Publications by authors named "Lars Eckardt"

358 Publications

[Life-threatening cardiac arrhythmias].

Dtsch Med Wochenschr 2021 Jun 15;146(12):838-849. Epub 2021 Jun 15.

Cardiac arrhythmias are a common phenomenon and can be a challenge for the treating physicians in the acute situation. The article presents the different bradycardic and tachycardic cardiac arrhythmias and their treatment with practical advices for diagnosis.
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http://dx.doi.org/10.1055/a-1376-2680DOI Listing
June 2021

Bullet-associated ventricular tachycardia: a case report.

Eur Heart J Case Rep 2021 Apr 26;5(4):ytab101. Epub 2021 Apr 26.

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

Background: The majority of ventricular tachycardias (VTs) occurs in patients with structural heart disease and is associated with an increased risk of sudden cardiac death. These VT are scar-related and may develop in patients with ischaemic or non-ischaemic cardiomyopathies.

Case Summary: We describe a 44-year-old patient without any pre-existing cardiovascular disease, presenting with the first documentation of a haemodynamically unstable sustained fast VT with a cycle length of 250 ms. He reported a suicidal attempt with a self-made handgun aged 16 when he had shot himself in the thorax and had injured the myocardium. After presenting with the VT coronary artery disease was excluded through cardiac catheterization. A cardiovascular magnetic resonance study showed a localized myocardial scar in the left ventricular free wall starting from the subepicardium and correlating to the scar described 28 years ago by the thoracic surgeons. In an electrophysiological study, non-sustained VT were easily inducible. Presuming a causal relationship between the fast VT and the epicardial scar, a single-chamber implantable cardioverter-defibrillator was implanted and beta-blocker therapy was initiated.

Discussion: Scar-related VT often occur many years after an acute event, e.g. an acute myocardial infarction. This case highlights, that any cardiac trauma, even a superficial epicardial projectile-related damage with subsequent scarring, may cause a VT after many years and to our knowledge for the first time describes the occurrence of a VT due to mechanical damage to the myocardium by a gunshot.
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http://dx.doi.org/10.1093/ehjcr/ytab101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188868PMC
April 2021

Evaluation of subcutaneous implantable cardioverter-defibrillator performance in patients with ion channelopathies from the EFFORTLESS cohort and comparison with a meta-analysis of transvenous ICD outcomes.

Heart Rhythm O2 2020 Dec 28;1(5):326-335. Epub 2020 Oct 28.

Academic Medical Center, Amsterdam, Netherlands.

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) is an alternative to conventional transvenous ICD (TV-ICD) therapy to reduce lead complications.

Objective: To evaluate outcomes in channelopathy vs patients with structural heart disease in the EFFORTLESS-SICD Registry and with a previously reported TV-ICD meta-analysis in channnelopathies.

Methods: The EFFORTLESS registry includes 199 patients with channelopathies (Brugada syndrome 83, long QT syndrome 24, idiopathic ventricular fibrillation 78, others 14) and 786 patients with structural heart disease.

Results: Channelopathy patients were younger (39 ± 14 years vs 51 ± 17 years; < .001) with left ventricular ejection fraction 59% ± 9% vs 41% ± 18% ( < .001). The complication rate (follow-up: 3.2 ± 1.5 years vs 3.0 ± 1.5 years) was similar: 13.6% vs 11.2% ( = .42). Appropriate shocks rates were 9.5% vs 10.8% ( = .70), with shocks for monomorphic ventricular tachycardia being 2.0% vs 6.9% ( < .02) and for polymorphic ventricular tachycardia/ventricular fibrillation (VT/VF) 8.0% vs 5.7% ( = .30). Conversion effectiveness of VT/VF episodes was similar: 36 of 37 (97.3%) vs 151 of 155 (97.4%, = .59). VT/VF storm event (2% vs 0.9%,  = .33) and lower inappropriate shock (IAS) (8.5% vs 12.5%,  = .12) rates were statistically similar between channelopathy and non-channelopathy patients, with 45.5% channelopathy vs 31.4% non-channelopathy patients managed with a conditional zone > 200 beats per minute ( = .0002). Annualized appropriate shock, IAS, and complication rates appear to be lower for the S-ICD vs meta-analysis TV-ICD patients, particularly lead complications.

