Publications by authors named "Lars Eckardt"

393 Publications

Outcomes in patients experiencing complications associated with atrial fibrillation ablation: Data from the German Ablation Registry.

Int J Cardiol 2022 Jun 12. Epub 2022 Jun 12.

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

Background: This study aims to report on the clinical and patient-reported outcomes in patients undergoing atrial fibrillation (AF) ablation with moderate or severe complications.

Methods: The prospective, multicentre German Ablation Registry of patients undergoing catheter ablation was studied to compare outcomes of patients with moderate or severe complications (group I) and patients without or minor complications (group II).

Results: A total of 3865 patients (group I = 158, group II = 3707) were included in this analysis. Procedural success (92.4% vs 96.1%, p = 0.019) was lower and arrhythmia recurrence before discharge significantly higher in group I (15.8% vs 6.5%, p < 0.001). Hospital stays were longer in in group I (6 days vs 3 days, p < 0.001). The in-hospital rate of death, myocardial infarction (MI) or stroke was 6.4% in group I. Age was an independent predictor of in-hospital complications (HR1.43, 95% CI 1.18-1.72). In the 1-year follow-up, the composite outcome of death, MI, stroke, or major bleeding (8.5% vs 1.5%, p < 0.001) was significantly higher in group I. The majority of patients were still feeling safe during treatment regardless of occurred complications (88.4% vs 94.0%, p = 0.14) and would choose the same centre again in most cases (90.7% vs 92.9%, p = 0.59). Patients reported no or improved symptoms in both cohorts (77.3% vs 78.6%) without significant differences.

Conclusion: Cardiovascular events in patients with severe complications are more common but patient satisfaction and symptomatic relief are high and comparable to those without complications.
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http://dx.doi.org/10.1016/j.ijcard.2022.06.019DOI Listing
June 2022

Incidence and predictors of cardiac arrhythmias in patients with COVID-19 induced ARDS.

J Cardiol 2022 May 16. Epub 2022 May 16.

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

Introduction: Recent studies suggest cardiac involvement with an increased incidence of arrhythmias in the setting of coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the risk of potentially lethal arrhythmias and atrial fibrillation in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) and to elicit possible predictors of arrhythmia occurrence.

Methods And Results: A total of 107 patients (82 male, mean age 60 ± 12 years, median body mass index 28 kg/m) treated for COVID-19-induced ARDS in a large tertiary university hospital intensive care unit between March 2020 and February 2021 were retrospectively analyzed. Eighty-four patients (79%) had at least moderate ARDS, 88 patients (83%) were mechanically ventilated, 35 patients (33%) received vvECMO. Forty-three patients (40%) died during their hospital stay. Twelve patients (11%) showed potentially lethal arrhythmias (six ventricular tachycardia, six significant bradycardia). Atrial fibrillation occurred in 27 patients (25%). In a multivariate logistic regression analysis, duration of hospitalization was associated with the occurrence of potentially lethal arrhythmias (p = 0.006). There was no association between possible predictive factors and the occurrence of atrial fibrillation. Invasive ventilation, antipsychotics, and the QT interval were independently associated with acute in-hospital mortality, but this was not arrhythmia-driven as there was no association between the occurrence of arrhythmias and mortality.

Conclusion: In this relatively young population with COVID-19-induced ARDS, the incidence of potentially lethal arrhythmias was low. While overall mortality was high in these severely affected patients, cardiac involvement and arrhythmia occurrence was not a significant driver of mortality.
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http://dx.doi.org/10.1016/j.jjcc.2022.04.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9108971PMC
May 2022

[Anatomy of the left ventricle for endocardial ablation].

Herzschrittmacherther Elektrophysiol 2022 Jun 13;33(2):161-174. Epub 2022 May 13.

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

As with all cardiac interventions, performing left ventricular ablation requires profound knowledge of cardiac anatomy. The aim of this article is to provide an overview of left ventricular anatomy and to characterize complex and clinically relevant structures from an electrophysiologist-centered perspective. In addition to the different access routes, the trabecular network, the left ventricular outflow tract, and the left ventricular conduction system, complex anatomical structures such as the aortomitral continuity and the left ventricular summit are also explained. In addition, this article offers multiple clinical examples that combine ECG, anatomy, and electrophysiologic study.
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http://dx.doi.org/10.1007/s00399-022-00859-7DOI Listing
June 2022

Thyroid Dysfunction under Amiodarone in Patients with and without Congenital Heart Disease: Results of a Nationwide Analysis.

J Clin Med 2022 Apr 5;11(7). Epub 2022 Apr 5.

Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, D-48149 Muenster, Germany.

Background: Amiodarone has a profound adverse toxicity profile. Large population-based analyses quantifying the risk of thyroid dysfunction (TD) in adults with and without congenital heart disease (ACHD) are lacking.

Methods: All adults registered with a major German health insurer (≈9.2 million members) with amiodarone prescriptions were analyzed. Occurrence of amiodarone-associated TD was assessed.

Results: Overall, 48,891 non-ACHD (37% female; median 73 years) and 886 ACHD (34% female; median 66 years) received amiodarone. Over 184,787 patient-years, 10,875 cases of TD occurred. The 10-year risk for TD was 38% in non-ACHD (35% ACHD). Within ACHD, compared to amiodarone-naïve patients, the hazard ratio (HR) for TD was 3.9 at 4 years after any amiodarone exposure. TD was associated with female gender (HR 1.42, < 0.001) and younger age (HR 0.97 per 10 years, = 0.009). Patients with congenital heart disease were not at increased risk (HR 0.98, = 0.80). Diagnosis of complex congenital heart disease, however, was a predictor for TD (HR 1.56, = 0.02). Amiodarone was continued in 47% of non-ACHD (38% ACHD), and 2.3% of non-ACHD (3.5% ACHD) underwent thyroid surgery/radiotherapy.

Conclusions: Amiodarone-associated TD is common and comparable in non-ACHD and ACHD. While female gender and younger age are predictors for TD, congenital heart disease is not necessarily associated with an elevated risk.
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http://dx.doi.org/10.3390/jcm11072027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8999848PMC
April 2022

Resolution of left atrial appendage thrombi: No difference between phenprocoumon and non-vitamin K-dependent oral antagonists.

