Publications by authors named "Daniel Steven"

151 Publications

The European TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: centre and patient experiences.

Europace 2021 Apr 2. Epub 2021 Apr 2.

Department of Cardiology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, 6202 AZ Maastricht, The Netherlands.

Aims: TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck®). We describe the characteristics, inclusion rates, and experiences from participating centres according the TeleCheck-AF infrastructure as well as characteristics and experiences from recruited patients.

Methods And Results: Three surveys exploring centre characteristics (n = 25), centre experiences (n = 23), and patient experiences (n = 826) were completed. Self-reported patient characteristics were obtained from the app. Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of the centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs. 52 weekly recruited patients). Majority (>80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Recruited patients [median age 64 (55-71), 62% male] agreed that the FibriCheck® app was easy to use (94%).

Conclusion: Despite different health care settings and mobile health experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19.
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http://dx.doi.org/10.1093/europace/euab050DOI Listing
April 2021

Mapping strategies for premature ventricular contractions-activation, voltage, and/or pace map.

Herzschrittmacherther Elektrophysiol 2021 Mar 3;32(1):27-32. Epub 2021 Feb 3.

Klinik III für Innere Medizin - Allgemeine und interventionelle Kardiologie, Elektrophysiologie, Angiologie, Pneumologie und internistische Intensivmedizin, Abteilung für Elektrophysiologie, Uniklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany.

A high premature ventricular contraction (PVC) burden is associated with an increase in cardiovascular mortality and may become clinically apparent through palpitations, reduced physical capacity or PVC-induced cardiomyopathy. Catheter ablation has been shown to be a more effective tool to treat patients with a high PVC burden than medical therapy alone. Current recommendations list catheter ablation as a class I option in patients with symptomatic idiopathic outflow tract PVCs as well as in patients with suspected PVC-induced cardiomyopathy. Careful planning is necessary to maximize efficiency and outcome of the ablation procedure. Prediction of the most likely PVC origin by studying the 12-lead electrocardiogram (ECG) is important. A high burden of spontaneous PVCs is associated with a better outcome during and after the procedure; pharmacological provocation can be performed. Developments in high density mapping systems have greatly advanced accuracy and efficiency of arrhythmia mapping in recent years. Different systems are now available that allow the simultaneous use and integration of different mapping information in an automated manner. Voltage mapping, activation mapping and pace mapping are used in clinical practice today. Activation mapping is used to visualize the area of earliest activation. While it is a very accurate tool, it relies on a high burden of spontaneous PVCs. Pace mapping aims to find the target area by means of stimulation and comparison of paced QRS complexes with the clinical PVC. Today, mostly a combination of both methods is used to maximize procedure outcome and efficiency. While voltage mapping plays a primary role in the mapping of substrate-based sustained arrhythmias in patients with underlying structural heart disease, activation and pace mapping are the methods of choice for PVC mapping.
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http://dx.doi.org/10.1007/s00399-021-00743-wDOI Listing
March 2021

ICD therapy in the elderly: a retrospective single-center analysis of mortality.

Herzschrittmacherther Elektrophysiol 2021 Jan 29. Epub 2021 Jan 29.

Department of Electrophysiology, Cologne, University Heart Center Cologne, Kerpener Str. 62, 50937, Köln, Germany.

Background: Current implantable cardioverter-defibrillator (ICD) guidelines do not impose age limitations for ICD implantation (IMPL) and generator exchange (GE); however, patients (pts) should be expected to survive for 1 year. With higher age, comorbidity and mortality due to non-sudden cardiac death increase. Thus, the benefit of ICD therapy in elderly pts remains unclear. Mortality after ICD IMPL or GE in pts ≥ 75 years was assessed.

Methods: Consecutive pts aged ≥ 75 years with ICD IMPL or GE at the University Hospital Cologne, Germany, between 01/2013 and 12/2017 were included in this retrospective analysis.

Results: Of 418 pts, 82 (20%) fulfilled the inclusion criteria; in 70 (55 = IMPL, 79%, 15 = GE, 21%) follow-up (FU) was available. The median FU was 3.1 years. During FU, 40 pts (57%) died (29/55 [53%] IMPL; 11/15 [73%] GE). Mean survival after surgery was 561 ± 462 days. The 1‑year mortality rate was 19/70 (27%) overall, 9/52 (17%) in pts ≥ 75 and 10/18 (56%) in pts ≥ 80 years. Deceased pts were more likely to suffer from chronic renal failure (85% vs. 53%, p = 0.004) and peripheral artery disease (18% vs. 0%, p = 0.02). During FU, seven pts experienced ICD shocks (four appropriate, three inappropriate). In primary prevention (n = 35) mortality was 46% and four pts experienced ICD therapies (two adequate); in secondary prevention (n = 35) mortality was 69% (p = 0.053) with three ICD therapies (two adequate).

Conclusion: Mortality in ICD pts aged ≥ 80 years was 56% at 1 and 72% at 2 years in this retrospective analysis. The decision to implant an ICD in elderly pts should be made carefully and individually.
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http://dx.doi.org/10.1007/s00399-021-00742-xDOI Listing
January 2021

Transseptal puncture for ablation of atrial fibrillation in a patient with an implanted atrial flow regulator: a case report.

Eur Heart J Case Rep 2020 Oct 25;4(5):1-4. Epub 2020 Aug 25.

Department of Electrophysiology, University Heart Center Cologne, Kerpener Str. 62, 50937 Cologne, Germany.

Background: Atrial flow regulator (AFR) (Occlutech, Helsingborg, Sweden) are self-expanding, circular devices. A flexible waist in the centre connects the two discs and has a centrally located shunt.