Conclusion: EFFORTLESS demonstrates similar S-ICD efficacy and a nonsignificant, lower rate of IAS in channelopathy patients as compared to structural heart disease. Comparable IAS rates were achieved with the device programmed to higher rates for channelopathy patients.
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http://dx.doi.org/10.1016/j.hroo.2020.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183957PMC
December 2020

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

Cardiac glycosides are not associated with increased mortality or hospitalization rates in ICD and CRT-ICD patients after adjustment for baseline-characteristics at one-year follow-up: Results from the German DEVICE registry.

Int J Cardiol 2021 Jun 1. Epub 2021 Jun 1.

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

Aims: Despite lacking supporting randomized trials, cardiac glycosides (CGs) are widely used in heart failure and/or atrial fibrillation. Moreover, several pro- and retrospective studies and registry-data have recently raised serious concerns in terms of efficacy and safety of CGs in this field. We have therefore examined the association between CGs and clinical outcome of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization (CRT-ICD) patients of the large German DEVICE registry.

Methods And Results: Between 2007 and 2014, 3782 ICD and 1529 CRT-ICD patients were enrolled in the German DEVICE registry. Those two groups were analyzed independently according to medication with or without CGs. After adjustment for patient characteristics, CGs were not significantly associated with increased one-year mortality (HR 1.27, 95%-CI 0.91-1.76, p = 0.162), major adverse cardiac and cerebrovascular events (OR 1.36, 95%-CI 0.98-1.89, p = 0.063), ICD-shocks (OR 1.29, 95%-CI 0.95-1.74, p = 0.104) or the need for rehospitalization in ICD patients at one-year-follow-up. Similar findings were obtained in CRT-ICD patients. Regarding possible determinants for glycoside treatment, atrial fibrillation at enrollment was found to be most strongly associated with the prescription of glycosides in ICD (adjusted OR 3.25, 95%-CI 2.63-4.02) and CRT-ICD patients (adjusted OR 3.17, 95%-CI 2.39-4.19).

Conclusion: Overall harmful effects of CGs in ICD- and CRT-ICD patients could not be confirmed in DEVICE. Further large and randomized-controlled trials that investigate dose-dependent effects of CGs in addition to contemporary therapy of heart failure and atrial fibrillation are needed.
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http://dx.doi.org/10.1016/j.ijcard.2021.05.047DOI Listing
June 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

The precordial R' wave: A novel discriminator between cardiac sarcoidosis and arrhythmogenic right ventricular cardiomyopathy in patients presenting with ventricular tachycardia.

Heart Rhythm 2021 May 3. Epub 2021 May 3.

Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands. Electronic address:

Background: Cardiac sarcoidosis (CS) with right ventricular (RV) involvement can mimic arrhythmogenic right ventricular cardiomyopathy (ARVC). Histopathological differences may result in disease-specific RV activation patterns detectable on the 12-lead electrocardiogram. Dominant subepicardial scar in ARVC leads to delayed activation of areas with reduced voltages, translating into terminal activation delay and occasionally (epsilon) waves with a small amplitude. Conversely, patchy transmural RV scar in CS may lead to conduction block and therefore late activated areas with preserved voltages reflected as preserved R' waves.

Objective: The purpose of this study was to evaluate the distinct terminal activation patterns in precordial leads V through V as a discriminator between CS and ARVC.

Methods: Thirteen patients with CS affecting the RV and 23 patients with gene-positive ARVC referred for ventricular tachycardia ablation were retrospectively included in a multicenter approach. A non-ventricular-paced 12-lead surface electrocardiogram was analyzed for the presence and the surface area of the R' wave (any positive deflection from baseline after an S wave) in leads V through V.