Clin Cardiol 2022 Jun 4;45(6):650-656. Epub 2022 Apr 4.

Department of Cardiology, St. Franziskus-Hospital, Münster, Germany.

Background: Atrial fibrillation is the most important risk factor for left atrial appendage (LAA) thrombi, a potentially life-threatening condition. Thrombus resolution may prevent embolic events and allow rhythm-control strategies, which have been shown to reduce cardiovascular complications.

Hypothesis: There is no significant difference between phenprocoumon and non-Vitamin K-dependent oral anticoagulants (NOACs) in the resolution of LAA-thrombi in a real-world setting.

Methods: Consecutive patients with LAA-thrombi from June 2013 to June 2017 were included in an observational single-center analysis. The primary endpoint was defined as the resolution of the thrombus. The observational period was 1 year. Resolutions rates in patients on phenprocoumon or NOACs were compared and the time to resolution was analyzed.

Results: We identified 114 patients with LAA-thrombi. There was no significant difference in the efficacy of resolution between phenprocoumon and NOACs (p = .499) at the time of first control which took place after a mean of 58 ± 42.2 (median 48) days. At first control most thrombi were dissolved (74.6%). The analysis after set-time intervals revealed a resolution rate of 2/3 of LAA-thrombi after 8-10 weeks in the phenprocoumon and NOAC groups. After 12 weeks a higher number of thrombi had resolved in the presence of NOAC (89.3%) whereas in the presence of phenprocoumon 68.3% had resolved (p = .046).

Conclusion: In this large observational study NOACs were found to be potent drugs for the resolution of LAA-thrombi. In addition, the resolution of LAA-thrombi was found to be faster in the presence of NOAC as compared to phenprocoumon.
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http://dx.doi.org/10.1002/clc.23823DOI Listing
June 2022

Machine learning in the detection and management of atrial fibrillation.

Clin Res Cardiol 2022 Mar 30. Epub 2022 Mar 30.

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

Machine learning has immense novel but also disruptive potential for medicine. Numerous applications have already been suggested and evaluated concerning cardiovascular diseases. One important aspect is the detection and management of potentially thrombogenic arrhythmias such as atrial fibrillation. While atrial fibrillation is the most common arrhythmia with a lifetime risk of one in three persons and an increased risk of thromboembolic complications such as stroke, many atrial fibrillation episodes are asymptomatic and a first diagnosis is oftentimes only reached after an embolic event. Therefore, screening for atrial fibrillation represents an important part of clinical practice. Novel technologies such as machine learning have the potential to substantially improve patient care and clinical outcomes. Additionally, machine learning applications may aid cardiologists in the management of patients with already diagnosed atrial fibrillation, for example, by identifying patients at a high risk of recurrence after catheter ablation. We summarize the current state of evidence concerning machine learning and, in particular, artificial neural networks in the detection and management of atrial fibrillation and describe possible future areas of development as well as pitfalls. Typical data flow in machine learning applications for atrial fibrillation detection.
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http://dx.doi.org/10.1007/s00392-022-02012-3DOI Listing
March 2022

Incidence and Predictors of Left Atrial Appendage Thrombus before Catheter Ablation of Thrombogenic Arrhythmias.

J Pers Med 2022 Mar 14;12(3). Epub 2022 Mar 14.

Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert Schweitzer Campus 1, 48149 Muenster, Germany.

Introduction: Transesophageal echocardiography (TEE) is routinely performed before catheter ablation of atrial tachyarrhythmias to rule out the presence of left atrial thrombi. However, data to support this practice are inconsistent.

Methods: We analyzed consecutive pre-procedural TEE in a high-volume electrophysiology center for the presence of left atrial thrombi and a relevant flow reduction in the left atrial appendage (LAA) defined as LAA sludge or LAA emptying velocity (LAAEV) < 20 cm/s. The possible predictors of reduced flow were recorded and compared in a multivariate logistic regression analysis.

Results: 1676 TEE were included (1122 before pulmonary vein isolation, 436 before atrial flutter ablation, 166 before other ablations). 543 patients (32%) were female and 991 (59%) were on DOAC. Nine patients (0.5%) had an LAA thrombus on pre-procedural TEE. Ninety-five further patients (5.7%) had a relevant reduction in LAA flow. The underlying rhythm showed a significant association with the presence of LAA thrombus or reduced LAA flow ( = 0.003). Patients in sinus rhythm and cavotricuspid isthmus-dependent atrial flutter exhibited the lowest risk. Additionally, reduced kidney function was associated with a reduction in LAA flow velocities ( = 0.04). Of note, two LAA thrombi occurred in patients in sinus rhythm and six out of nine patients with an LAA thrombus were on vitamin-K antagonists.

Conclusions: LAA thrombus is a rare occurrence before an elective catheter ablation. The underlying rhythm and kidney function may serve as markers of a higher likelihood of significantly reduced LAAEV and LAA thrombus.
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http://dx.doi.org/10.3390/jpm12030460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8953099PMC
March 2022

Cardiovascular risk of energy drinks: Caffeine and taurine facilitate ventricular arrhythmias in a sensitive whole-heart model.

J Cardiovasc Electrophysiol 2022 Jun 27;33(6):1290-1297. Epub 2022 Mar 27.

Department of Cardiology II (Electrophysiology), University Hospital Münster, Münster, Germany.

Background: Several case reports have suggested an increased risk of sudden cardiac death due to energy drinks. Therefore, the purpose of this study was to assess acute electrophysiologic effects of caffeine and taurine, two of the main ingredients of energy drinks, in an experimental whole-heart model.

