Publications by authors named "Julia Köbe"

82 Publications

Predicting inappropriate S-ICD® episodes by simple 12-lead surface ECG parameters.

J Electrocardiol 2021 May 27;67:89-93. Epub 2021 May 27.

Department of Cardiology II - Electrophysiology, University Hospital Muenster, Muenster, Germany. Electronic address:

Aims: The present study aims at analyzing the role of a preimplantation 12-lead electrocardiogram (ECG) on the prediction of inappropriate S-ICD® episodes.

Methods: N=116 screened patients (pts) with an S-ICD® and a follow-up of at least 6 months were included. A preimplantation 12-lead ECG (50 mm/s, 10 mm/mV) was analyzed with regard to QRS and T-wave amplitude, T wave concordance or discordance and QRS/T wave ratio in all 12 leads. To ensure an exact determination of parameters Datinf® Measure software was used. Results were correlated to the occurrence of oversensing of cardiac signals during follow-up.

Results: N = 116 pts. (63,8% male, mean age 40,9 ± 15,5 years) were included (primary prevention in 47.4% of pts). The most frequent cardiac diseases were hypertrophic cardiomyopathy (HCM) in n = 25 (21,6%), electrical heart disease in n = 20 (17,2%), and dilated cardiomyopathy in n = 17 (14,7%). Mean follow-up was 740 ± 549 days. During follow- up n = 17 (14.7%) pts. experienced n = 27 inappropriate episodes due to T-wave oversensing. Besides HCM (OR 6.16, CI 1.79-21.15, p = 0.004) a discordance of QRS to T-wave in lead I (OR 6.5, CI 1.86-22.67, p = 0.003) was found to be a strong predictor for inappropriate shocks. In multivariate analysis the pts. with a combination of both had an 8.4-fold higher risk of misclassification of intracardiac signals (p = 0.003) with consecutive inappropriate therapy.

Conclusion: A discordance of QRS to T-wave in lead I turned out to be a strong predictor for future inappropriate shocks in a typical S-ICD® cohort with special impact on HCM pts.
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http://dx.doi.org/10.1016/j.jelectrocard.2021.05.011DOI Listing
May 2021

Therapy of supraventricular and ventricular arrhythmias in adults with congenital heart disease-narrative review.

Cardiovasc Diagn Ther 2021 Apr;11(2):550-562

Department of Cardiology II - Electrophysiology, University Hospital Muenster, Cardiology, Muenster, Germany.

Arrhythmias are among the most common late complications in adults with congenital heart disease (ACHD) and a frequent reason for hospital admission. Both, supraventricular and ventricular arrhythmias, not only cause debilitating symptoms, but may be life-threatening by increasing risk of stroke, causing or worsening heart failure and being associated with sudden death. Substrate and risk for arrhythmia differs widely between congenital defects with specific arrhythmias being much more common in some patients than others. Atrial macroreentrant arrhythmias are particularly frequent in patients with atrial septal defects and repair that involves atrial incisions including patients with transposition of the great arteries (TGA) and atrial switch. Accessory pathways and related arrhythmias are often associated with Ebstein's anomaly and congenitally corrected TGA. Monomorphic ventricular arrhythmias occur in patients with ventricular incisions, namely patients with Tetralogy of Fallot. Changes in surgical repair techniques influence arrhythmia prevalence and substrate as well as anatomical access for catheter ablation procedures. In addition, epidemiologic changes associated with improved long-term survival will further increase the prevalence of atrial fibrillation in ACHD. This article summarizes current understanding of prevalence of specific arrhythmias, underlying mechanisms, medical and interventional treatment options and their outcome in ACHD.
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http://dx.doi.org/10.21037/cdt-20-634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102262PMC
April 2021

Narrative review of: risk stratification and implantable cardioverter-defibrillator therapy in adults with congenital heart disease.

Cardiovasc Diagn Ther 2021 Apr;11(2):538-549

Department of Cardiology II - Electrophysiology, University Hospital Muenster, Muenster, Germany.

Fortunately, the population of adults with congenital heart disease (ACHD) is growing due to improved operation techniques. Life expectancy is continuously rising, nevertheless, sudden cardiac death is one of the leading causes of mortality in ACHD late after initial diagnosis. Risk stratification in ACHD remains challenging as large study results are missing, congenital defects and operation methods differ considerably between individual patients and results from acquired heart diseases are often not conferrable. The purpose of this narrative review is to objectively summarize the current knowledge on arrhythmogenic risk of ACHD and to give an overview on implantable cardioverter-defibrillator (ICD) therapy in this collective. Remarkable progress has been made in electrophysiological understanding of critical areas of slow conduction especially in patients with Tetralogy of Fallot (ToF). In patients with transposition of the great arteries after atrial baffling (Mustard/Senning procedure) atrial arrhythmias play a crucial role in sudden cardiac death. ICD therapy in ACHD may pose special technical challenges due to limited access for intracardiac leads. The introduction of the totally subcutaneous ICD improved therapeutic options for ACHD especially when contraindications for transvenous leads are present. Risk stratification in ACHD has to be seen as a team approach, requires thorough understanding of congenital heart defects and the operation techniques and needs unconventional technical approaches in some cases.
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http://dx.doi.org/10.21037/cdt-20-633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102248PMC
April 2021

Prospective blinded evaluation of smartphone-based ECG for differentiation of supraventricular tachycardia from inappropriate sinus tachycardia.

Clin Res Cardiol 2021 Jun 7;110(6):905-912. Epub 2021 May 7.

Department of Cardiology II-Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.

Introduction: Supraventricular tachycardias (SVT) are often difficult to document due to their intermittent, short-lasting nature. Smartphone-based one-lead ECG monitors (sECG) were initially developed for the diagnosis of atrial fibrillation. No data have been published regarding their potential role in differentiating inappropiate sinus tachycardia (IST) from regular SVT. If cardiologists could distinguish IST from SVT in sECG, economic health care burden might be significantly reduced.

Methods: We prospectively recruited 75 consecutive patients with known SVT undergoing an EP study. In all patients, four ECG were recorded: a sECG during SVT and during sinus tachycardia and respective 12-lead ECG. Two experienced electrophysiologists were blinded to the diagnoses and separately evaluated all ECG.

Results: Three hundred individual ECG were recorded in 75 patients (47 female, age 50 ± 18 years, BMI 26 ± 5 kg/m, 60 AVNRT, 15 AVRT). The electrophysiologists' blinded interpretation of sECG recordings showed a sensitivity of 89% and a specificity of 91% for the detection of SVT (interobserver agreement κ = 0.76). In high-quality sECG recordings (68%), sensitivity rose to 95% with a specificity of 92% (interobserver agreement of κ = 0.91). Specificity increased to 96% when both electrophysiologists agreed on the diagnosis. Respective 12-lead ECG had a sensitivity of 100% and specificity of 98% for the detection of SVT.

