the treatment of hypertension and heart failure. Our findings suggest differences in pre- and postsynaptic inhibition between the various compounds, since for eprosartan and losartan the sympatholytic doses and postsynaptic inhibitory doses differed far less than for the other AT1 receptor antagonists.
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