Case Summary: We report a case of an 80-year-old woman undergoing a repeat left atrial ablation for persistent atrial fibrillation with an implanted AFR. The AFR was implanted 1 year prior to the procedure for heart failure with preserved ejection fraction as part of the AFR-PRELIEVE trial. A single, fluoroscopy-guided, transseptal puncture was performed infero-posterior to the device, allowing the positioning of the mapping (LASSO 20 mm, Biosense Webster, Irvine, CA, USA) and ablation (Thermocool Smarttouch SF, CARTO, Biosense Webster, Irvine, CA, USA) catheter in the left atrium. Three-dimensional mapping (CARTO, Biosense Webster, Irvine, CA, USA) and left atrial ablation were successfully performed. After the procedure, fluoroscopy and transthoracic echocardiography showed an unchanged device position.

Discussion: To our knowledge, this is the first case report of a transseptal puncture in a patient with an implanted AFR. Transseptal puncture in patients with an implanted AFR seems to be safe and feasible. With device diameters of 21-23 mm and based on previous studies on similar devices, transseptal puncture should be possible in most patients, as opposed to puncture through the device.
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http://dx.doi.org/10.1093/ehjcr/ytaa242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649456PMC
October 2020

Cardiac involvement in sarcoidosis and necessary ventricular tachycardia ablation.

Eur Heart J 2021 Feb;42(5):544

Department of Cardiology and Electrophysiology, Universitätsklinik Köln, Kerpener Straße 62, 50937 Cologne, Germany.

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http://dx.doi.org/10.1093/eurheartj/ehaa773DOI Listing
February 2021

On-demand mobile health infrastructures to allow comprehensive remote atrial fibrillation and risk factor management through teleconsultation.

Clin Cardiol 2020 Nov 8;43(11):1232-1239. Epub 2020 Oct 8.

Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.

Background: Although novel teleconsultation solutions can deliver remote situations that are relatively similar to face-to-face interaction, remote assessment of heart rate and rhythm as well as risk factors remains challenging in patients with atrial fibrillation (AF).

Hypothesis: Mobile health (mHealth) solutions can support remote AF management.

Methods: Herein, we discuss available mHealth tools and strategies on how to incorporate the remote assessment of heart rate, rhythm and risk factors to allow comprehensive AF management through teleconsultation.

Results: Particularly, in the light of the coronavirus disease 2019 (COVID-19) pandemic, there is decreased capacity to see patients in the outpatient clinic and mHealth has become an important component of many AF outpatient clinics. Several validated mHealth solutions are available for remote heart rate and rhythm monitoring as well as for risk factor assessment. mHealth technologies can be used for (semi-)continuous longitudinal monitoring or for short-term on-demand monitoring, dependent on the respective requirements and clinical scenarios. As a possible solution to improve remote AF care through teleconsultation, we introduce the on-demand TeleCheck-AF mHealth approach that allows remote app-based assessment of heart rate and rhythm around teleconsultations, which has been developed and implemented during the COVID-19 pandemic in Europe.

Conclusion: Large scale international mHealth projects, such as TeleCheck-AF, will provide insight into the additional value and potential limitations of mHealth strategies to remotely manage AF patients. Such mHealth infrastructures may be well suited within an integrated AF-clinic, which may require redesign of practice and reform of health care systems.
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http://dx.doi.org/10.1002/clc.23469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661648PMC
November 2020

Hydrochlorothiazide therapy: impact on early recurrence of atrial fibrillation after catheter ablation?

Minerva Cardiol Angiol 2021 Feb 29;69(1):102-108. Epub 2020 Sep 29.

Department of Electrophysiology, University Hospital of Cologne, Cologne, Germany.

Background: Hypokalemia has been linked to electrocardiogram changes and afterdepolarization-mediated arrhythmias. However, the association between hypokalemia and atrial fibrillation (AF) has not been well studied. Hydrochlorothiazide (HCT) diuretic therapy was shown to be associated with hypokalemia in multiple studies. We aimed to determine whether HCT therapy is associated with early recurrence of AF after radiofrequency (RF) catheter ablation during a 3-month follow-up.

Methods: We performed a retrospective registry analysis of our internal AF ablation registry, containing 807 consecutive patients that underwent RF ablation for symptomatic AF. Propensity score matching was used to match 156 patients on HCT therapy with 156 controls. Furthermore, we performed propensity score matching between the first and the fourth quartile of baseline serum potassium (K) concentrations in the initial population (N.=807).

Results: We observed a small but statistically significant difference in baseline mean potassium levels between the HCT group and the control group (4.03 mmol/L vs. 4.19 mmol/L respectively, P=0.001). There was no difference in short term recurrence of atrial fibrillation in the HCT group compared to the propensity score matched control group (41.0% [N.=64] vs. 45.5% [N.=71], P=0.424). In the comparison between the first and the fourth quartile of baseline serum potassium values, no difference in AF recurrence (38.2% [N.=63] vs. 37.0% [N.=61], P=0.820) during a 3-month follow-up after ablation was observed between both groups.

Conclusions: Patients on HCT therapy showed no difference in short term recurrence of AF after ablation compared to propensity matched controls.
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http://dx.doi.org/10.23736/S0026-4725.20.05170-1DOI Listing
February 2021

First transcatheter leadless pacemaker implantation in a pediatric patient with a genetic disease.

Herzschrittmacherther Elektrophysiol 2020 Jun 5;31(2):235-237. Epub 2020 May 5.

Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.