Conclusion: A smartphone-based one-lead ECG monitor allows for differentiation of SVT from IST in about 90% of cases. These results should encourage cardiologists to integrate wearables into clinical practice, possibly reducing time to definitive diagnosis of an arrhythmia and unnecessary EP procedures. A smartphone-based one lead ECG device (panel A) can be used reliably to differentiate supraventricular tachycardia (panel B) from inappropriate sinus tachycardia when compared to a simultaneously conducted gold-standard electrophysiology study (panels C, D).
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http://dx.doi.org/10.1007/s00392-021-01856-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103426PMC
June 2021

[Management of premature ventricular ectopy in cardiac resynchronization therapy : Treatment strategies for an optimized cardiac resynchronization].

Herzschrittmacherther Elektrophysiol 2021 Mar 29;32(1):41-47. Epub 2021 Jan 29.

Klinik für Kardiologie II: Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, 48149, Münster, Deutschland.

Cardiac resynchronization therapy (CRT) is an integral part in the treatment of chronic heart failure. However, a high degree of biventricular pacing is essential for the effectiveness of this therapy. In addition to atrial fibrillation, premature ventricular contractions (PVC) are a common cause of reduced biventricular stimulation in CRT. In addition to the prognostically unfavorable reduction of biventricular pacing, PVC are generally associated with reduced outcome in the presence of structural heart disease. Options to increase biventricular stimulation percentage by reprogramming the CRT devices are limited in the majority of cases. Due to the mutual relationship between cardiomyopathy and ventricular arrhythmias, adequate heart failure therapy is essential for the reduction of ventricular ectopy. In addition to beta-blocker therapy, specific antiarrhythmic medication is mostly limited to class III antiarrhythmic drugs due to the structural heart disease usually present in CRT patients. Catheter ablation is superior to pharmacological therapy especially in the field of idiopathic PVC, but promising data are also available for catheter ablation of PVC in structural heart disease and CRT nonresponders.
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http://dx.doi.org/10.1007/s00399-021-00745-8DOI Listing
March 2021

Predictors of AVNRT Recurrence After Slow Pathway Modification.

Int Heart J 2021 Jan 16;62(1):72-77. Epub 2021 Jan 16.

Department of Cardiology II - Electrophysiology, University Hospital Muenster.

Atrioventricular nodal reentry tachycardia (AVNRT) is the most common regular supraventricular tachycardia (SVT). Slow pathway modification (SPM) is the accepted first line treatment with reported success rates around 95%. Information regarding possible predictors of AVNRT recurrence is scarce.Out of 4170 consecutive patients with SPM in our department from 1993-2018, we identified 78 patients (1.9%) receiving > 1 SPM (69% female, median age 50 years) with a recurrence of AVNRT after a successful SPM. We matched these patients for age, gender and number of radiofrequency applications during first SPM with 78 patients who received one successful SPM in our center without AVNRT recurrence. Both groups were analyzed for possible predictors of a recurrence of AVNRT during long-term follow-up. The recurrence group contained a significantly lower proportion of patients with an occurrence of junctional beats during SPM (69% versus 89%, P = 0.006). Moreover, significantly more cases of previously diagnosed atrial fibrillation/tachycardia (AF/AT; 21% versus 5%, P = 0.007) and inducible AF/AT during electrophysiology study (23% versus 6%, P = 0.006) were present in the recurrence group. While more than half of patients had a recurrence within the first year, in 20% symptoms reappeared ≥ 4 years after ablation.In a small percentage of patients, AVNRT recurs after an initially successful ablation. Interestingly, these patients had significantly fewer junctional beats during ablation and a higher rate of other (inducible) arrhythmias. AVNRT recurrence spanned a considerable timeframe and should remain a differential diagnosis, even years after ablation.
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http://dx.doi.org/10.1536/ihj.20-463DOI Listing
January 2021

Predictors of response to cardiac resynchronization therapy in patients with chronic right ventricular pacing.

Clin Res Cardiol 2021 Jun 15;110(6):877-883. Epub 2020 Dec 15.

Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.

Background: The benefits of de novo cardiac resynchronization therapy (CRT) in patients with QRS-prolongation and impaired left-ventricular function (LVEF) are well established. Current guidelines also recommend CRT-upgrade in patients requiring permanent or frequent right ventricular pacing (RVP) with symptomatic heart failure and reduced LVEF. Whereas several predictors of response to de novo CRT-implantation such as female gender, QRS-duration, non-ischemic cardiomyopathy (NICM) are known due to large prospective trials, similar factors regarding CRT-upgrade are currently lacking.

Methods And Results: We examine 114 patients 3-6 months after CRT-upgrade due to frequent RVP (> 50%) and symptomatic heart failure. Response to CRT was evaluated by improvement in NYHA class referring to the Minnesota Living With Heart Failure Questionnaire. Only cardiomyopathy type and use of Angiotensin-converting-enzyme (ACE) inhibitor had an impact on response to CRT-upgrade in a linear regression model. Patients with NICM presented a greater responder rate than patients with ischemic cardiomyopathy (ICM) (80.4 vs. 60.3%, p < 0.05). Other traditional response predictors in de novo CRT recipients (e.g. QRS-width, female gender) showed no effect on CRT-response in this cohort.

Conclusion: Only underlying heart disease (NICM vs. ICM) and the use of ACE inhibitor were significant predictors of response to CRT-upgrade. In contrast to de novo CRT-recipients, where pre-implant QRS-duration is a key predictor, QRS-duration during RV-pacing has no significant impact on CRT-response in this cohort.
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http://dx.doi.org/10.1007/s00392-020-01785-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166655PMC
June 2021

Pitfalls of the S-ICD therapy: experiences from a large tertiary centre.

Clin Res Cardiol 2021 Jun 1;110(6):861-867. Epub 2020 Nov 1.

Clinic for Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany.

Aim: The subcutaneous ICD (S-ICD) has evolved to a potential first option for many patients who have to be protected from sudden cardiac death. Many trials have underlined a similar performance regarding its effectiveness in relation to transvenous ICDs and have shown the expected benefits concerning infective endocarditis and lead failure. However, there have also been problems due to the peculiarities of the device, such as oversensing and myopotentials. In this study, we present patients from a large tertiary centre suffering from complications with an S-ICD and propose possible solutions.

Methods And Results: All S-ICD patients who experienced complications related to the device (n = 40) of our large-scale single-centre S-ICD registry (n = 351 patients) were included in this study. Baseline characteristics, complications occurring and solutions to these problems were documented over a mean follow-up of 50 months. In most cases (n = 23), patients suffered from oversensing (18 cases with T wave or P wave oversensing, 5 due to myopotentials). Re-programming successfully prevented further oversensing episode in 13/23 patients. In 9 patients, generator or lead-related complications, mostly due to infectious reasons (5/9), occurred. Further problems consisted of ineffective shocks in one patient and need for antibradycardia stimulation in 2 patients and indication for CRT in 2 other patients. In total, the S-ICD had to be extracted in 10 patients. 7 of them received a tv-ICD subsequently, 3 patients refused re-implantation of any ICD. One other patient kept the ICD but had antitachycardic therapy deactivated due to inappropriate shocks for myopotential oversensing.