Results: An R' wave in leads V through V was present in all patients with CS compared to 11 (48%) patients with ARVC (P = .002). An algorithm including a PR interval of ≥220 ms, the presence of an R' wave, and the surface area of the maximum R' wave in leads V through V of ≥1.65 mm had 85% sensitivity and 96% specificity for diagnosing CS, validated in a second cohort (18 CS and 40 ARVC) with 83% sensitivity and 88% specificity.

Conclusion: An easily applicable algorithm including PR prolongation and the surface area of the maximum R' wave in leads V through V of ≥1.65 mm distinguishes CS from ARVC. This QRS terminal activation in precordial leads V through V may reflect disease-specific scar patterns.
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http://dx.doi.org/10.1016/j.hrthm.2021.04.032DOI Listing
May 2021

The impact of basic atrial rhythm during catheter ablation of atrial fibrillation on clinical outcomes: Lessons from the German Ablation Registry.

J Cardiovasc Electrophysiol 2021 May 5. Epub 2021 May 5.

Department of Cardiology, Universitäres Herz-und Gefäßzentrum Hamburg-Eppendorf, Hamburg, Germany.

Background: The impact of basic atrial rhythm (sinus rhythm [SR] vs. atrial fibrillation [AF]) during AF ablation on efficacy and safety is unknown.

Methods: About 3375 patients from the German Ablation Registry undergoing first-time AF ablation were divided according to the type of AF and the basic atrial rhythm during the ablation procedure: paroxysmal AF (PAF) and SR [group Ia], PAF and AF [group Ib]), persistent AF and SR (IIa), and persistent AF and AF (IIb).

Results: Patients in SR (n = 2312 [67%]) underwent cryoballoon ablation more often (Ia vs. Ib p = .002 and IIa vs. IIb p = .010, whereas in patients in AF (n = 1063 [33%]) radiofrequency (RF)-based ablation (Ia vs. Ib p = .006 and IIa vs. IIb p = .014) including left and/or right atrial substrate modification was more frequently performed. Depending on the basic rhythm there was no difference regarding arrhythmia recurrence during long-term follow-up. For patients suffering from persistent AF acute procedure-related complications were more often documented when ablated in AF (9.1% vs. 4.6%, p = .012). which was mainly driven by the higher occurrence of pericardial effusion/tamponade. For patients suffering from persistent AF, favorable results were found regarding 366-day Kaplan-Meier estimates of the incidence of MACCE (death, myocardial infarction, and stroke; p = .011) and the composite endpoint of death, myocardial infarction, stroke, and major bleeding (p = .006), when ablated in SR.

Conclusion: Basic atrial rhythm at the time of AF ablation did not affect long-term rhythm outcome. For patients suffering from persistent AF a more favorable acute and long-term safety profile was observed when ablated in SR.
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http://dx.doi.org/10.1111/jce.15072DOI Listing
May 2021

Cardiac Arrhythmias in Survivors of Sudden Cardiac Death Requiring Impella Assist Device Therapy.

J Clin Med 2021 Mar 31;10(7). Epub 2021 Mar 31.

Department of Cardiology, University Hospital Aachen, RWTH University Aachen, 52062 Aachen, Germany.

In this retrospective single-center trial, we analyze 109 consecutive patients (female: 27.5%, median age: 69 years, median left ventricular ejection fraction: 20%) who survived sudden cardiac death (SCD) and needed hemodynamic support from an Impella assist device between 2008 and 2018. Rhythm monitoring is investigated in this population and associations with hospital survival are analyzed. Hospital mortality is high, at 83.5%. Diverse cardiac arrhythmias are frequently registered during Impella treatment. These include atrial fibrillation (AF, 21.1%) and ventricular tachycardia (VT, 18.3%), as well as AV block II°/III° (AVB, 7.3%), while intermittent asystole (ASY) is the most frequently observed arrhythmia (42.2%). Nevertheless, neither ventricular nor supraventricular tachycardias are associated with patients' survival. In patients who experience intermittent asystole, a trend towards a fatal outcome is noted ( = 0.06). Conclusions: Mortality is high in these severely sick patients. While cardiac arrhythmias were frequent, they did not predict hospital mortality in this population. The hemodynamic support of the pump seems to counterbalance the adverse effects of these events.
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http://dx.doi.org/10.3390/jcm10071393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037009PMC
March 2021

[Cardiac arrhythmias in pregnancy : Epidemiology, clinical characteristics, and treatment options].