A pediatric patient suffering from Marden-Walker syndrome, a rare genetic disease, was referred to the authors' hospital for syncope due to bradycardia. Since this disease is associated with severe joint contractures, a transcatheter leadless pacing system (TPS) was chosen. Despite the small body size and complex anatomy, TPS implantation was feasible, demonstrating that it is a safe alternative in difficult venous access compared to a conventional pacemaker with increased risk of lead complications in these patients.
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http://dx.doi.org/10.1007/s00399-020-00685-9DOI Listing
June 2020

Outcome of catheter ablation of non-reentrant ventricular arrhythmias in patients with and without structural heart disease.

Eur J Med Res 2020 Mar 17;25(1). Epub 2020 Mar 17.

Department of Cardiology-Electrophysiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.

Background: Catheter ablation of non-reentrant, commonly termed "idiopathic" ventricular arrhythmias (VA) is highly effective in patients without structural heart disease (SHD). Meanwhile, the outcome of catheter ablation of these arrhythmias in patients with SHD remains unclear. This study sought to characterize the outcome of patients with and without SHD undergoing catheter ablation of non-reentrant VA.

Methods: In this single-centre study the acute and long-term outcome of 266 consecutive patients undergoing catheter ablation of non-reentrant VA was investigated. In 41.0% of patients a SHD was present (n = 109, 80.7% male, age 59.1 ± 14.7 years), 59.0% had no SHD (n = 157; 44.0% male, age 49.9 ± 16.5 years).

Results: Acute procedural success (absence of spontaneous or provoked VA at the end of procedure and within 48 h after the procedure) was achieved in 89.9% of patients with SHD vs. 94.3% without SHD (p = 0.238). During a mean follow-up of 34.7 ± 15.1 months a repeat catheter ablation was performed in 19.6% of patients with SHD vs. 13.0% without SHD (p = 0.179). Patients with dilated cardiomyopathy (DCM) were the most likely to require a repeat ablation procedure (32.0% of patients with DCM vs. 13.0% without SHD; p = 0.022). Periprocedural complications occurred in 5.5% of patients with SHD vs. 5.7% without SHD (p > 0.999). All complications were managed without sequelae.

Conclusions: The outcome of catheter ablation of non-reentrant VA in patients with SHD appears good and is comparable to patients without SHD. A slightly higher rate of repeat ablations was observed in patients with DCM.
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http://dx.doi.org/10.1186/s40001-020-0400-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076989PMC
March 2020

Outcomes in patients with dual antegrade conduction in the atrioventricular node: insights from a multicentre observational study.

Clin Res Cardiol 2020 Aug 30;109(8):1025-1034. Epub 2020 Jan 30.

Department of Cardiology-Electrophysiology, University Heart and Vascular Center, Hamburg, Germany.

Background: Supraventricular tachycardias induced by dual antegrade conduction via the atrioventricular (AV) node are rare but often misdiagnosed with severe consequences for the affected patients. As long-term follow-up in these patients was not available so far, this study investigates outcomes in patients with dual antegrade conduction in the AV node.

Methods And Results: In this multicentre observational study, patients from six European centres were studied. Catheter ablation was performed in 17 patients (52 ± 16 years) with dual antegrade conduction via both AV nodal pathways between 2012 and 2018. Patients with the final diagnosis of a manifest dual AV nodal non-re-entrant tachycardia had a mean delay of the correct diagnosis of over 1 year (range 2-31 months). Two patients received prescription of non-indicated oral anticoagulation, two further patients suffered from inappropriate shocks of an implantable cardioverter defibrillator. In 12 patients, a co-existence of dual antegrade and re-entry conduction in the AV node was present. Mean fast pathway conduction time was 138 ± 61 ms and mean slow pathway conduction time was 593 ± 134 ms. Successful radiofrequency catheter ablation was performed in all patients. Post-procedurally oral anticoagulation was discontinued, without detection of cerebrovascular events or atrial fibrillation during a long-term follow-up of median 17 months (range 6-72 months).

Conclusion: This first multicentre study investigating patients with supraventricular tachycardia and dual antegrade conduction in the AV node demonstrates that catheter ablation is safe and effective while long-term patient outcome is good. Autonomic tone dependent changes in ante- vs. retrograde conduction via slow and/or fast pathway can challenge the diagnosis and therapy in some patients.
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http://dx.doi.org/10.1007/s00392-020-01596-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375989PMC
August 2020

Preventive or Deferred Ablation of Ventricular Tachycardia in Patients With Ischemic Cardiomyopathy and Implantable Defibrillator (BERLIN VT): A Multicenter Randomized Trial.

Circulation 2020 03 31;141(13):1057-1067. Epub 2020 Jan 31.

Asklepios Klinik St Georg, Hamburg, Germany (A.M., K.-H.K.).

Background: Catheter ablation for ventricular tachycardia (VT) reduces the recurrence of VT in patients with implantable cardioverter-defibrillators (ICDs). The appropriate timing of VT ablation and its effects on mortality and heart failure progression remain a matter of debate. In patients with life-threatening arrhythmias necessitating ICD implantation, we compared outcomes of preventive VT ablation (undertaken before ICD implantation to prevent ICD shocks for VT) and deferred ablation after 3 ICD shocks for VT.

Methods: The BERLIN VT study (Preventive Ablation of Ventricular Tachycardia in Patients With Myocardial Infarction) was a prospective, open, parallel, randomized trial performed at 26 centers. Patients with stable ischemic cardiomyopathy, a left ventricular ejection fraction between 30% and 50%, and documented VT were randomly assigned 1:1 to a preventive or deferred ablation strategy. The primary outcome was a composite of all-cause death and unplanned hospitalization for either symptomatic ventricular arrhythmia or worsening heart failure. Secondary outcomes included sustained ventricular tachyarrhythmia and appropriate ICD therapy. We hypothesized that preventive ablation strategy would be superior to deferred ablation strategy in the intention-to-treat population.