Conclusion: The S-ICD is a valuable option for many patients for the prevention of sudden cardiac death. Nonetheless, certain problems are immanent to the S-ICD (limited re-programming options, size of the generator) and should be addressed in future generations of the S-ICD.
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http://dx.doi.org/10.1007/s00392-020-01767-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166696PMC
June 2021

Ablation of paroxysmal and persistent atrial fibrillation in the very elderly real-world data on safety and efficacy.

Clin Cardiol 2020 Dec 19;43(12):1579-1584. Epub 2020 Oct 19.

Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany.

Background: The role and technique of catheter ablation of atrial fibrillation (AF) in the elderly is unclear. While in young patients pulmonary vein isolation (PVI) has evolved as first option, in older patients decision is often made in favor of drugs as higher complication rates and less benefit are suspected. Therefore, data on PVI of paroxysmal and persistent AF in these patients is still sparse but of eminent importance.

Hypothesis: PVI is comparably safe in the very elderly with similar recurrence and complication rates.

Methods: We enrolled all patients (n = 146) aged >75 years who underwent a first PVI over a period of 10 years (2009-2019) from our prospective single-center ablation registry. Mean follow-up time was 231 ± 399 days.

Results: Acute ablation success defined as complete PVI and sinus rhythm at the end of the ablation procedure was high (99%). Severe periprocedural complications occurred in 3.3% (stroke/TIA n = 2; 1.3%; pericardial effusion n = 3; 2%). In 4.6% of patients symptomatic sick-sinus-syndrome was unmasked after PVI resulting in pacemaker implantation. There were no deaths related to PVI. Recurrence rate of symptomatic AF was 37.3% resulting in a Re-PVI and/or substrate ablation in 32 pts (20.9%). During follow-up pacemaker implantation plus atrioventricular node ablation was performed in 10 pts (6.8%). There was a trend toward lower recurrence rates with single-shot devices (cryoballoon, multielectrode phased-radiofrequency ablation catheter) than with point-by-point radiofrequency while complication rates did not differ.

Conclusion: PVI for AF is a feasible treatment option also in patients >75 years with a reasonable success and safety profile. Higher success rates occurred in patients treated with a single-shot device as compared to point-by-point ablation.
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http://dx.doi.org/10.1002/clc.23485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724234PMC
December 2020

Outcome of catheter ablation in the very elderly-insights from a large matched analysis.

Clin Cardiol 2020 Dec 31;43(12):1423-1427. Epub 2020 Aug 31.

Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany.

Background: Ablation emerged as first line therapy in the treatment of various arrhythmias. Nevertheless, in older patients (pts), decision is often made pro drug treatment as more complications and less benefit are suspected.

Hypothesis: We hypothesized that different kind of ablations can be performed safely regardless of the pts age.

Methods: We enrolled all pts aged >80 years (yrs) who underwent ablation for three different arrhythmias (atrial flutter [AFL], atrioventricular nodal re-entry tachycardia [AVNRT], ventricular tachycardia [VT]) between August 2002 and December 2018. Procedural data and outcome were compared with matched groups aged 60 to 80 years and 40 to 60 years, respectively. Periprocedural and in-hospital complications were analyzed.

Results: The analysis included 1191 patients (397 pts per group: 63% AFL, 23% AVNRT, 14% VT) who underwent ablation. Acute success was high in all types of arrhythmias irrespective of age (>80, 60-80, 40-60 years: AFL 97%/98%/98%, AVNRT 97%/95%/97%, VT 82%/86%/93%). Rate of periprocedural complications were similar in all groups treated for AFL and AVNRT. For VT ablations significant differences were noted between pts > 80 or 60 to 80 years and those aged 40-60 years (16.1%/14.3%/3.6%). Most complications were infections and groin haematoma. No strokes, iatrogenic atrioventricular blocks and deaths related to the ablation occurred.

Conclusion: Ablation appears safe in pts > 80 years. Success rates were comparable to matched younger cohorts. A significant difference was observed for VT patients.
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http://dx.doi.org/10.1002/clc.23455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724238PMC
December 2020

Clinical experience regarding safety and diagnostic value of cardiovascular magnetic resonance in patients with a subcutaneous implanted cardioverter/defibrillator (S-ICD) at 1.5 T.

J Cardiovasc Magn Reson 2020 05 18;22(1):35. Epub 2020 May 18.

Department of Cardiology I, Division of Cardiovascular Imaging, University Hospital Münster, Münster, Germany.

Background: Cardiovascular magnetic resonance (CMR) studies in patients with implanted cardioverter/defibrillators (ICD) are increasingly required in daily clinical practice. However, the clinical experience regarding the feasibility as well as clinical value of CMR studies in patients with subcutaneous ICD (S-ICD) is still limited. Besides safety issues, image quality and analysis can be impaired primarily due the presence of image artefacts associated with the generator.

Methods: Twenty-three patients with an implanted S-ICD (EMBLEM, Boston Scientific, Marlborough, Massachusetts, USA; MR-conditional) with suspected cardiomyopathy and/or myocarditis underwent multi-parametric CMR imaging. Studies were performed on a 1.5 T CMR scanner after device interrogation and comprised standard a) balanced steady state free precession cine, b) T2 weighted-edema, c) velocity-encoded cine flow, d) myocardial perfusion, e) late-gadolinium-enhancement (LGE)-imaging and f) 3D-CMR angiography of the aorta. In case of substantial artefacts, alternative CMR techniques such as spoiled gradient-echo cine-sequences and wide-band inversion-recovery LGE (wb-LGE) sequences were applied.

Results: Successful CMR studies could be performed in all patients without any case of unexpected early termination or relevant technical complication other than permanent loss of the S-ICD system beeper volume in 52% of our patients. Assessment of cine-CMR images was predominantly impaired in the left ventricular (LV) anterior, lateral and inferior wall segments and a switch to spoiled gradient echo-based cine-CMR allowed an accurate assessment of cine-images in N = 17 (74%) patients with only limited artefacts. Hyperintensity artefacts in conventional LGE-images were predominantly observed in the LV anterior, lateral and inferior wall segments and image optimisation by use of the wb-LGE was helpful in 15 (65%) cases. Aortic flow measurements and 3D-CMR angiography were assessable in all patients Perfusion imaging artefacts precluded a meaningful assessment in at least one half of the patients. A benefit in clinical-decision making was documented in 17 (74%) patients in the present study.