Methods And Results: Twenty-five rabbit hearts were excised, retrogradely perfused, and assigned to two groups. Hearts were perfused with caffeine (2, 10, and 50 µM) or taurine (2, 10, and 50 µM) after generating baseline data. Eight monophasic action potentials and electrocardiography recordings showed a significant abbreviation of action potential duration (APD ), QT interval, and effective refractory periods (ERP) after caffeine treatment. With taurine, cardiac repolarization duration and ERP were significantly shortened. A ventricular vulnerability was assessed by a predefined pacing protocol. With caffeine, we observed a trend towards more ventricular arrhythmias in a dose-dependent manner. After treatment with taurine, significantly more episodes of ventricular arrhythmias occurred.

Conclusion: In this experimental whole-heart study, treatment with caffeine and taurine provoked ventricular arrhythmias. The underlying mechanism was an abbreviation of cardiac repolarizations and effective refractory periods that may facilitate re-entry and thereby provokes arrhythmias. These findings help to understand the potentially hazardous and fatal outcomes after intoxication with energy drinks.
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http://dx.doi.org/10.1111/jce.15458DOI Listing
June 2022

Incidence and predictors of left atrial appendage thrombus on transesophageal echocardiography before elective cardioversion.

Sci Rep 2022 03 7;12(1):3671. Epub 2022 Mar 7.

Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.

Guidelines recommend transesophageal echocardiography (TEE) before cardioversion in thrombogenic arrhythmias when the requirement of ≥ 3 weeks of anticoagulation is not met. Current data to support this approach, especially with direct oral anticoagulants (DOAC), are scarce. We analyzed consecutive elective pre-cardioversion TEE in a high-volume electrophysiology center for the occurrence of left atrial appendage (LAA) thrombi or reduced LAA flow velocity. Possible predictors were recorded and compared in a multivariate logistic regression analysis. Consecutive pre-cardioversion TEE in 512 patients (148 female, median age 69 years) were included. In all patients, indication for TEE was either intake of anticoagulation < 3 weeks before cardioversion or uncertain adherence to the prescribed anticoagulation regimen. Of the 512 TEE, 19 (3.7%) depicted a LAA thrombus. An additional 41 patients (8.0%) showed either a reduced LAA flow velocity (≤ 20 cm/s), LAA sludge, or both. In a multivariate logistic regression analysis, QRS width on admission 12-lead ECG emerged as a possible predictor of LAA thrombus and reduced LAA flow (p = 0.008). Noteworthy, a high CHADS-VASc score was not associated with an increased risk of reduced LAA emptying velocity and LAA thrombi were even found in patients with a CHADS-VASc score of 0 (n = 1) and 1 (n = 1). The presence of LAA thrombus before an elective cardioversion is a rare event in the age of direct oral anticoagulants. However, LAA thrombi occurred even in supposed low-risk individuals according to the CHADS-VASc score. QRS width may aid in identifying patients at risk of reduced LAA flow velocity.
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http://dx.doi.org/10.1038/s41598-022-07428-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8901763PMC
March 2022

Evidence-based treatment of atrial fibrillation around the globe: comparison of the latest ESC, AHA/ACC/HRS, and CCS guidelines on the management of atrial fibrillation.

Rev Cardiovasc Med 2022 Feb;23(2):56

Clinic of Cardiology II (Electrophysiology), University Hospital Münster, 48149 Münster, Germany.

Recent versions of evidence-based guidelines on the management of atrial fibrillation (AF) have been published by the European Society of Cardiology (ESC) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS), the American College of Cardiology, American Heart Association, and the Heart Rhythm Society (AHA/ACC/HRS), and the Canadian Cardiovascular Society/Canadian Heart Rhythm Society (CCS). As all societies refer to the same multicentric and usually multinational studies, the similarities undoubtedly outweigh the differences. Nonetheless, interesting differences can often be found in details, which are usually based on a different assessment of the same study, the availability of data in relation to the publication date and local preferences and availabilities of certain cardiovascular drugs. The following article aims at lining out these similarities and differences.
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http://dx.doi.org/10.31083/j.rcm2302056DOI Listing
February 2022

Cardiovascular Magnetic Resonance-Guided Radiofrequency Ablation: Where Are We Now?

JACC Clin Electrophysiol 2022 02;8(2):261-274

Department of Cardiology, Division of Cardiovascular Imaging, University Hospital Münster, Münster, Germany. Electronic address:

The possibilities of cardiovascular magnetic resonance (CMR) imaging for myocardial tissue characterization and catheter ablation guidance are accompanied by some fictional concepts. In this review, we present the available facts about CMR-guided catheter ablation procedures as well as promising, however unproven, theoretical concepts. CMR promises to visualize the respective arrhythmogenic substrate and may thereby make it more localizable for electrophysiology (EP)-based ablation. Robust CMR imaging is challenged by motion of the heart resulting from cardiac and respiratory cycles. In contrast to conventional "passive" tracking of the catheter tip by real-time CMR, novel approaches based on "active" tracking are performed by integrating microcoils into the catheter tip that send a receiver signal. Several experimental and clinical studies were already performed based on real-time CMR for catheter ablation of atrial and ventricular arrhythmias. Importantly, successful ablation of the cavotricuspid isthmus was already performed in patients with typical atrial flutter. However, a complete EP procedure with real-time CMR-guided transseptal puncture and subsequent pulmonary vein isolation has not been shown so far in patients with atrial fibrillation. Moreover, real-time CMR-guided EP for ventricular tachycardia ablation was only performed in animal models using a transseptal, retrograde, or epicardial access-but not in humans. Essential improvements within the next few years regarding basic technical requirements, such as higher spatial and temporal resolution of real-time CMR imaging as well as clinically approved cardiac magnetic resonance-conditional defibrillators, are ultimately required-but can also be expected-and will move this field forward.
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http://dx.doi.org/10.1016/j.jacep.2021.11.017DOI Listing
February 2022

The Incidence, Electrophysiological Characteristics and Ablation Outcome of Left Atrial Tachycardias after Pulmonary Vein Isolation Using Three Different Ablation Technologies.

J Cardiovasc Dev Dis 2022 Feb 3;9(2). Epub 2022 Feb 3.

Department of Cardiology II-Electrophysiology, University Hospital Muenster, Cardiol, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany.