Authors:
Lars Eckardt

Herzschrittmacherther Elektrophysiol 2021 Jun 19;32(2):137-144. Epub 2021 Mar 19.

Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus1, Gebäude A1, 48149, Münster, Deutschland.

Symptomatic arrhythmias rarely occur during pregnancy and are predominantly benign. However, the increasing average age of women who are pregnant, especially in Western European countries, has contributed to a significant increase in arrhythmias in pregnant women in recent years. Previous or existing heart diseases can increase the occurrence of arrhythmias. In most cases pregnancy is safe and without consequences for the child and/or mother. Further cardiological work-up (including ECG and echocardiography, and possibly cardiac MRI) should always be performed. The indication for treatment should be made in close cooperation between obstetricians and cardiologists considering symptoms, hemodynamics and prognosis. In the absence of larger studies on efficacy and side effects of antiarrhythmic drugs, these should be administered very cautiously, under strict indication and whenever possible by avoiding the first trimester. Cardiologists with special expertise in arrhythmias should always be consulted, especially in the case of complex and relevant rhythm disturbances.
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http://dx.doi.org/10.1007/s00399-021-00752-9DOI Listing
June 2021

[Atrial and ventricular premature contractions-the "wolf in sheep's clothing"? : What is new, what is important, what to do?]

Authors:
Lars Eckardt

Herzschrittmacherther Elektrophysiol 2021 Mar;32(1):1-2

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

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http://dx.doi.org/10.1007/s00399-021-00747-6DOI Listing
March 2021

Impella use in real-world cardiogenic shock patients: Sobering outcomes.

PLoS One 2021 26;16(2):e0247667. Epub 2021 Feb 26.

Division of Cardiology, Hospital Maria Hilf Mönchengladbach, Mönchengladbach, Germany.

Background: Critically ill patients with cardiogenic shock could benefit from ventricular assist device support using the Impella microaxial blood pump. However, recent studies suggested Impella not to improve outcomes. We, therefore, evaluated outcomes and predictors in a real-world scenario.

Methods: In this retrospective single-center trial, 125 patients suffering from cardiac arrest/cardiogenic shock between 2008 and 2018 were analyzed. 93 Patients had a prior successful cardiopulmonary resuscitation. The primary endpoint was hospital mortality. Associations of covariates with the primary endpoint were assessed by univariable and multivariable logistic regression. Adjusted odds ratios (aOR) and optimal cut-offs (using Youden index) were obtained.

Results: Hospital mortality was high (81%). Baseline lactate was 4.7mmol/L [IQR = 7.1mmol/L]. In multivariable logistic regression, only age (aOR 1.13 95%CI 1.06-1.20; p<0.001) and lactate (aOR 1.23 95%CI 1.004-1.516; p = 0.046) were associated with hospital mortality, and the respective optimal cut-offs were >3.3mmol/L and age >66 years. Patients were retrospectively stratified into three risk groups: Patients aged ≤66 years and lactate ≤3.3mmol (low-risk; n = 22); patients aged >66 years or lactate >3.3mmol/L (medium-risk; n = 52); and patients both aged >66 years and lactate >3.3mmol/L (high-risk, n = 51). Risk of death increased from 41% in the low-risk group, to 79% in the medium risk group and 100% in the high-risk group. The predictive abilities of this model were high (AUC 0.84; 95% 0.77-0.92).