Conclusion: Safe 1.5 T CMR imaging was possible in all patients with an S-ICD, though the majority had permanent loss of the S-ICD beeper volume. Achieving good image quality may be challenging in some patients - particularly for perfusion imaging. Using spoiled gradient echo-based cine-sequences and wb-LGE sequences may help to reduce the extent of artefacts, thereby allowing accurate cardiac assessment. Thus, 1.5 T CMR studies should not be withhold in patients with S-ICD for safety concerns and/or fear of extensive imaging artefacts precluding successful image analysis.
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http://dx.doi.org/10.1186/s12968-020-00626-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232845PMC
May 2020

Clinical, procedural and long-term outcome of ischemic VT ablation in patients with previous anterior versus inferior myocardial infarction.

Clin Res Cardiol 2020 Oct 10;109(10):1282-1291. Epub 2020 Mar 10.

Department of Cardiology II - Electrophysiology, University Hospital Muenster, Cardiol, Muenster, Germany.

Background: Outcome of ischemic VT ablation may differ between patients with previous myocardial infarction (MI) in relation to infarct localization.

Methods: We analyzed procedural data, acute and long-term outcomes of 152 consecutive patients (139 men, mean age 67 ± 9 years) with previous anterior or inferior MI who underwent ischemic VT ablation at our institution between January 2010 and October 2015.

Results: More patients had a history of inferior MI (58%). Mean ejection fraction was significantly lower in anterior MI patients (28 ± 10% vs. 34 ± 10%, p < 0.001). NYHA class and presence of comorbidities were not different between the groups. Indication for the procedure was electrical storm in 43% of patients, and frequent implantable cardioverter defibrillator (ICD) therapies in 57%, and did not differ significantly between anterior and inferior MI patients. A mean of 3 ± 2 VT morphologies were inducible, with a trend towards more VT in the anterior MI group (3.1 ± 2.2 vs. 2.6 ± 1.9, p = 0.18). Procedural parameters and acute success did not differ between the groups. During a mean follow-up of 3 ± 2 years, more anterior MI patients had undergone a re-ablation (49% vs. 33%, p = 0.09, Chi-square test). There was a trend towards more ICD shocks in patients with previous anterior MI (46% vs. 34%). After adjusting for risk factors and ejection fraction, multivariable Cox regression analyses showed no significant difference in mortality (p = 0.78) and cardiovascular mortality between infarct localizations (p = 0.6).

Conclusion: Clinical characteristics of patients with anterior and inferior MI are similar except for ejection fraction. Patients with inferior MI appear to have better outcome regarding survival, ICD shocks and re-ablation, but this appears to be related to better ejection fraction when compared with anterior MI.
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http://dx.doi.org/10.1007/s00392-020-01622-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515937PMC
October 2020

The role of entirely subcutaneous ICD™ systems in patients with dilated cardiomyopathy.

J Cardiol 2020 05 16;75(5):567-570. Epub 2019 Nov 16.

Clinic for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany. Electronic address:

Background: The subcutaneous implantable-cardioverter defibrillator (S-ICD™, Boston Scientific, Natick, MA, USA) is an important advance in device therapy for the prevention of sudden cardiac death (SCD). Although current guidelines recommend S-ICD™ use, long-term data are still limited, especially in subgroups. Dilated cardiomyopathy (DCM) is a common reason for the implantation of an ICD. However, there are no sufficient data on the performance of the S-ICD™ in this patient cohort.

Materials And Methods: All S-ICD™ patients with DCM as the main indication for ICD implantation (n=47 patients) in our large-scaled single-center S-ICD™ registry (n=294 patients) were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a mean follow-up of 22.9±18.5 months.

Results: A total of 47 patients with DCM as the underlying structural heart disease received an S-ICD™ in our institution. Mean left ventricular ejection fraction was 37±12% and a 28% had a history of ventricular tachyarrhythmia. During follow-up eight ventricular tachyarrhythmias were adequately terminated in three patients. In four patients, oversensing resulting in an inappropriate shock was observed, which could be managed by changing the sensing vector. There was no need for a change to a cardiac resynchronization (CRT) system while one system was changed to a VVI-ICD due to S-ICD™ wound infection.

Conclusion: The S-ICD™ seems to be a valuable option for the prevention of SCD in patients with DCM and no indication for CRT. As clinically relevant ventricular arrhythmias consisted of ventricular fibrillation or fast ventricular tachycardia in all patients in our cohort, no change to transvenous ICDs for anti-tachycardia pacing delivery was necessary.
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http://dx.doi.org/10.1016/j.jjcc.2019.10.005DOI Listing
May 2020

Long-term experience of atrioventricular node ablation in patients with refractory atrial arrhythmias.

Heart Vessels 2020 May 8;35(5):699-704. Epub 2019 Nov 8.

Clinic for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.

Atrial fibrillation and other atrial tachyarrhythmias are increasing with age and concomitant morbidity. First options in symptomatic patients are drug treatment and catheter ablation. Nevertheless, a considerable number of patients suffer from refractory atrial tachyarrhythmias despite treatment. Atrioventricular node ablation (AVNA) may be helpful in many of these patients. Therefore, we investigated AVNA patients with a long-term follow-up. We enrolled 82 patients with a follow-up longer than 1 year receiving AVNA for drug- and ablation-resistant atrial tachyarrhythmias (AA) in a retrospective manner. Mean follow-up duration was 48 ± 24 months. 50% of the patients initially received AVNA to optimize biventricular pacing in cardiac resynchronization therapy, the other 50% because of refractory symptomatic tachyarrhythmias. Persistent AV block was achieved in every patient. Symptom relief and patient satisfaction were high during follow-up. Due to system upgrades there were 63% of patients with a biventricular system during follow-up. In these patients, left-ventricular ejection fraction (LV-EF) increased by 7% (42-49%) after ablation. AVNA is effective in increasing biventricular pacing as well as for symptom relief in patients with refractory atrial tachyarrhythmias. AVNA should be considered as a valuable option in patients with refractory atrial tachyarrhythmias lacking other treatment options.
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http://dx.doi.org/10.1007/s00380-019-01536-5DOI Listing
May 2020

Outcome differences and device performance of the subcutaneous ICD in patients with and without structural heart disease.

Clin Res Cardiol 2020 Jun 31;109(6):755-760. Epub 2019 Oct 31.

Clinic for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.

Background: The performance of the subcutaneous ICD (S-ICD™) has been described in different kinds of heart disease and has been proven to be an important advance in prevention of sudden cardiac death (SCD). While positive experiences with the S-ICD™ initially came from collectives of patients without structural heart diseases, positive results have also been collected from cohorts with structural heart disease.

Materials And Methods: All S-ICD™ patients with either ischemic cardiomyopathy (ICM), dilated cardiomyopathy (DCM) or hypertrophic cardiomyopathy (HCM) as the main indication for ICD implantation (n = 144 patients) or electrical heart disease/idiopathic ventricular fibrillation (n = 83 patients) in our large-scaled single-center S-ICD™ registry were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a mean follow-up of 18 ± 15 months.