Background: Left atrial tachycardias (LAT) are a well-known outcome of pulmonary vein isolation (PVI). Few data are available on whether the catheter used to perform PVI influences the incidence, as well as the characteristics of post PVI LAT. We present data on LAT following PVI by the following three ablation technologies: (1) phased multi-electrode radiofrequency catheter (PVAC), (2) irrigated single-tip catheter (iRF), and (3) cryoballoon ablation.

Methods: Using a prospectively designed single-center database, we analyzed 650 patients (300 iRF, 150 PVAC, and 200 cryoballoon) with paroxysmal ( = 401) and persistent atrial fibrillation (AF), who underwent their first PVI at our center.

Results: The three populations were comparable in their baseline characteristics; however, the cryoballoon group comprised a higher percentage of patients with persistent AF ( = 0.05). The LAT rates were 3.7% in the iRF group (mean follow-up 22 ± 14 months), 0.7% in the PVAC group (mean follow-up 21 ± 14 months), and 4% in the cryoballoon group (mean follow-up 15 ± 8 months). The predominant mechanism of LAT was macro-reentrant tachycardia. Reconnection of at least one pulmonary vein was observed in 87% of the patients who underwent 3D mapping. No predictors for LAT occurrence were identified.

Conclusion: The occurrence of LAT post PVI is rare; the predominant mechanism was macro-reentrant tachycardia. Reconnection of at least one pulmonary vein was observed in nearly all the LAT patients. In our retrospective analysis, the lowest rate of LAT was observed with the PVAC. No predictors for LAT occurrence were identified.
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http://dx.doi.org/10.3390/jcdd9020050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8879099PMC
February 2022

Accuracy of Deep Learning Echocardiographic View Classification in Patients with Congenital or Structural Heart Disease: Importance of Specific Datasets.

J Clin Med 2022 Jan 28;11(3). Epub 2022 Jan 28.

Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.

Introduction: Automated echocardiography image interpretation has the potential to transform clinical practice. However, neural networks developed in general cohorts may underperform in the setting of altered cardiac anatomy.

Methods: Consecutive echocardiographic studies of patients with congenital or structural heart disease (C/SHD) were used to validate an existing convolutional neural network trained on 14,035 echocardiograms for automated view classification. In addition, a new convolutional neural network for view classification was trained and tested specifically in patients with C/SHD.

Results: Overall, 9793 imaging files from 262 patients with C/SHD (mean age 49 years, 60% male) and 62 normal controls (mean age 45 years, 50.0% male) were included. Congenital diagnoses included among others, tetralogy of Fallot (30), Ebstein anomaly (18) and transposition of the great arteries (TGA, 48). Assessing correct view classification based on 284,250 individual frames revealed that the non-congenital model had an overall accuracy of 48.3% for correct view classification in patients with C/SHD compared to 66.7% in patients without cardiac disease. Our newly trained convolutional network for echocardiographic view detection based on over 139,910 frames and tested on 35,614 frames from C/SHD patients achieved an accuracy of 76.1% in detecting the correct echocardiographic view.

Conclusions: The current study is the first to validate view classification by neural networks in C/SHD patients. While generic models have acceptable accuracy in general cardiology patients, the quality of image classification is only modest in patients with C/SHD. In contrast, our model trained in C/SHD achieved a considerably increased accuracy in this particular cohort.
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http://dx.doi.org/10.3390/jcm11030690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8836991PMC
January 2022

Lyme carditis manifesting with sinoatrial exit block: a case report.

Eur Heart J Case Rep 2022 Jan 18;6(1):ytac022. Epub 2022 Jan 18.

Department for Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, D-48149 Münster, Germany.

Background: Lyme disease is the most common vector-borne disease in North America and Europe. Infection with the spirochete complex can involve cardiac tissue causing Lyme carditis (LC). Due to the infection of conductive tissue, LC typically presents with varying degrees of atrioventricular conduction block. Here, we provide the first evidence that conductive tissue of the sinus node can be involved in LC resulting in higher degree sinoatrial (SA) block with concomitant syncope.

Case Summary: We report the case of an otherwise healthy 31-year-old female presenting with LC manifesting with SA exit block causing asystole over 12 s with concomitant syncope. Signs of SA block completely resolved with antibiotic treatment with a third-generation cephalosporin. The patient did not require permanent pacemaker implantation and had no sinus pauses after 12 months of follow-up as confirmed via implantable loop recorder.

Conclusion: The possibility of LC in patients with sinus node dysfunction should be considered, as adequate antibiotic therapy can spare patients from potentially unnecessary pacemaker implantation.
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http://dx.doi.org/10.1093/ehjcr/ytac022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8801048PMC
January 2022

Subcutaneous implantable cardioverter-defibrillators: long-term results of the EFFORTLESS study.

Eur Heart J 2022 Jun;43(21):2037-2050

Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands.

Aims: To report 5-year outcomes of EFFORTLESS registry patients with early generation subcutaneous implantable cardioverter-defibrillator (S-ICD) devices.

Methods And Results: Kaplan-Meier, trend and multivariable analyses were performed for mortality and late (years 2-5) complications, appropriate shock (AS) and inappropriate shock (IAS) rates. Nine hundred and eighty-four of 994 enrolled patients with diverse diagnoses (28% female, 48 ± 17 years, body mass index 27 ± 6 kg/m2, ejection fraction 43 ± 18%) underwent S-ICD implantation. Median follow-up was 5.1 years (interquartile range 4.7-5.5 years). All-cause mortality was 9.3% (95% confidence interval 7.2-11.3%) at 5 years; 703 patients remained in follow-up on study completion, 171 withdrew including 87 (8.8%) with device explanted, and 65 (6.6%) lost to follow-up. Of the explants, only 20 (2.0%) patients needed a transvenous device for pacing indications. First and final shock efficacy for discrete ventricular arrhythmias was consistent at 90% and 98%, respectively, with storm episode final shock efficacy at 95.2%. Time to therapy remained unaltered. Overall 1- and 5-year complication rates were 8.9% and 15.2%, respectively. Early complications did not predict later complications. There were no structural lead failures. Inappropriate shock rates at 1 and 5 years were 8.7% and 16.9%, respectively. Self-terminating inappropriately sensed episodes predicted late IAS. Predictors of late AS included self-terminating appropriately sensed episodes and earlier AS.