Results: During a mean follow-up of 396±284 days, the primary end point occurred in 25 (32.9%) of 76 patients in the preventive ablation group and 23 (27.7%) of 83 patients in the deferred ablation group (hazard ratio, 1.09 [95% CI, 0.62-1.92]; =0.77). On the basis of prespecified criteria for interim analyses, the study was terminated early for futility. In the preventive versus deferred ablation group, 6 versus 2 patients died (7.9% versus 2.4%; =0.18), 8 versus 2 patients were admitted for worsening heart failure (10.4% versus 2.3%; =0.062), and 15 versus 21 patients were hospitalized for symptomatic ventricular arrhythmia (19.5% versus 25.3%; =0.27). Among secondary outcomes, the proportions of patients with sustained ventricular tachyarrhythmia (39.7% versus 48.2%; =0.050) and appropriate ICD therapy (34.2% versus 47.0%; =0.020) were numerically reduced in the preventive ablation group.

Conclusions: Preventive VT ablation before ICD implantation did not reduce mortality or hospitalization for arrhythmia or worsening heart failure during 1 year of follow-up compared with the deferred ablation strategy. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02501005.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.043400DOI Listing
March 2020

Pulmonary vein isolation in a patient with congenital pulmonary atresia: a case report.

Eur Heart J Case Rep 2019 Sep 13;3(3):ytz115. Epub 2019 Jul 13.

Department of Electrophysiology, Heart Center, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany.

Background : Tetralogy of Fallot is a congenital heart defect characterized by pulmonary valve stenosis, ventricular septal defect (VSD), overriding aorta, and right ventricular hypertrophy. In its' extreme form, the pulmonary valve orifice does not develop during organogenesis, resulting in pulmonary atresia. We report a case of catheter ablation of symptomatic atrial fibrillation (AF) in a 37-year-old patient with congenital pulmonary atresia.

Case Summary : The young man described paroxysmal tachycardia correlating to AF episodes in the previously implanted event recorder. Computed tomography scan described the complex anatomy with congenital pulmonary atresia, VSD, and major aortopulmonary collateral arteries. Electroanatomical mapping revealed typical pulmonary vein electrograms in a hypotrophic left atrium. Modified pulmonary vein isolation was successfully performed and non-excitability of the ablation line was reached. The patient recovered uneventfully and event recorder interrogation showed no AF recurrence after 3 months.

Discussion : Incidence of pulmonary atresia is low. Untreated survival rate is 50% after 1 year and 8% after 10 years. Tachycardia is a major cause of increased morbidity and mortality in patients with cyanotic congenital heart defects and pulmonary vein foci are described as driver for AF. Considerations preceding catheter ablation included pathophysiological mechanism, complex anatomy, atypical left atrium access, and reduced pulmonary perfusion resulting in a hypotrophic left atrium. Pulmonary veins showed typical electrograms, and isolation of pulmonary veins was feasible without adverse events.
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http://dx.doi.org/10.1093/ehjcr/ytz115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6764579PMC
September 2019

AAP President's Address.

Authors:
Steven R Daniel

J Periodontol 2019 10 15;90(10):1075-1078. Epub 2019 Sep 15.

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http://dx.doi.org/10.1002/JPER.19-0511DOI Listing
October 2019

Internal Versus External Electrical Cardioversion of Atrial Arrhythmia in Patients With Implantable Cardioverter-Defibrillator: A Randomized Clinical Trial.

Circulation 2019 09 30;140(13):1061-1069. Epub 2019 Aug 30.

University of Cologne, University Hospital Cologne, Department of Electrophysiology (J.L., A.S., D.S.), Germany.

Background: Atrial arrhythmias are common in patients with implantable cardioverter-defibrillator (ICD). External shocks and internal cardioversion through commanded ICD shock for electrical cardioversion are used for rhythm-control. However, there is a paucity of data on efficacy of external versus internal cardioversion and on the risk of lead and device malfunction. We hypothesized that external cardioversion is noninferior to internal cardioversion for safety, and superior for successful restoration of sinus rhythm.

Methods: Consecutive patients with ICD undergoing elective cardioversion for atrial arrhythmias at 13 centers were randomized in 1:1 fashion to either internal or external cardioversion. The primary safety end point was a composite of surrogate events of lead or device malfunction. Conversion of atrial arrhythmia to sinus rhythm was the primary efficacy end point. Myocardial damage was studied by measuring troponin release in both groups.

Results: N=230 patients were randomized. Shock efficacy was 93% in the external cardioversion group and 65% in the internal cardioversion group (<0.001). Clinically relevant adverse events caused by external or internal cardioversion were not observed. Three cases of pre-existing silent lead malfunction were unmasked by internal shock, resulting in lead failure. Troponin release did not differ between groups.

Conclusions: This is the first randomized trial on external vs internal cardioversion in patients with ICDs. External cardioversion was superior for the restoration of sinus rhythm. The unmasking of silent lead malfunction in the internal cardioversion group suggests that an internal shock attempt may be reasonable in selected ICD patients presenting for electrical cardioversion.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03247738.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.041320DOI Listing
September 2019

Porous tip contact force-sensing catheters for pulmonary vein isolation: performance in a clinical routine setting.

J Interv Card Electrophysiol 2020 Mar 19;57(2):251-259. Epub 2019 Jul 19.