Results: Baseline characteristics were significantly different between the two groups in most categories. In contrast, there was no difference concerning neither appropriate nor inappropriate shock delivery between the two groups. Also other outcome parameters such as need for surgical revisions and all-cause mortality did not differ. There was a significant difference between the first- and second-generation S-ICDs™ in inadequate shocks mainly driven by patients with HCM.

Conclusion: In our study, S-ICD™ performance was similar in patients with and without structural heart disease. Decision pro- or contra-S-ICD™ should be made rather on the basis of expected shock rate and probability of the need for future anti-tachycardia or anti-bradycardia pacing than in dependence of the underlying heart disease.
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http://dx.doi.org/10.1007/s00392-019-01564-1DOI Listing
June 2020

Performance of the entirely subcutaneous ICD in borderline indications.

Clin Res Cardiol 2020 Jun 4;109(6):694-699. Epub 2019 Oct 4.

Clinic for Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1 Gebäude A1, 48149, Münster, Germany.

Background: The subcutaneous ICD (S-ICD™) is an important advance in device therapy for prevention of sudden cardiac death (SCD). In some patients, decision pro- or contra-ICD implantation is particularly challenging due to inconsistent data on risk of ventricular tachyarrhythmias or sudden cardiac death, rare entities, special medical or family history, or patients' wishes. Whether decision-making in these borderline cases has been facilitated with the new option of a S-ICD™ is unknown.

Material And Methods: All patients with an implanted S-ICD™ without a class I or IIa recommendation for primary prophylaxis of sudden cardiac death in the current guidelines (n = 30 patients) in our large-scaled single-centre S-ICD™ registry (n = 249 patients) were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a mean follow-up of 40 months.

Results: In all patients S-ICD™ implantation was performed for primary prevention of SCD. Of all 30 patients with an overall mean age of 40.5 ± 15.6 years, 17 were male (57%). The mean left ventricular ejection fraction (LVEF) was 54.5 ± 9.9%. Indication were highly variable and ranged from structural heart disease, nsVT and LV-EF > 35% to patients with polymorphic non-sustained ventricular tachycardia (nsVT) and suspect syncope. During follow-up, six episodes of sustained ventricular tachyarrhythmias and four episodes of ventricular fibrillation (VF) were adequately terminated in three patients (10%). Two of these patients were implanted for polymorphic nsVT and previous syncope without structural heart disease. In three patients, T-wave-oversensing and in one patient also P-wave-oversensing resulted in an inappropriate shock (five in total), two additional episodes of oversensing ended before shock delivery. There were no S-ICD™ system-related infections. In five patients S-ICD™ replacement was performed due to battery depletion (four regular, one premature). In five patients, ablation procedures were performed after implantation (four because of frequent symptomatic ventricular extra beats, one because of atrial flutter). Change to a transvenous system was necessary in two patients due to need for antibradycardia pacing.

Conclusion: The use of the S-ICD™ was safe in patients with borderline or unclear indication for ICD implantation in our study. Of note, during a relatively short mean follow-up there were several appropriate therapies, especially for VF in these patients. On the other hand, oversensing also occurred in about 10% of patients, while lead problems were not problematic in this collective. S-ICD™ implantation may be considered as a possible alternative in cases of borderline indications and clinical uncertainty when decision pro-ICD implantation is made. Incidence of arrhythmias was quite high and mostly consisted of VF. Nevertheless, patient education seems even more important as there is a considerable risk for inappropriate therapies as well.
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http://dx.doi.org/10.1007/s00392-019-01558-zDOI Listing
June 2020

Outcome of catheter ablation of supraventricular tachyarrhythmias in cardiac sarcoidosis.

Clin Cardiol 2019 Nov 3;42(11):1121-1125. Epub 2019 Sep 3.

Department for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.

Background: Sarcoidosis is a multisystem granulomatous disease of not sufficiently understood origin. Some patients develop cardiac involvement in course of the disease which is mostly responsible for adverse outcome. In addition to complications like high degree atrioventricular (AV) block or ventricular tachyarrhythmias, there is a certain percentage of patients developing atrial tachyarrhythmias. Data is limited and the role of catheter ablation uncertain. Therefore, we studied sarcoid patients who presented with supraventricular tachyarrhythmias.

Hypothesis: Treatment and ablation of supraventricular tachycardia could be hampered by inflammation in patients with cardiac sarcoidosis.

Methods: We enrolled 37 consecutive patients with cardiac sarcoidosis who presented with atrial tachyarrhythmias and underwent an electrophysiologic study over a period of 6 years (03/2013-04/2019). In total, 16 catheter ablations for atrial tachyarrhythmias were performed. Mean follow-up duration was 2.5 years.

Results: Most common ablation performed was cavo-tricuspid isthmus ablation for typical atrial flutter in seven patients (54%). Pulmonary vein isolation for treatment of atrial fibrillation (AF) was performed in five patients (38%). Two patients received slow-pathway modulation for treatment of recurrent atrioventricular nodal reentry tachycardia (AVNRT). All but two patients with AF had no clinical recurrence during follow-up. Two patients had recurrence of AF but still reported markedly improved european heart rhythm association (EHRA) class. Periprocedural safety was very high. There were no adverse events related to the ablation procedure. One patient died during follow-up in the presence of electrical storm.

Conclusion: Catheter ablations of supraventricular tachycardias seem to be safe and effective in patients with cardiac sarcoidosis. Outcome is comparable to patients without inflammatory heart disease, although data from larger patient collectives are mandatory to make recommendations in this special entity.
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http://dx.doi.org/10.1002/clc.23263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837022PMC
November 2019

The entirely subcutaneous ICDTM system in patients with congenital heart disease: experience from a large single-centre analysis.

Europace 2019 Oct;21(10):1537-1542

Department for Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1 Gebäude A1, D Münster, Germany.

Aims: The subcutaneous implantable cardioverter-defibrillator (S-ICDTM) is an important advance in device therapy for the prevention of sudden cardiac death (SCD). Although current guidelines recommend S-ICDTM use, long-term data are still limited, especially in subgroups such as adult patients with congenital heart diseases. This cohort is of high interest because of the difficult anatomic conditions in these patients.

Methods And Results: All S-ICDTM patients with an underlying congenital heart disease (CHD) resulting in an indication for ICD implantation (n = 20 patients) in our large-scaled single-centre S-ICDTM registry (n = 249 patients) were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a mean follow-up of 36 months. Primary prevention of SCD was the indication for implantation of an S-ICDTM in six patients (30%). Of all 20 patients with an overall mean age of 40.5 ± 11.5 years, 12 were male (60%). The mean left ventricular ejection fraction was 46.5 ± 11.3%. Nine episodes of ventricular tachycardia (two monomorphic and seven polymorphic) were adequately terminated in three patients (15%). In two patients, T-Wave-Oversensing resulting in an inappropriate shock was observed, which could be managed by changing the sensing vector or activation of the SMART PASSTM filter. There were no S-ICDTM system-related infections. In one patient, surgical revision was necessary due to a persistent haematoma.