Conclusion: In this diverse S-ICD registry population, spontaneous shock efficacy was consistently high over 5 years. Very few patients underwent S-ICD replacement with a transvenous device for pacing indications. Treated and self-terminating arrhythmic episodes predict future shock events, which should encourage more personalized device optimization.
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http://dx.doi.org/10.1093/eurheartj/ehab921DOI Listing
June 2022

Improvement of Retinal Microcirculation after Pulmonary Vein Isolation in Patients with Atrial Fibrillation-An Optical Coherence Tomography Angiography Study.

Diagnostics (Basel) 2021 Dec 24;12(1). Epub 2021 Dec 24.

Department of Ophthalmology, Hospital Fulda, University of Marburg, Campus Fulda, D-36043 Fulda, Germany.

Purpose: To evaluate retinal and optic nerve head (ONH) perfusion in patients with atrial fibrillation (AF) before and after catheter ablation of AF with pulmonary vein isolation (PVI).

Methods: 34 eyes of 34 patients with AF and 35 eyes of 35 healthy subjects were included in this study. Flow density data were obtained using spectral-domain OCT-A (RTVue XR Avanti with AngioVue, Optovue, Inc, Fremont, California, USA). The data of the superficial and deep vascular layers of the macula and the ONH (radial peripapillary capillary network, RPC) before and after PVI were extracted and analysed.

Results: The flow density in the superficial OCT-angiogram (whole en face) and the ONH (RPC) in patients with AF was significantly lower compared to healthy controls (OCT-A superficial: study group: 48.77 (45.19; 52.12)%; control group: 53.01 (50.00; 54.25)%; < 0.001; ONH: study group: 51.82 (48.41; 54.03)%; control group: 56.00 (54.35; 57.70)%; < 0.001;). The flow density in the ONH (RPC) improved significantly in the study group following PVI (before: 51.82 (48.41; 54.03)%; after: 52.49 (50.34; 55.62)%; = 0.007).

Conclusions: Patients with AF showed altered ocular perfusion as measured using OCTA when compared with healthy controls. Rhythm control using PVI significantly improved ocular perfusion as measured using OCT-A. Non-contact imaging using OCTA provides novel information about the central global microperfusion of patients with AF.
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http://dx.doi.org/10.3390/diagnostics12010038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8774642PMC
December 2021

Selection and outcome of implantable cardioverter-defibrillator patients with and without cardiac resynchronization therapy: Comparison of 4384 patients from the German Device Registry to randomized controlled trials.

J Cardiovasc Electrophysiol 2022 03 23;33(3):483-492. Epub 2022 Jan 23.

Division of Electrophysiology, Department of Cardiology and Angiology, Münster, Germany.

Background: Registry data add important information to randomized controlled trials (RCT) on real-life aspects of implantable cardioverter-defibrillator (ICD) patients with and without cardiac resynchronization therapy (CRT-D). This analysis of the prospectively conducted German Device Registry aims at comparing mortality rates, comorbidities, complication rates to results from RCT.

Methods: The German Device registry (DEVICE) prospectively collected data on ICD and CRT-D first implantations from 50 German centres. Demographic data, details on cardiac disease, electrocardiogram (ECG), medication, and data about procedure, complications, and hospital stay were stored in electronic case report forms. One year after device implantation patients were contacted for follow-up.

Results: DEVICE included n = 4384 first ICD/CRT-D implantations (29.3% CRT-D devices). We found a strong adherence to guidelines with over 90% of patients being on ß-blocker and ACE-inhibitor medication and adequate QRS width in the majority of CRT-D patients. Patients receiving a CRT-D were older (67.6 ± 11.0 years vs. 63.9 ± 13.4 years, p < .001) and had lower ejection fractions (mean 25% vs. 30%, p < .001) compared to ICD patients. Dilated cardiomyopathy was the predominant underlying heart disease in CRT-D (53.3%), coronary artery disease in ICD patients (64.7%). Compared to RCT our DEVICE patients had more comorbidities (17.9% chronic kidney disease [CKD]) and higher 1-year mortality rates (10.7% ICD group, 12.3% CRT group). In multivariate analysis, CKD patients had an almost 2-fold higher risk of 1-year mortality.

Conclusion: Despite relevant limitations of registry data, DEVICE highlights important differences between RCT and real-world registry data and the impact of comorbidities on mortality of ICD and CRT-D recipients.
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http://dx.doi.org/10.1111/jce.15365DOI Listing
March 2022

Electrophysiologic effects of sacubitril in different arrhythmia models.

Eur J Pharmacol 2022 Feb 10;917:174747. Epub 2022 Jan 10.

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

Background: Previous studies report conflicting data regarding anti- or proarrhythmic effects of sacubitril. Aim of this study was to assess the impact of acute sacubitril treatment in different arrhythmia models.

Methods: Sacubitril was administered (3, 5, 10 μM) in 12 isolated rabbit hearts. Further 12 hearts were treated with erythromycin to simulate long-QT-syndrome-2 (LQT2). Other 12 hearts were perfused with veratridine to mimic long-QT-syndrome-3 (LQT3). Both LQT-groups were treated with sacubitril (5 μM) additionally. Ventricular vulnerability was assessed by a pacing protocol. AV-blocked bradycardic hearts were perfused with a hypokalemic solution to trigger torsade de pointes (TdP). In further 13 hearts, AF was induced by a combination of acetylcholine and isoproterenol and sacubitril (5 μM) was added afterwards.