Department of Electrophysiology, Heart Center, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.

Purpose: In catheter ablation of atrial fibrillation (AF), contact force (CF)-sensing catheters with an irrigated tip are used to deliver radiofrequency (RF) energy to the tissue. The ThermoCool® Smarttouch™ Surroundflow catheter (STSF) integrates CF-sensing technology and a new porous tip for advanced external cooling. The aim was to evaluate the performance and safety of STSF in a clinical setting of pulmonary vein isolation (PVI) in comparison with standard contact force-sensing catheter (ST).

Methods: We assigned consecutive patients (n = 80, prospectively, open-label, non-randomized) with symptomatic AF to either PVI with STSF (n = 60) or ST (n = 20).

Results: Total ablation time to achieve PVI was significantly shorter in STSF compared to that in ST (STSF, 1556 ± 435 s vs. ST, 1922 ± 961 s; p = 0.045). Ablation time to achieve loss of pace capture of left pulmonary veins was shorter using STSF (left veins, 155 ± 140 s vs. 291 ± 188 s; p = 0.01; right veins, 208 ± 196 s vs. 369 ± 306 s; p = 0.09). Furthermore, administered irrigation fluid was significantly reduced in STSF (241.4 ± 79.6 ml vs. 540.3 ± 229.5 ml; p < 0.01). CF was lower during ablation of left pulmonary veins. One steam pop occurred in STSF, which did not lead to pericardial effusion (vs. no steam pop in ST). The Kaplan-Meier estimate 12-month AF recurrence was 34.3% and 37.7% (p = 0.8).

Conclusions: Integrating CF technology and the porous tip technology enables effective energy transfer to the tissue resulting in shorter ablation time and less irrigation fluid administration. In our cohort, PVI using the STSF was not associated with an increased complication rate or AF recurrence rate after 12-month follow-up when compared with the ST.
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http://dx.doi.org/10.1007/s10840-019-00591-2DOI Listing
March 2020

Targeting Nonpulmonary Vein Sources in Persistent Atrial Fibrillation Identified by Noncontact Charge Density Mapping: UNCOVER AF Trial.

Circ Arrhythm Electrophysiol 2019 07 27;12(7):e007233. Epub 2019 Jun 27.

Royal Papworth Hospital Foundation Trust, Cambridge (A.G.).

Background Identification and elimination of nonpulmonary vein targets may improve clinical outcomes in patients with persistent atrial fibrillation (AF). We report on the use of a novel, noncontact imaging and mapping system that uses ultrasound to reconstruct atrial chamber anatomy and measures timing and density of dipolar, ionic activation (ie, charge density) across the myocardium to guide ablation of atrial arrhythmias. Methods The prospective, nonrandomized UNCOVER AF trial (Utilizing Novel Dipole Density Capabilities to Objectively Visualize the Etiology of Rhythms in Atrial Fibrillation) was conducted at 13 centers across Europe and Canada. Patients with persistent AF (>7 days, <1 year) aged 18 to 80 years, scheduled for de novo catheter ablation, were eligible. Before pulmonary vein isolation, AF was mapped and then iteratively remapped to guide each subsequent ablation of charge density-identified targets. AF recurrence was evaluated at 3, 6, 9, and 12 months using continuous 24-hour ECG monitors. The primary effectiveness outcome was freedom from AF >30 seconds at 12 months for a single procedure with a secondary outcome being acute procedural efficacy. The primary safety outcome was freedom from device/procedure-related major adverse events. Results Between October 2016 and April 2017, 129 patients were enrolled, and 127 underwent mapping and catheter ablation. Acute procedural efficacy was demonstrated in 125 patients (98%). At 12 months, single procedure freedom from AF on or off antiarrhythmic drugs was 72.5% (95% CI, 63.9%-80.3%). After 1 or 2 procedures, freedom from AF was 93.2% (95% CI, 87.1%-97.0%). A total of 29 (23%) retreatments because of arrhythmia recurrence were performed with average time from index procedure to first retreatment being 7 months. The primary safety outcome was 98% with no device-related major adverse events reported. Conclusions This novel ultrasound imaging and charge density mapping system safely guided ablation of nonpulmonary vein targets in persistent AF patients with 73% single procedure and 93% second procedure freedom from AF at 12 months. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02825992 EU/NCT02462980 CN.
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http://dx.doi.org/10.1161/CIRCEP.119.007233DOI Listing
July 2019

Predictors of freedom from atrial arrhythmia recurrence after cryoballoon ablation for persistent atrial fibrillation: A multicenter study.

J Cardiovasc Electrophysiol 2019 09 2;30(9):1436-1442. Epub 2019 Jul 2.

Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.

Aims: We sought to assess (1) clinical outcomes of second-generation cryoballoon (CB) ablation for persistent atrial fibrillation (AF), and (2) the association of baseline and procedural covariates with atrial arrhythmia recurrence (AAR) after ablation.

Methods: A total of 135 patients (63 ± 11 years, 96 men [71%]) with persistent AF underwent CB ablation at three experienced electrophysiology centers. Freedom from AAR was estimated with the Kaplan-Meier method. A Cox proportional-hazards model was used to estimate the effects of baseline and procedural covariates on the likelihood of AAR.

Results: Freedom from AAR at 6, 12, and 18 months was estimated at 91% (95% confidence interval [CI] 86%-96%), 75% (95% CI, 67%-83%), and 53% (95% CI, 43%-65%), respectively. The presence of an implantable cardiac device (Hazard ratio [HR] 3.09; 95% CI, 1.37-7.00; P = .007), a left atrial (LA) diameter > 50 mm (HR 1.69; 95% CI, 1.02-2.79; P = .043), and absence of antiarrhythmic drug (AAD) therapy before the ablation procedure (HR 3.12; 95% CI, 1.72-5.64; P < .001) were associated with AAR. A trend toward an increased risk of AAR was revealed for women (HR 1.73; 95% CI, 0.96-3.11; P = .069).