Conclusion: Mortality was high in this real-world collective of severely ill cardiogenic shock patients. Better patient selection is warranted to avoid unethical use of Impella. Age and lactate might help to improve patient selection.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247667PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909706PMC
February 2021

Dynamic risk assessment to improve quality of care in patients with atrial fibrillation: the 7th AFNET/EHRA Consensus Conference.

Europace 2021 Mar;23(3):329-344

Atrial Fibrillation NETwork (AFNET), Münster, Germany.

Aims: The risk of developing atrial fibrillation (AF) and its complications continues to increase, despite good progress in preventing AF-related strokes.

Methods And Results: This article summarizes the outcomes of the 7th Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA) held in Lisbon in March 2019. Sixty-five international AF specialists met to present new data and find consensus on pressing issues in AF prevention, management and future research to improve care for patients with AF and prevent AF-related complications. This article is the main outcome of an interactive, iterative discussion between breakout specialist groups and the meeting plenary. AF patients have dynamic risk profiles requiring repeated assessment and risk-based therapy stratification to optimize quality of care. Interrogation of deeply phenotyped datasets with outcomes will lead to a better understanding of the cardiac and systemic effects of AF, interacting with comorbidities and predisposing factors, enabling stratified therapy. New proposals include an algorithm for the acute management of patients with AF and heart failure, a call for a refined, data-driven assessment of stroke risk, suggestions for anticoagulation use in special populations, and a call for rhythm control therapy selection based on risk of AF recurrence.

Conclusion: The remaining morbidity and mortality in patients with AF needs better characterization. Likely drivers of the remaining AF-related problems are AF burden, potentially treatable by rhythm control therapy, and concomitant conditions, potentially treatable by treating these conditions. Identifying the drivers of AF-related complications holds promise for stratified therapy.
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http://dx.doi.org/10.1093/europace/euaa279DOI Listing
March 2021

Proarrhythmic potential of metoclopramide in a sensitive whole-heart model.

Basic Clin Pharmacol Toxicol 2021 Jun 25;128(6):741-746. Epub 2021 Feb 25.

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

Background: Metoclopramide (MCP) is a dopamine D -receptor antagonist, mainly used to treat post-operative or chemotherapy-induced nausea. While it is very effective in the cure of gastric symptoms, MCP can cause severe neurologic side effects. Furthermore, there is growing evidence for severe arrhythmic side effects resulting from inhibitory effects on cardiac sodium and potassium channels.

Methods And Results: Thirteen hearts of New Zealand white rabbits were retrogradely perfused, and electrophysiology studies were performed to obtain action potential duration (APD ) and effective refractory period (ERP). After generating baseline data, the hearts were perfused with increasing concentrations of metoclopramide (MCP 10 µM, MCP 50 µM, MCP 100 µM) and the standardized protocol was repeated for each concentration. Perfusion with MCP resulted in a significant prolongation of APD and QT interval. In parallel, the incidence of ventricular tachycardias was significantly increased by high doses of MCP.

Conclusion: This is the first experimental study that investigated the effect of increasing doses of metoclopramide on a sensitive whole-heart model of proarrhythmia. MCP led to a significant increase in action potential duration and QT interval; meanwhile, the number of ventricular tachycardias was significantly increased.
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http://dx.doi.org/10.1111/bcpt.13567DOI Listing
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

Effects of genetic background, sex, and age on murine atrial electrophysiology.

Europace 2021 Jun;23(6):958-969

Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.

Aims: Genetically altered mice are powerful models to investigate mechanisms of atrial arrhythmias, but normal ranges for murine atrial electrophysiology have not been robustly characterized.