Results: With sacubitril, action potential duration (APD) was abbreviated whereas spatial dispersion of repolarisation (SDR) remained stable. In both LQT groups, APD and SDR were increased. Infusion of sacubitril reduced APD (- 21 ms, p < 0.01) and SDR (- 8 ms) in the LQT2-group and did not alter APD (+2 ms) but reduced SDR (-19 ms, p < 0.01) in the LQT3-group. Ventricular vulnerability was not altered by sacubitril. No TdP were observed with sacubitril or under baseline conditions in any group. Sacubitril significantly suppressed TdP in the LQT2-group (3 vs. 43 episodes, p < 0.05) but not in the LQT3-group (10 vs. 16 episodes, p = ns). Sacubitril reduced inducibility of AF (9 vs. 31 episodes).

Conclusion: Sacubitril abbreviated APD. In addition, sacubitril exhibits potential antiarrhythmic effects in LQT2 and may be beneficial in LQT3 and AF.
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http://dx.doi.org/10.1016/j.ejphar.2022.174747DOI Listing
February 2022

Management of ventricular tachycardia in patients with ischaemic cardiomyopathy: contemporary armamentarium.

Europace 2022 04;24(4):538-551

Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.

Worldwide, ∼4 million people die from sudden cardiac death every year caused in more than half of the cases by ischaemic cardiomyopathy (ICM). Prevention of sudden cardiac death after myocardial infarction by implantation of a cardioverter-defibrillator (ICD) is the most common, even though not curative, therapy to date. Optimized ICD programming should be strived for in order to decrease the incidence of ICD interventions. Catheter ablation reduces the recurrence of ventricular tachycardias (VTs) and is an important adjunct to sole ICD-based treatment or pharmacological antiarrhythmic therapy in patients with ICM, as conclusively demonstrated by seven randomized controlled trials (RCTs) in the last two decades. However, none of the conducted trials was powered to reveal a survival benefit for ablated patients as compared to controls. Whereas thorough consideration of an early approach is necessary following two recent RCTs (PAUSE-SCD, BERLIN VT), catheter ablation is particularly recommended in patients with recurrent VT after ICD therapy. In this context, novel, pathophysiologically driven ablation strategies referring to deep morphological and functional substrate phenotyping based on high-resolution mapping and three-dimensional visualization of scars appear promising. Emerging concepts like sympathetic cardiac denervation as well as radioablation might expand the therapeutical armamentarium especially in patients with therapy-refractory VT. Randomized controlled trials are warranted and on the way to investigate how these translate into improved patient outcome. This review summarizes therapeutic strategies currently available for the prevention of VT recurrences, the optimal timing of applicability, and highlights future perspectives after a PAUSE in BERLIN.
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http://dx.doi.org/10.1093/europace/euab274DOI Listing
April 2022

Safe electrophysiologic profile of dexmedetomidine in different experimental arrhythmia models.

Sci Rep 2021 12 14;11(1):23940. Epub 2021 Dec 14.

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

Previous studies suggest an impact of dexmedetomidine on cardiac electrophysiology. However, experimental data is sparse. Therefore, purpose of this study was to investigate the influence of dexmedetomidine on different experimental models of proarrhythmia. 50 rabbit hearts were explanted and retrogradely perfused. The first group (n = 12) was treated with dexmedetomidine in ascending concentrations (3, 5 and 10 µM). Dexmedetomidine did not substantially alter action potential duration (APD) but reduced spatial dispersion of repolarization (SDR) and rendered the action potentials rectangular, resulting in no proarrhythmia. In further 12 hearts, erythromycin (300 µM) was administered to simulate long-QT-syndrome-2 (LQT2). Additional treatment with dexmedetomidine reduced SDR, thereby suppressing torsade de pointes. In the third group (n = 14), 0.5 µM veratridine was added to reduce the repolarization reserve. Further administration of dexmedetomidine did not influence APD, SDR or the occurrence of arrhythmias. In the last group (n = 12), a combination of acetylcholine (1 µM) and isoproterenol (1 µM) was used to facilitate atrial fibrillation. Additional treatment with dexmedetomidine prolonged the atrial APD but did not reduce AF episodes. In this study, dexmedetomidine did not significantly alter cardiac repolarization duration and was not proarrhythmic in different models of ventricular and atrial arrhythmias. Of note, dexmedetomidine might be antiarrhythmic in acquired LQT2 by reducing SDR.
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http://dx.doi.org/10.1038/s41598-021-03364-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8671395PMC
December 2021

Very Long-Term Follow-Up in Cardiac Resynchronization Therapy: Wider Paced QRS Equals Worse Prognosis.

J Pers Med 2021 Nov 11;11(11). Epub 2021 Nov 11.

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

Background: Different electrocardiogram (ECG) findings are known to be independent predictors of clinical response to cardiac resynchronization therapy (CRT). It remains unknown how these findings influence very long-term prognosis.

Methods And Results: A total of 102 consecutive patients (75 males, mean age 65 ± 10 years) referred to our center for CRT implantation had previously been included in this prospective observational study. The same patient group was now re-evaluated for death from all causes over a prolonged median follow-up of 10.3 years (interquartile range 9.4-12.5 years). During follow-up, 55 patients died, and 82% of the clinical non-responders ( = 23) and 44% of the responders ( = 79) were deceased. We screened for univariate associations and found QRS width during biventricular (BIV) pacing ( = 0.02), left ventricular (LV) pacing ( < 0.01), Δ LV paced-right ventricular (RV) paced ( = 0.03), age ( = 0.03), New York Heart Association (NYHA) class ( < 0.01), CHADS-Vasc score ( < 0.01), glomerular filtration rate ( < 0.01), coronary artery disease ( < 0.01), non-ischemic cardiomyopathy (NICM) ( = 0.01), arterial hypertension ( < 0.01), NT-proBNP ( < 0.01), and clinical response to CRT ( < 0.01) to be significantly associated with mortality. In the multivariate analysis, NICM, the lower NYHA class, and smaller QRS width during BIV pacing were independent predictors of better outcomes.

Conclusion: Our data show that QRS width duration during biventricular pacing, an ECG parameter easily obtainable during LV lead placement, is an independent predictor of mortality in a long-term follow-up. Our data add further evidence that NICM and lower NYHA class are independent predictors for better outcome after CRT implantation.
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http://dx.doi.org/10.3390/jpm11111176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8620956PMC
November 2021

[New developments in leadless pacing systems].