Conclusion: The S-ICDTM seems to be a valuable option for the prevention of SCD in patients with various CHDs and complex anatomical anomalies. The S-ICDTM is safe and works effectively, also in these complex patients. Inadequate shock delivery was rare and could be managed by reprogramming.
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http://dx.doi.org/10.1093/europace/euz190DOI Listing
October 2019

Feasibility of entirely subcutaneous ICD™ systems in patients with coronary artery disease.

Clin Res Cardiol 2019 Nov 21;108(11):1234-1239. Epub 2019 Mar 21.

Clinic for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.

Background: The subcutaneous ICD (S-ICD™) is an important advance in device therapy for the prevention of sudden cardiac death (SCD). Although current guidelines recommend S-ICD™ use, long-term data are still limited, especially in subgroups. Among several cardiac diseases that prone to SCD, coronary artery disease (CAD) carries several peculiarities that may hamper S-ICD™ therapy in this cohort. CAD can lead to an ischemic cardiomyopathy (ICM) with a reduced left-ventricular ejection fraction (LVEF) and bundle branch blocks, which can be difficult for ICD sensing and discrimination of arrhythmia. CAD is mainly driven by risk factors such as diabetes mellitus, which put these patients at an elevated risk for infectious complications of cardiac devices. Furthermore, in ICM myocardial scars are frequent and are a potential substrate for ventricular tachycardia, which may be accessible for antitachycardia pacing. At the moment, it remains unclear if there is a value of S-ICD™ therapy in this subgroup. Therefore, this study analysed patients with CAD.

Materials And Methods: All S-ICD™ patients with CAD as the main indication for ICD implantation (n = 45 patients) in our large-scaled single-center S-ICD™ registry (n = 249 patients) were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a mean follow-up of 22.5 ± 8.3 months.

Results: Primary prevention of SCD was the indication for implantation of an S-ICD™ in 28 patients (62%). Of all 45 patients with an overall mean age of 58.1 ± 11.4 years, 40 were male (88%). The mean LVEF was 37.7 ± 12.6%. Three episodes of ventricular arrhythmia (one monomorphic, one polymorphic, one ventricular fibrillation) were adequately terminated in three patients (7%). In only one patient, oversensing resulting in an inappropriate shock was observed, which could be managed by changing the sensing vector. 15 of the examined 45 patients previously had a transvenous ICD, which was explanted due to system-related infections. In only two patients, S-ICD™ was changed to transvenous ICD because of the need of antibradycardia stimulation. There were no S-ICD™ system-related infections.

Conclusion: The S-ICD™ seems to be a valuable option for the prevention of SCD in CAD patients. Patients with systemic infections of a transvenous ICD and, therefore, a need for an alternative might benefit from the absence of intracardiac leads as the S-ICD™ is safe and works flawlessly in these patients. Inadequate shock delivery was very rare, while every episode of ventricular arrhythmia was terminated by the first shock.
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http://dx.doi.org/10.1007/s00392-019-01455-5DOI Listing
November 2019

Spotlight on S-ICD™ therapy: 10 years of clinical experience and innovation.

Europace 2019 Jul;21(7):1001-1012

Division of Electrophysiology, Department of Cardiology and Angiology, University Hospital of Muenster, Muenster, Germany.

Subcutaneous ICD (S-ICD™) therapy has been established in initial clinical trials and current international guideline recommendations for patients without demand for pacing, cardiac resynchronization, or antitachycardia pacing. The promising experience in 'ideal' S-ICD™ candidates increasingly encourages physicians to provide the benefits of S-ICD™ therapy to patients in clinical constellations beyond 'classical' indications of S-ICD™ therapy, which has led to a broadening of S-ICD™ indications in many centres. However, the decision for S-ICD™ implantation is still not covered by controlled randomized trials but rather relies on patient series or observational studies. Thus, this review intends to give a contemporary update on available empirical evidence data and technical advancements of S-ICD™ technology and sheds a spotlight on S-ICD™ therapy in recently discovered fields of indication beyond ideal preconditions. We discuss the eligibility for S-ICD™ therapy in Brugada syndrome as an example for an adverse and dynamic electrocardiographic pattern that challenges the S-ICD™ sensing and detection algorithms. Besides, the S-ICD™ performance and defibrillation efficacy in conditions of adverse structural remodelling as exemplified for hypertrophic cardiomyopathy is discussed. In addition, we review recent data on potential device interactions between S-ICD™ systems and other implantable cardio-active systems (e.g. pacemakers) including specific recommendations, how these could be prevented. Finally, we evaluate limitations of S-ICD™ therapy in adverse patient constitutions, like distinct obesity, and present contemporary strategies to assure proper S-ICD™ performance in these patients. Overall, the S-ICD™ performance is promising even for many patients, who may not be 'classical' candidates for this technology.
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http://dx.doi.org/10.1093/europace/euz029DOI Listing
July 2019

Short Communication: Viral Genetic Linkage Analysis Among Black Men Who Have Sex With Men (HIV Prevention Trials Network 061).

AIDS Res Hum Retroviruses 2019 05 18;35(5):434-436. Epub 2019 Mar 18.

2 Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Analysis of viral genetic linkage can reveal generalized transmission patterns within a population. The HIV Prevention Trials Network 061 study evaluated HIV incidence among black men who have sex with men. HIV genotypes from 169 men who were HIV infected at enrollment and 23 men who seroconverted during the study were analyzed for genetic linkage. This analysis showed some associations of viral linkage with income, study site, and timing of infection.
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http://dx.doi.org/10.1089/AID.2018.0204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6508062PMC
May 2019

A Game-Theoretic Model of Cholera with Optimal Personal Protection Strategies.

Bull Math Biol 2018 10 10;80(10):2580-2599. Epub 2018 Sep 10.

Department of Mathematics and Statistics, University of North Carolina at Greensboro, Greensboro, NC, 27402, USA.

Cholera is an acute gastro-intestinal infection that affects millions of people throughout the world each year, primarily but not exclusively in developing countries. Because of its public health ramifications, considerable mathematical attention has been paid to the disease. Here we consider one neglected aspect of combating cholera: personal participation in anti-cholera interventions. We construct a game-theoretic model of cholera in which individuals choose whether to participate in either vaccination or clean water consumption programs under assumed costs. We find that relying upon individual compliance significantly lowers the incidence of the disease as long as the cost of intervention is sufficiently low, but does not eliminate it. The relative costs of the measures determined whether a population preferentially adopts a single preventative measure or employs the measure with the strongest early adoption.
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http://dx.doi.org/10.1007/s11538-018-0476-5DOI Listing
October 2018

Follow-up of the first patients with a totally subcutaneous ICD in Germany from implantation till battery depletion.

Clin Res Cardiol 2019 Jan 12;108(1):16-21. Epub 2018 Jun 12.