Methods And Results: We analyzed results from 221 electrophysiological (EP) studies in isolated, Langendorff-perfused hearts of wildtype mice (114 female, 107 male) from 2.5 to 17.7 months (mean 7 months) with different genetic backgrounds (C57BL/6, FVB/N, MF1, 129/Sv, Swiss agouti). Left atrial monophasic action potential duration (LA-APD), interatrial activation time (IA-AT), and atrial effective refractory period (ERP) were summarized at different pacing cycle lengths (PCLs). Factors influencing atrial electrophysiology including genetic background, sex, and age were determined. LA-APD70 was 18 ± 0.5 ms, atrial ERP was 27 ± 0.8 ms, and IA-AT was 17 ± 0.5 ms at 100 ms PCL. LA-APD was longer with longer PCL (+17% from 80 to 120 ms PCL for APD70), while IA-AT decreased (-7% from 80 to 120 ms PCL). Female sex was associated with longer ERP (+14% vs. males). Genetic background influenced atrial electrophysiology: LA-APD70 (-20% vs. average) and atrial ERP (-25% vs. average) were shorter in Swiss agouti background compared to others. LA-APD70 (+25% vs. average) and IA-AT (+44% vs. average) were longer in 129/Sv mice. Atrial ERP was longer in FVB/N (+34% vs. average) and in younger experimental groups below 6 months of age.

Conclusion: This work defines normal ranges for murine atrial EP parameters. Genetic background has a profound effect on these parameters, at least of the magnitude as those of sex and age. These results can inform the experimental design and interpretation of murine atrial electrophysiology.
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http://dx.doi.org/10.1093/europace/euaa369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184223PMC
June 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

Role of the rabbit whole-heart model for electrophysiologic safety pharmacology of non-cardiovascular drugs.

Europace 2021 Jun;23(6):828-836

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

Plenty of non-cardiovascular drugs alter cardiac electrophysiology and may ultimately lead to life-threatening arrhythmias. In clinical practice, measuring the QT interval as a marker for the repolarization period is the most common tool to assess the electrophysiologic safety of drugs. However, the sole measurement of the QT interval may be insufficient to determine the proarrhythmic risk of non-cardiovascular agents. Several other markers are considered in pre-clinical safety testing to determine potential harm on cardiac electrophysiology. Besides measuring typical electrophysiologic parameters such as repolarization duration, whole-heart models allow the determination of potential predictors for proarrhythmia. Spatial and temporal heterogeneity as well as changes of shape of the action potential can be easily assessed. In addition, provocation manoeuvers (either by electrolyte imbalances or programmed pacing protocols) may induce sustained arrhythmias and thereby determine ventricular vulnerability to arrhythmias. Compared with the human heart, the rabbit heart possesses a similar distribution of ion currents that govern cardiac repolarization, resulting in a rectangular action potential configuration in both species. In addition, similar biophysical properties of rabbit and human cardiac ion channels lead to a comparable pharmacologic response in human and rabbit hearts. Of note, arrhythmia patterns resemble in both species due to the similar effective size of human and rabbit hearts. Thus, the rabbit heart is particularly suitable for testing the electrophysiologic safety of drugs. Several experimental setups have been developed for studying cardiac electrophysiology in rabbits, ranging from single cell to tissue preparations, whole-heart setups, and in vivo models.
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http://dx.doi.org/10.1093/europace/euaa288DOI Listing
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

Divergent Electrophysiological Effects of Loperamide and Naloxone in a Sensitive Whole-Heart Model.

Cardiovasc Toxicol 2021 Mar 30;21(3):248-254. Epub 2020 Oct 30.