Herz 2021 Dec 22;46(6):513-519. Epub 2021 Oct 22.

Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1 Gebäude A1, 48149, Münster, Deutschland.

Leadless pacing systems, especially the Micra™ TPS system, deliver an effective and safe alternative to the previous conventional transvenous systems in patients with impossible transvenous access and seem to be compatible with other implantable devices (S-ICD, deep brain stimulators) with no limitations in efficacy or safety. Also, new outlooks on leadless resynchronization therapy seem promising and could prevent future patients from lead- or operation-associated complications. Current limits to the implementation in everyday clinical practice are mostly the unavailability of the devices or cost issues through lack of health insurance reimbursement. However, more promising data through further studies and rising implantation rates are expected based on the positive current clinical data.
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http://dx.doi.org/10.1007/s00059-021-05075-6DOI Listing
December 2021

Cardiac Sympathetic Activity and Rhythm Control Following Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation-A Prospective I-mIBG-SPECT/CT Imaging Study.

J Pers Med 2021 Sep 30;11(10). Epub 2021 Sep 30.

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

Background: Pulmonary vein isolation (PVI) and antiarrhythmic drug therapy are established treatment strategies to preserve sinus rhythm in atrial fibrillation (AF). However, the efficacy of both interventional and pharmaceutical therapy is still limited. Solid evidence suggests an important role of the cardiac sympathetic nervous system in AF. In this blinded, prospective observational study, we studied left ventricular cardiac sympathetic activity in patients treated with PVI and with antiarrhythmic drugs. Prospectively, Iodine-123-benzyl-guanidine single photon emission computer tomography (I-mIBG-SPECT) was performed in a total of 23 patients with paroxysmal AF, who underwent PVI ( = 20) or received antiarrhythmic drug therapy only ( = 3), respectively. I-mIBG planar and SPECT/CT scans were performed before and 4 to 8 weeks after PVI (or initiation of drug therapy, respectively). For semiquantitative SPECT image analysis, attenuation-corrected early/late images were analyzed. Quantitative SPECT analysis was performed using the AHA 17-segment model of the left ventricle.

Results: PVI with point-by-point radiofrequency ablation led to a significantly ( < 0.05) higher visual sympathetic innervation defect score when comparing pre-and post PVI. Newly emerging innervation deficits post PVI were localized predominantly in the inferior lateral wall. These findings were corroborated by semiquantitative SPECT analysis identifying inferolateral segments with a reduced tracer uptake in comparison to SPECT before PVI. Following PVI, patients with an AF relapse showed a different sympathetic innervation pattern compared to patients with sufficient rhythm control.

Conclusions: PVI results in novel defects of cardiac sympathetic innervation. Differences in cardiac sympathetic innervation remodelling following PVI suggest an important role of the cardiac autonomous nervous system in the maintenance of sinus rhythm following PVI.
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http://dx.doi.org/10.3390/jpm11100995DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8549007PMC
September 2021

Antiarrhythmic drug therapy after catheter ablation for atrial fibrillation-Insights from the German Ablation Registry.

Pharmacol Res Perspect 2021 12;9(6):e00880

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

Data on the optimal treatment strategy for antiarrhythmic drug therapy (AAD) after catheter ablation for atrial fibrillation (AF) are inconsistent. The present study investigates whether postinterventional AAD leads to an improved long-term outcome. Patients from the prospective German Ablation Registry (n = 3275) discharged with or without AAD after catheter ablation for AF were compared regarding the rates of recurrences, reablations and cardiovascular events as well as patient reported outcomes during 12 months follow-up. In patients with paroxysmal AF (n = 2138) the recurrence rate did not differ when discharged with (n = 1051) or without (n = 1087) AAD (adjusted odds ratio (OR) 1.13, 95% confidence interval (CI) [0.95-1.35]). The reablation rate was higher and reduced treatment satisfaction was reported more often in those discharged with AAD (reablation: OR 1.30, 95% CI [1.05-1.61]; reduced treatment satisfaction: OR 1.76, 95% CI [1.20-2.58]). Similar rates of recurrences, reablations and treatment satisfaction were found in patients with persistent AF (n = 1137) discharged with (n = 641) or without (n = 496) AAD (recurrence: OR 1.22, 95% CI [0.95-1.56]; reablation: OR 1.21, 95% CI [0.91-1.61]; treatment satisfaction: OR 1.24, 95% CI [0.74-2.08]). The incidence of cardiovascular events and mortality did not differ at follow-up in patients discharged with or without AAD. In conclusion, the rates of recurrences, cardiovascular events and mortality did not differ between patients discharged with or without AAD after AF catheter ablation. However, AAD should be considered carefully in patients with paroxysmal AF, in whom it was associated with a higher reablation rate and reduced treatment satisfaction. Clinical trial registration: The trial has been registered under the number NCT01197638.
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http://dx.doi.org/10.1002/prp2.880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8525107PMC
December 2021

Experimental evidence for proarrhythmic effects of nonsteroidal anti-inflammatory drugs in a sensitive whole-heart model.

Basic Clin Pharmacol Toxicol 2022 Jan 26;130(1):103-109. Epub 2021 Oct 26.

Department of Cardiology II (Electrophysiology), University Hospital Münster, Münster, Germany.

Background: Previous studies have raised serious concerns on cardiovascular safety of widely prescribed nonsteroidal anti-inflammatory drugs (NSAIDs). Therefore, the aim of this study was to characterize the electrophysiological effects of certain NSAIDs in an established whole heart model of proarrhythmia.

Methods And Results: Thirty-eight hearts of New Zealand White rabbits were harvested and retrogradely perfused employing a Langendorff setup, and electrophysiology studies were performed to investigate action potential duration at 90% of repolarization (APD ), QT intervals, and effective refractory period (ERP). After generating baseline data, hearts were perfused with ibuprofen (Group 1, n = 12; 10 and 30 μM), indomethacin (Group 2, n = 13; 10 and 20 μM) and diclofenac (Group 3, n = 13; 10 and 20 μM), respectively, and the pacing protocols were repeated for each concentration. In all groups, perfusion with the NSAIDs resulted in a significant and reproducible shortening of APD and QT interval. In all groups, the arrhythmia susceptibility was significantly raised as occurrence of monomorphic ventricular tachycardia under programmed ventricular stimulation was significantly increased under perfusion with ibuprofen, indomethacin and diclofenac in all concentrations.