Department of Cardiology II-Electrophysiology, University Hospital Münster, Munster, Germany.

Background: The subcutaneous ICD is a promising treatment option in patients at risk for sudden cardiac death. Approved in 2009, the first S-ICD in Germany was implanted in June 2010. Although large prospective registry studies have shown safety and efficacy of the system, there is a lack of long-term data with regard to battery longevity of the S-ICD. Therefore, we report follow-up of our first initial S-ICD cases from implantation till battery depletion.

Materials And Methods: All S-ICD patients with device replacement for battery depletion in our large single-center S-ICD registry were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a median follow-up of 75.9 ± 6.8 months.

Results: Twenty-eight patients with S-ICD systems were included in this study. Of these patients, 21 were male and 7 were female, with an overall mean age of 41.9 ± 12.6 years. Primary prevention of sudden cardiac death was the indication in 19 patients (67.9%). Ventricular tachycardia was adequately terminated in two patients (7.1%). In 7 patients, non-sustained ventricular arrhythmias were not treated. A total of three inappropriate shocks occurred in three patients (10.7%). Mean time from implantation till battery depletion was 65.8 ± 8.1 months. Only one patient presented premature elective replacement criteria because of rapid battery depletion. No lead-related complication occurred during follow-up and no complications were seen regarding device replacement. In one patient (3.6%), the system was explanted without replacement due to patient's preference.

Conclusion: The estimated battery longevity of S-ICD of about 5 years was reached in all but one patient. Compared to larger S-ICD registry studies, frequency of inappropriate shocks was relatively high in the initial S-ICD cases. Both technological improvement as well as programming and operators' experience have led to a reduction of complications. Replacement of the S-ICD seems to be a safe and effective procedure.
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http://dx.doi.org/10.1007/s00392-018-1296-1DOI Listing
January 2019

Long-term single-center experience of defibrillator therapy in children and adolescents.

Int J Cardiol 2018 Nov 1;271:105-108. Epub 2018 Jun 1.

Department of Pedriatric Cardiology, University of Münster, Münster, Germany.

Background: Implantable cardioverter-defibrillator (ICD) systems are established therapy for prevention of sudden cardiac death. Long-term data on ICD systems in children and adolescents is rare. The present study displays a long-term single-center follow-up of children and adolescents with ICD systems.

Methods And Results: The present study represents a single-center experience of patients younger than 18 years who received an ICD (n = 58). Follow-up data included in-house follow-up as well as examinations of collaborating specialists. Mean age at implantation was 14.0 ± 3.3 years and 33 patients (56.9%) were male. A transvenous ICD system was implanted in 54 patients (93.1%). In 33 patients (56.9%) electrical heart disease or idiopathic ventricular fibrillation represented the underlying condition of ICD implantation. Median follow-up duration was 70 months (45; 94). 3 patients (5.2%) died during the observation period. None of these deaths was associated with ICD failure. Appropriate shocks occurred in 32 patients (55.2%). Inappropriate shock delivery was recorded in 17 patients (29.3%). Supraventricular tachycardia represented the most frequent cause of inappropriate shock delivery (9 patients, 52.9%). T-wave oversensing led to inappropriate shock delivery in 3 patients (17.6%). In 5 patients (29.4%), lead failure caused inappropriate shock delivery. Of note, during follow-up lead failure was reported in 15 patients (25.9%) leading to surgical revision.

Conclusion: ICD therapy in children and adolescents is effective for prevention of sudden cardiac death. The rate of appropriate shock deliveries was significantly higher as compared with large ICD trials. Inappropriate therapies occurred frequently. In particular supraventricular tachycardia, T-wave oversensing and lead failures were responsible for these episodes.
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http://dx.doi.org/10.1016/j.ijcard.2018.05.130DOI Listing
November 2018

Direct comparison of the novel automated screening tool (AST) versus the manual screening tool (MST) in patients with already implanted subcutaneous ICD.

Int J Cardiol 2018 Aug;265:90-96

Division of Electrophysiology, Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany.

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has evolved as a valuable alternative to the transvenous ICD, especially in young patients. Unfortunately, some of these patients are ineligible for S-ICD implantation due to specific electrocardiographic features. So far, these patients were identified by mandatory pre-implantation screening using the manual screening tool (MST), which lacks objective value. Therefore, a novel automated screening tool (AST) has been introduced recently for objective screening, which has not been evaluated yet.

Methods/results: We here first investigate the novel AST, in direct comparison to MST, in 33 consecutive patients with already implanted S-ICD system to compare predicted eligibility by screening tools with true sensing of the S-ICD system. Both screening tools reliably predicted true ineligible single vectors, but also suggested overall ineligibility in a similar fraction of patients (MST: 3.0%; AST: 6.1%), albeit the implanted S-ICD worked flawlessly in these patients. AST did not predict the finally selected sensing vector better than MST. There was a surprising mismatch between AST and MST for the predicted eligibility of single vectors; only in 49% of patients did both screening tools predict eligibility for the same vectors.

Conclusions: The novel AST predicted overall eligibility approximately similar to MST. Both tools predicted ineligibility in a few patients, who were actually eligible. There was a striking mismatch between both screening tools when eligibility of single vectors was predicted. Thus, the AST seems to be a valuable advance, due to its standardized and objective process, but it still lacks specificity.
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http://dx.doi.org/10.1016/j.ijcard.2018.02.030DOI Listing
August 2018

Change of sensing vector in the subcutaneous ICD during follow-up and after device replacement.

J Cardiovasc Electrophysiol 2018 09 19;29(9):1241-1247. Epub 2018 Jun 19.

Department of Cardiology II - Electrophysiology, University Hospital Münster, Münster, Germany.

Background: The subcutaneous implantable cardioverter defibrillator (S-ICD) has been established as a valuable alternative to transvenous ICD for prevention of sudden cardiac death. The system automatically chooses the optimal sensing vector. However, during follow-up and especially after device replacement we observed a change of the suggested sensing vector in automatic setup. Therefore, we analyzed frequency and reasons of vector change and its impact on inappropriate shocks (IAS).

Material And Methods: Between June 2010 and December 2017, a total of 216 patients with S-ICD were included in this analysis. In all patients sensing vectors at the time of implantation, during follow-up, and after device replacement were investigated. Median follow-up time was 27.3 ± 25.3 months.

Results: A change of the initial vector was seen in 77 patients (35.7%). The most frequent reason for vector change was the postoperative setup in supine and erect position in 54 patients (70.1%). In 12 patients (15.5%), the vector was manually changed due to inappropriate sensing and/or therapies. Routine setup during follow-up led to automatic vector change in 10 cases (13.0%). In only 1 patient the vector was manually changed due to oversensing in an exercise treadmill test. In 27 patients, the device was replaced due to battery depletion and in 6 of these patients the sensing vector was changed by the automatic setup. Vector change did not have an impact for inappropriate therapies in the follow-up; only 1 patient received an IAS due to an inadvertent vector change after device replacement.