Conclusions: CB ablation for persistent AF resulted in freedom from AAR about that reported for RF ablation. The presence of an implantable cardiac device, LA size, and absence of AAD therapy at baseline were associated with the risk of AAR.
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http://dx.doi.org/10.1111/jce.14023DOI Listing
September 2019

Rationale and design of BERLIN VT study: a multicenter randomised trial comparing preventive versus deferred ablation of ventricular tachycardia.

BMJ Open 2019 05 9;9(5):e022910. Epub 2019 May 9.

Department of Electrophysiology, Heart Center, Köln, Germany.

Introduction: Catheter ablation (CA) has shown to effectively reduce the burden of ventricular tachycardia in patients with implanted cardioverter-defibrillator (ICD). However, in patients with ICD implantation for secondary prevention of ventricular tachycardia (VT), the appropriate time point of CA and its effect on mortality and heart failure progression remains a matter of debate.

Methods And Analysis: We present the design of the ongoing preventive lation of ntriculartachyca dia in patients with myocardia farction (BERLIN VT) study that aims to prospectively enrol 208 patients with a stable ischaemic cardiomyopathy, a left ventricular ejection fraction of 30% to 50% and documented ventricular tachycardia. Patients will be 1:1 randomised to undergo CA at the time of ICD implantation or CA after the third appropriate ICD shock for ventricular tachycardia. ICD implantation will be performed in all patients. The primary endpoint is defined as the time to first event comprising all-cause mortality and unplanned hospital admission for congestive heart failure or for symptomatic VT/ventricular fibrillation. The patients will be followed until study termination according to the event driven design. Completion of enrolment is expected for mid of 2019.

Ethics And Dissemination: The study had been approved by the "Ethik-kommission der Landesärztekammer Hamburg" as well as the local institutional review boards for each of the participation sites. The results of the trial will be published in peer-reviewed journals TRIAL REGISTRATION NUMBER: NCT02501005.
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http://dx.doi.org/10.1136/bmjopen-2018-022910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528000PMC
May 2019

Incidence of myopotential induction in subcutaneous implantable cardioverter-defibrillator patients: Is the oversensing issue really solved?

Heart Rhythm 2019 10 7;16(10):1523-1530. Epub 2019 Jun 7.

University of Cologne, Department of Electrophysiology, University Hospital Cologne, Cologne, Germany.

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has established its role in the prevention of sudden cardiac death in a defined population. Inappropriate shocks and device malfunction in S-ICD therapy may be caused by myopotential (MP) oversensing.

Objective: The purpose of this study was to systematically evaluate a cohort of consecutive S-ICD patients for MP inducibility.

Methods: After S-ICD implantation, all vectors (primary [PrimV], secondary [SecV], alternative [AltV]) were analyzed during isometric chest press (ICP), lifting and holding a 20-kg weight, and side plank exercise (SPE), supporting the body weight on the left arm. When MPs were induced, signal classification was assessed: adequate noise detection, induced undersensing (R waves classified as noise), and oversensing (noise annotated as R waves). In case of noise induction in the current vector, device reprogramming to a noise-free vector was done.

Results: We systematically assessed 41 patients. In nearly all patients (90.2%), MPs were inducible. ICP was the most potent inductor of MPs. Whereas SecV (70.7%) and AltV (75.6%) were most vulnerable during ICP, PrimV was most affected during SPE (51.2%). In only a few cases did the S-ICD software distinguish correctly between MPs and QRS. MPs predominantly led to undersensing (up to 65.9%), but in up to 22% of patients MP-induced oversensing occurred but did not lead to tachycardia detection. No relation was seen between S-ICD lead and generator position and MP inducibility.

Conclusion: Induction of MPs during physical exercise was observed frequently. Although in most cases MP noise led to undersensing, oversensing events were commonly observed.
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http://dx.doi.org/10.1016/j.hrthm.2019.04.044DOI Listing
October 2019

Implantation of a subcutaneous implantable cardioverter defibrillator with right parasternal electrode position in a patient with D-transposition of the great arteries and concomitant AAI pacemaker: a case report.

Eur Heart J Case Rep 2018 Sep 12;2(3):yty099. Epub 2018 Sep 12.

Department of Electrophysiology, University Hospital Cologne, Heart Center, Kerpener Str. 62, Cologne, Germany.

Background: Implantable cardioverter defibrillator (ICD) therapy is indicated in patients with structural heart disease who have had an aborted cardiac arrest (ACA). After atrial repair of d-transposition of the great arteries (d-TGA, Mustard repair) patients seem to be at a higher risk of failing intraoperative subcutaneous ICD (S-ICD) shock testing.

Case Summary: We report the case of a 45-year-old patient with congenital heart disease (CHD) who suffered a cardiac arrest from ventricular fibrillation and was subsequently implanted with a S-ICD. We describe the challenges of ICD therapy in patients after Mustard procedure for d-TGA, with the additional challenge of concomitant AAI pacemaker therapy. In this patient, we opted for the implantation of an S-ICD, and detail the necessary considerations and operative technique employed in this patient. A right parasternal electrode position was chosen and intraoperative shock testing was successful.