Conclusion: The perfusion with ibuprofen, indomethacin and diclofenac in commonly used doses raised the arrhythmia susceptibility in an established rabbit whole-heart model while APD shortening and shortened ERP seem to be crucial for arrhythmogenesis.
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http://dx.doi.org/10.1111/bcpt.13671DOI Listing
January 2022

Smartphone-based ECG devices: Beyond atrial fibrillation screening.

Eur J Intern Med 2022 01 5;95:111-112. Epub 2021 Oct 5.

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

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http://dx.doi.org/10.1016/j.ejim.2021.09.017DOI Listing
January 2022

Quantifying Left Atrial Size in the Context of Atrial Fibrillation Ablation: Which Echocardiographic Method Correlates to Outcome of Pulmonary Venous Isolation?

J Pers Med 2021 Sep 13;11(9). Epub 2021 Sep 13.

Department of Cardiology II-Electrophysiology, University Hospital Muenster, Cardiol, Albert-Schweitzer-Campus 1, A1, 48149 Muenster, Germany.

Introduction: Multiple studies have shown that left atrial (LA) enlargement is a strong predictor of poor outcome after catheter ablation of atrial fibrillation (AF). LA size is commonly approximated as the diameter in the parasternal long axis. It remains unknown whether more precise echocardiographic measurements of LA size allow for better correlation with outcome after pulmonary vein isolation (PVI).

Methods And Results: We performed a retrospective study of 131 consecutive patients (43 females, 60% paroxysmal AF, mean CHA2DS2-Vasc score 1.6, mean age 61 ± 12 years) referred for PVI. Measurements of the LA were carried out by a single observer in transthoracic echocardiograms (TTE) performed prior to ablation. We calculated diameter of the LA in the parasternal long axis (PLAX), LA area in the 2- as well as 4-Chamber (CH) view. LA volume was computed using the disc summation technique (LAV) and indexed to body surface area (LAVI). Procedural and follow-up data were gathered from a prospective AF database. Ablation was performed exclusively using the second generation cryoballoon by the same operators. Follow-up visits at 3, 6 and 12 months showed freedom from AF in 76%, 73% and 73% respectively. Mean values of LA calculations were LAPLAX: 37.9 mm ± 6.3 mm, 2CH area: 22.5 cm ± 6.7 cm, 4CH area: 21.4 cm ± 5.5 cm, LAV: 73.7 mL ± 26.1 mL and LAVI: 36.2 mL/m ± 12.7 mL/m, respectively. C statistic revealed the best concordance of LAVI with outcome after 12 months (C = 0.67), LAV also exhibited a satisfactory value (C = 0.61) in comparison to surfaces in 2CH (C = 0.59) and 4CH (C = 0.57). PLAX showed the worst correlation (C = 0.51). Additionally, different binary logistic regression models identified three independent predictors of AF outcome after cryoballoon PVI: gender (OR = 0.95 per year; = 0.01); LAV (OR = 1.3/10mL; = 0.02) and LAVI (OR = 1.58/10 mL/m; = 0.02). In all models, PLAX and area measurements were not predictive.

Conclusions: Our data add further to evidence that LA size lends itself well as a predictor of PVI outcome. LAVI and LAV were independently predictive of rhythm outcome after PVI. This did not hold true for more commonly used measurements, such as PLAX diameter and surfaces of the LA, irrespective of the view chosen.
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http://dx.doi.org/10.3390/jpm11090913DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8469525PMC
September 2021

Patient With Presyncope and Variable PR Interval and QRS Morphology.

JACC Case Rep 2021 Sep 1;3(11):1390-1392. Epub 2021 Sep 1.

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

We describe the case of a 72-year-old female patient, presenting with presyncope and variable PR Interval and changing QRS morphology on the electrocardiogram. Differential diagnosis is discussed. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.06.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8414434PMC
September 2021

Anticoagulation, therapy of concomitant conditions, and early rhythm control therapy: a detailed analysis of treatment patterns in the EAST - AFNET 4 trial.

Europace 2022 04;24(4):552-564

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

Aims: Treatment patterns were compared between randomized groups in EAST-AFNET 4 to assess whether differences in anticoagulation, therapy of concomitant diseases, or intensity of care can explain the clinical benefit achieved with early rhythm control in EAST-AFNET 4.

Methods And Results: Cardiovascular treatment patterns and number of visits were compared between randomized groups in EAST-AFNET 4. Oral anticoagulation was used in >90% of patients during follow-up without differences between randomized groups. There were no differences in treatment of concomitant conditions between groups. The type of rhythm control varied by country and centre. Over time, antiarrhythmic drugs were given to 1171/1395 (84%) patients in early therapy, and to 202/1394 (14%) in usual care. Atrial fibrillation (AF) ablation was performed in 340/1395 (24%) patients randomized to early therapy, and in 168/1394 (12%) patients randomized to usual care. 97% of rhythm control therapies were within class I and class III recommendations of AF guidelines. Patients randomized to early therapy transmitted 297 166 telemetric electrocardiograms (ECGs) to a core lab. In total, 97 978 abnormal ECGs were sent to study sites. The resulting difference between study visits was low (0.06 visits/patient/year), with slightly more visits in early therapy (usual care 0.39 visits/patient/year; early rhythm control 0.45 visits/patient/year, P < 0.001), mainly due to visits for symptomatic AF recurrences or recurrent AF on telemetric ECGs.

Conclusion: The clinical benefit of early, systematic rhythm control therapy was achieved using variable treatment patterns of antiarrhythmic drugs and AF ablation, applied within guideline recommendations.
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http://dx.doi.org/10.1093/europace/euab200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8982435PMC
April 2022
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