Conclusion: In the present study, a significant number of S-ICD patients had a manual or automatic vector change during follow-up and after device replacement. The study underlines the importance of a thoroughly performed screening and at least two valuable sensing vectors preimplant. Further studies are needed to evaluate the necessity of a routine automatic setup during follow-up.
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http://dx.doi.org/10.1111/jce.13647DOI Listing
September 2018

Long-Term Experience With the Subcutaneous Implantable Cardioverter-Defibrillator in Teenagers and Young Adults.

JACC Clin Electrophysiol 2017 12 6;3(13):1499-1506. Epub 2017 Nov 6.

Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany.

Objectives: This study sought to examine the use of the subcutaneous implantable cardioverter-defibrillator (S-ICD) in teenagers and young adults.

Background: The S-ICD is an important advance in device therapy for the prevention of sudden cardiac death. Although guidelines recommend S-ICD use, long-term data are still limited, especially in subgroups. Therefore, this study analyzed teenagers and young adults <26 years of age with S-ICD in our large single-center S-ICD registry.

Methods: Between July 2010 and December 2016, 147 S-ICD systems were inserted at our institution. Thirty-one patients were included in the study; 13 were teenagers (<20 years of age), and 18 were young adults (20 to 26 years of age). The patients were compared with an age-matched control group with transvenous ICDs.

Results: Primary prevention of sudden cardiac death was the indication in 13 patients (41.9%). Ventricular arrhythmias were adequately terminated in 8 patients (25.8%). In 5 patients (16.1%), oversensing resulting in at least 1 inappropriate shock was observed. All inappropriate shocks occurred in teenagers. Younger age was an independent predictor of inappropriate shocks in S-ICD (hazard ratio: 0.56; 95% confidence interval: 0.34 to 0.92; p < 0.05). No ineffective shocks were observed in a median follow-up of 25.7 ± 20.2 months.

Conclusions: Young patients may be suitable candidates for S-ICD because of the high number of lead failures with transvenous systems expected in these patients during their lifetime. In the present study, S-ICD therapy was safe and feasible in teenagers and young adults. However, episodes of inappropriate shocks may occur, but rates of inappropriate shocks were comparable to those in patients with transvenous ICDs.
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http://dx.doi.org/10.1016/j.jacep.2017.08.017DOI Listing
December 2017

Postoperative ergometry-guided programming does not prevent T-wave oversensing and inappropriate shocks in S-ICD patients.

Pacing Clin Electrophysiol 2018 06 25;41(6):567-571. Epub 2018 Apr 25.

Division of Electrophysiology, Department of Cardiovascular Medicine, University of Muenster, Muenster, Germany.

Background: T-wave oversensing (TWOS) is a feared complication after subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, potentially leading to inappropriate shocks (IS) with tremendous impact on quality of life.

Hypothesis: Postoperative ergometry facilitates primary and secondary prevention of TWOS or other potential causes of IS and optimizes S-ICD programming.

Methods: We analyze the impact of ergometry guided-programming (EMGP) on primary and secondary prevention of TWOS/IS in S-ICD patients, we screened 146 patients implanted in our center (2010-2016) for the incidence of TWOS/IS during postoperative ergometry. Furthermore, to evaluate the outcome in 123 eligible patients complete follow-up (FU) of at least 6 months up to 2 years was retrospectively analyzed.

Results: (1) Primary prevention: TWOS could only be provoked postoperatively in 3.7% of patients (n = 3/82). FU analyses did not reveal significant differences compared to our control group (Ctrl: n = 6/61, 9.8% vs EMGP: n = 5/62, 8.1%; P = 0.731). Further subgroup analyses of patients with postoperative ergometry in the close postoperative period (< 7 days; n = 3/45, 6.7%; P = 0.563) did not yield any significant difference. (2) Secondary prevention: We found various causes of TWOS/IS. In patients who underwent reprogramming due to previous TWOS/IS events we observed a 66.7% (n = 6/9) reduction of TWOS/IS using EMGP.

Conclusion: TWOS/IS has various causes while not all cases are exercise-associated. Postoperative ergometry does not seem to be useful for primary prevention. Further trials need to investigate the potential benefit of EMGP for secondary prevention of TWOS/IS.
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http://dx.doi.org/10.1111/pace.13327DOI Listing
June 2018

[Management of inappropriate shocks/T-wave-oversensing in S-ICD®-patients].

Herzschrittmacherther Elektrophysiol 2018 Mar 12;29(1):122-126. Epub 2018 Feb 12.

Division of Electrophysiology, Department of Cardiovascular Medicine, University of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Deutschland.

Inappropriate shocks are a feared complication after implantable cardioverter-defibrillator (ICD) implantation and have a tremendous impact on quality of life. Inappropriate shocks in patients with subcutaneous ICD (S-ICD®, Boston Scientific, Marlborough, MA, USA) have various underlying causes. This review summarizes the current literature on this topic and lists possible treatment options.
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http://dx.doi.org/10.1007/s00399-018-0555-1DOI Listing
March 2018

Right versus left parasternal electrode position in the entirely subcutaneous ICD.

Clin Res Cardiol 2018 May 28;107(5):389-394. Epub 2017 Dec 28.

Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.

Objectives: The subcutaneous implantable cardioverter defibrillator (S-ICD) has been established as an alternative to conventional transvenous ICD for the prevention of sudden cardiac death. Initial studies have shown safety and efficacy of the system with a left parasternal (LP) electrode. However, several case studies reported a right parasternal (RP) position. The purpose of this study was to analyze shock efficacy and safety of an RP electrode position.

Methods: Between June 2010 and May 2016, 120 S-ICD were implanted at our institution. On the basis of the heart location on preoperative chest radiography (CXR), the investigators decided on an RP (n = 52) or LP electrode position (n = 68). All perioperative induced VF episodes, and spontaneous appropriate and inappropriate episodes during follow-up were analyzed.

Results: Patients with an RP electrode did not differ in terms of age, sex, or ejection fraction. A statistically significant difference in underlying cardiac disease was observed between the RP and LP electrode group, with more patients with channelopathies in the RP electrode group and more patients with non-ischemic cardiomyopathy in the LP electrode group. During a mean follow-up of 24.3 ± 19.5 months, 27 appropriate (19 in the LP group and 8 in the RP group) and 28 inappropriate (18 LP and 10 RP) ICD shocks occurred (p value = NS).

Conclusions: In the present study, an RP electrode position was chosen on the basis of chest radiographic characteristics and was efficient in terms of sensing and shock efficacy. Thus, a right-sided electrode implant might be an alternative if a left-sided electrode implant is inadequate. It might also be favorable for young patients with narrow heart silhouettes in the midsagittal position.
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http://dx.doi.org/10.1007/s00392-017-1194-yDOI Listing
May 2018