Discussion: Patients after atrial switch surgery for d-TGA and ACA require careful consideration of the appropriate type of ICD therapy. Subcutaneous ICD implantation with right parasternal electrode position may be a viable option in these patients.
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http://dx.doi.org/10.1093/ehjcr/yty099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6177110PMC
September 2018

Anxiety, depression and quality of life in acute high risk cardiac disease patients eligible for wearable cardioverter defibrillator: Results from the prospective multicenter CRED-registry.

PLoS One 2019 11;14(3):e0213261. Epub 2019 Mar 11.

Department III of Internal Medicine, Heart Center, University of Cologne, Cologne, Germany.

Background: Psychological distress is common in patients with cardiovascular disease and negatively impacts outcome.

Hypothesis: Psychological distress is high in acute high risk cardiac patients eligible for a WCD, and associated with low quality of life. Distress is aggravated by WCD.

Methods: Consecutive patients eligible for a WCD were included in the prospective, multicenter "Cologne Registry of External Defibrillator" registry. Quality of life (Short Form-12), depressive symptoms (Beck-Depression Inventory II) and anxiety (State Trait Anxiety Inventory) were assessed at enrollment and 6-weeks, and associations with WCD prescription were analyzed.

Results: 123 patients (mean [SD] age 59 [± 14] years, 75% male) were included, 85 (69%) of whom received a WCD. At enrollment 21% showed clinically significant depressive symptoms and 52% anxiety symptoms, respectively. At 6 weeks, depressive and anxious symptoms significantly decreased to 7% and 25%, respectively. Depressive symptoms at enrollment and changes at 6 weeks showed significant associations with health-related quality of life, whereas anxious symptoms did not. There was a trend for better improvement of depression scores in patients with WCD (mean [SD] change in score points: -4.1 [6.1] vs -1.8 [3.9]; p = 0.09), whereas change of the anxiousness score was not different (-4.6 [9.5]) vs -3.7 [9.1], p = 0.68).

Conclusion: In patients eligible for a WCD, depressive and anxiety symptoms were initially common and depressive symptoms showed a strong association with reduced health-related quality of life contributing to their clinical relevance. WCD recipients showed at least similar improvement of depression and anxiety at 6 weeks when compared to non recipients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213261PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411111PMC
December 2019

The use of a high-resolution mapping system may facilitate standard clinical practice in VE and VT ablation.

J Interv Card Electrophysiol 2019 Sep 7;55(3):287-295. Epub 2019 Mar 7.

Department of Electrophysiology, University of Cologne, Kerpener Straße 62, 50937, Köln, Germany.

Background: First experiences using a 64-electrode mini-basket catheter (BC) paired with an automatic mapping system (Rhythmia™) for catheter ablation (CA) of ventricular ectopy (VE) and ventricular tachycardia (VT) have been reported.

Objectives: We aimed to evaluate (1) differences in ventricular access for the BC and (2) benefit of this technology in the setting of standard clinical practice.

Methods: Patients (pts) undergoing CA for VE or VT using the Intellamap Orion™ paired with the Rhythmia™ automated-mapping system were included in this study. For LV access, transseptal and retrograde access were compared.

Results: All 32 pts (29 men, age 63 ± 15 years) underwent CA for VE (17 pts) or VT (15 pts). For mapping of VE originating from the left ventricle (LV) in 10 out of 13 pts, a transaortic access was feasible. The predominant access for CA of VT was transaortic (5/7). Feasibility and safety seem to be equal. The total procedure time was 179.1 ± 21.2 min for VE ablation and 212.0 ± 71.7 min for VT ablation (p = 0.177). For VE, an acquisition of 1602 ± 1672 map points and annotation of 140 ± 98 automated mapping points sufficed to abolish VE in all pts. During a 6-month follow-up (FU) after CA for VE, a VE burden reduction from 18.5 ± 2.1% to 2.8 ± 2.2% (p = 0.019) was achieved. In VT pts, one patient showed recurrence of sustained VT episodes during FU.

Conclusion: Use of a high-resolution mapping system for VE/VT CA potentially facilitates revelation of VE origin and VT circuits in the setting of standard clinical practice. Feasibility and safety of a venous, transaortic, transseptal, or a combined approach seem to be equal.
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http://dx.doi.org/10.1007/s10840-019-00530-1DOI Listing
September 2019

[Rhythmogenic syncopes and survived sudden cardiac death].

Herzschrittmacherther Elektrophysiol 2019 Mar 7;30(1):72-88. Epub 2019 Mar 7.

Medizinische Klinik I, Krankenhaus Landshut-Achdorf, Achdorfer Weg 3, 84036, Landshut, Deutschland.

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http://dx.doi.org/10.1007/s00399-019-0614-2DOI Listing
March 2019

[Narrow complex tachycardias].

Herzschrittmacherther Elektrophysiol 2019 Mar;30(1):24-37

Herzzentrum, Abteilung für Elektrophysiologie, Universitätsklinik Köln, Kerpenerstraße 62, 50937, Köln, Deutschland.

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http://dx.doi.org/10.1007/s00399-019-0608-0DOI Listing
March 2019

Long-term efficacy and safety of radiofrequency catheter ablation of atrial fibrillation in patients with cardiac implantable electronic devices and transvenous leads.

J Cardiovasc Electrophysiol 2019 05 10;30(5):679-687. Epub 2019 Mar 10.

Department of Cardiology-Electrophysiology, University Hospital Hamburg, University Heart Center Hamburg, Hamburg, Germany.

Introduction: Long-term efficacy and safety are uncertain in patients with cardiac implantable electronic devices (CIED) and transvenous leads (TVL) undergoing radiofrequency catheter ablation of atrial fibrillation (AF). Thus, we assessed the outcome of AF ablation in those patients during long-term follow-up using continuous atrial rhythm monitoring (CARM).

Methods And Results: A total of 190 patients (71.3 ± 10.7 years; 108 (56.8% men) were included in this study. At index procedure 81 (42.6%) patients presented with paroxysmal AF and 109 (57.4%) with persistent AF. The ablation strategy included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines, if appropriate. AF recurrences were assessed by CARM- and CIED-related complications by device follow-up. After a mean follow-up of 55.4 ± 38.1 months, freedom of AF was found in 86 (61.4%) and clinical success defined as an AF burden less than or equal to 1% in 101 (72.1%) patients. Freedom of AF was reported in 74.6% and 51.9% (P = 0.006) and clinical success in 89.8% and 59.3% (P < 0.001) of patients with paroxysmal and persistent AF, respectively. In 3 of 408 (0.7%) ablation procedures, a TVL malfunction occurred within 90 days after catheter ablation. During long-term follow-up 9 (4.7%) patients showed lead dislodgement, 2 (1.1%) lead fracture, and 2 (1.1%) lead insulation defect not related to the ablation procedure.

Conclusion: Our findings using CARM demonstrate long-term efficacy and safety of radiofrequency catheter ablation of AF in patients with CIED and TVL.
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http://dx.doi.org/10.1111/jce.13890DOI Listing
May 2019

[Premature ventricular contractions and tachycardia in a structurally normal heart : Idiopathic PVC and VT].

Herzschrittmacherther Elektrophysiol 2019 Jun 14;30(2):212-224. Epub 2019 Feb 14.

Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München (LMU München), München, Deutschland.

Premature ventricular contractions (PVC) are a common, often incidental and mostly benign finding. Treatment is indicated in frequent and symptomatic PVC or in cases of worsening of left ventricular function. Idiopathic ventricular tachycardia (VT) is mostly found in patients with a structurally healthy heart. These PVC/VT usually have a focal origin. The most likely mechanism is delayed post-depolarization. Localization of the origin is based on the creation of an activation map with or without combination of pace mapping. Idiopathic PVC/VT are most frequently located on the outflow tracts of the right and left ventricles, including the aortic root. Other typical locations include the annulus of the tricuspid or mitral valve, papillary muscles and Purkinje fibers. Catheter ablation is an alternative to antiarrhythmic medication in symptomatic monomorphic PVC/VT. The success rate is good whereby mapping and ablation can often represent a challenge. This article is the fifth part of a series dedicated to specific advanced training in the field of special rhythmology and invasive electrophysiology. It describes the pathophysiological principles, types and typical findings that can be obtained during an electrophysiological investigation.
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http://dx.doi.org/10.1007/s00399-019-0607-1DOI Listing
June 2019

Clostridium scindens ATCC 35704: Integration of Nutritional Requirements, the Complete Genome Sequence, and Global Transcriptional Responses to Bile Acids.

Appl Environ Microbiol 2019 04 22;85(7). Epub 2019 Mar 22.

Microbiome Metabolic Engineering Theme, Carl R. Woese Institute for Genomic Biology, Urbana, Illinois, USA

In the human gut, ATCC 35704 is a predominant bacterium and one of the major bile acid 7α-dehydroxylating anaerobes. While this organism is well-studied relative to bile acid metabolism, little is known about the basic nutrition and physiology of ATCC 35704. To determine the amino acid and vitamin requirements of , the leave-one-out (one amino acid group or vitamin) technique was used to eliminate the nonessential amino acids and vitamins. With this approach, the amino acid tryptophan and three vitamins (riboflavin, pantothenate, and pyridoxal) were found to be required for the growth of In the newly developed defined medium, fermented glucose mainly to ethanol, acetate, formate, and H The genome of ATCC 35704 was completed through PacBio sequencing. Pathway analysis of the genome sequence coupled with transcriptome sequencing (RNA-Seq) under defined culture conditions revealed consistency with the growth requirements and end products of glucose metabolism. Induction with bile acids revealed complex and differential responses to cholic acid and deoxycholic acid, including the expression of potentially novel bile acid-inducible genes involved in cholic acid metabolism. Responses to toxic deoxycholic acid included expression of genes predicted to be involved in DNA repair, oxidative stress, cell wall maintenance/metabolism, chaperone synthesis, and downregulation of one-third of the genome. These analyses provide valuable insight into the overall biology of which may be important in treatment of disease associated with increased colonic secondary bile acids. is one of a few identified gut bacterial species capable of converting host cholic acid into disease-associated secondary bile acids such as deoxycholic acid. The current work represents an important advance in understanding the nutritional requirements and response to bile acids of the medically important human gut bacterium, ATCC 35704. A defined medium has been developed which will further the understanding of bile acid metabolism in the context of growth substrates, cofactors, and other metabolites in the vertebrate gut. Analysis of the complete genome supports the nutritional requirements reported here. Genome-wide transcriptomic analysis of gene expression in the presence of cholic acid and deoxycholic acid provides a unique insight into the complex response of ATCC 35704 to primary and secondary bile acids. Also revealed are genes with the potential to function in bile acid transport and metabolism.
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http://dx.doi.org/10.1128/AEM.00052-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585500PMC
April 2019

Functional parameters impairment after MRI in a patient with a transcatheter pacing system.

J Magn Reson Imaging 2019 07 15;50(1):334-335. Epub 2019 Jan 15.

Department of Electrophysiology, University Heart Centre Cologne University Hospital Cologne Cologne, Germany.

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http://dx.doi.org/10.1002/jmri.26588DOI Listing
July 2019