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

Several case reports suggest QT prolongation leading to ventricular arrhythmias with fatal outcome after intoxication with the μ-opioid receptor agonist and anti-diarrheal agent loperamide. The number of cases of loperamide misuse are growing due to its potential stimulating effects. Loperamide intoxications can be treated by naloxone. However, previous reports described a further QT prolongation associated with naloxone administration. Therefore, the aim of this study was to investigate the effects of loperamide and naloxone on the cardiac electrophysiology in a sensitive whole-heart model. Twenty-six hearts of New Zealand White rabbits were retrogradely perfused in a modified Langendorff apparatus. Monophasic action potentials were recorded by endo- and epicardially positioned catheters. Hearts were stimulated at different cycle lengths, thereby obtaining action potential duration at 90% of repolarization (APD) and QT intervals. Programmed ventricular stimulation was used to assess ventricular vulnerability. Fourteen hearts were perfused with ascending concentrations of loperamide (0.2 μM, 0.35 μM, and 0.5 μM) after obtaining baseline data. Another 12 hearts were treated with naloxone (0.1 μM, 0.5 μM, 2 μM). Loperamide led to a significant increase in QT interval, APD, and ventricular tachycardia (VT) episodes. In contrast, naloxone led to a decrease in QT interval and APD. Accordingly, the number of VT episodes was unaltered. To the best of our knowledge, this is the first experimental study that investigated the effects of loperamide and naloxone in a whole-heart model. Loperamide led to a significant increase in action potential duration and QT interval. Simultaneously, the number of ventricular tachycardias was significantly increased. In contrast, naloxone led to a shortening of the action potential duration without altering arrhythmia susceptibility.
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http://dx.doi.org/10.1007/s12012-020-09616-zDOI Listing
March 2021

Safety and patient-reported outcomes in index ablation versus repeat ablation in atrial fibrillation: insights from the German Ablation Registry.

Clin Res Cardiol 2021 Jun 28;110(6):841-850. Epub 2020 Oct 28.

Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.

Background: Pulmonary vein isolation is an established strategy for catheter ablation of atrial fibrillation (AF). However, in a significant number of patients, a repeat procedure is mandatory due to arrhythmia recurrence. In this study, we report safety data and procedural details of patients undergoing index ablation versus repeat ablation in a registry-based real-life setting.

Methods: Patients from the German Ablation Registry, a prospective, multicentre registry of patients undergoing ablation between January 2007 and January 2010 were included.

Results: A total of 4155 patients were enrolled in the study. Group I (index ablation) consisted of 3377/4155 (82.1%) and group II (repeat ablation) of 738/4155 (17.9%). Patients in group I had a significantly higher ratio of paroxysmal AF (69.3% vs 61.9%, p < 0.001) and significantly less persistent AF (30.7% vs 38.1%, p < 0.001). The repeat group showed significantly lower mean RF application duration (2580 s. vs 1960, p < 0.001), less fluoroscopy time (29 min. vs. 27 min., p < 0.001), less mean dose area product (DAP) (3744 cGy × cm vs 3325 cGy × cm, p = 0.001), and shorter study duration (181.2 min. vs 163.6 min., p < 0.001). No statistical difference between the groups was found in terms of mortality (0.3% vs 0.1%, p = 0.39), MACE (0.4% vs 0.3%, p = 0.58), MACCE (0.8% vs 0.6%, p = 0.47), composite safety endpoint (1.5% vs 1.4%, p = 0.76), and arrhythmia recurrence (43.8% vs 41.9%, p = 0.37) during 1-year follow-up. Both groups reported to have improved or no symptoms (80.4% vs 77.8%, p = 0.13).

Conclusion: Repeat catheter ablation is safe and provides a symptomatic relief comparable to index ablation. Repeat procedures are significantly shorter and use less fluoroscopy.
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http://dx.doi.org/10.1007/s00392-020-01763-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166687PMC
June 2021

Clinical risk predictors in atrial fibrillation patients following successful coronary stenting: ENTRUST-AF PCI sub-analysis.

Clin Res Cardiol 2021 Jun 24;110(6):831-840. Epub 2020 Oct 24.

Department of Cardiology and Intensive Care, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Hasselt, Belgium.

Aims: This subgroup analysis of the ENTRUST-AF PCI trial (ClinicalTrials.gov Identifier: NCT02866175; Date of registration: August 2016) evaluated type of AF, and CHADS-VASc score parameters as predictors for clinical outcome.

Methods: Patients were randomly assigned after percutaneous coronary intervention (PCI) to either edoxaban (60 mg/30 mg once daily [OD]; n = 751) plus a P2Y inhibitor for 12 months or a vitamin K antagonist [VKA] (n = 755) plus a P2Y inhibitor and aspirin (100 mg OD, for 1-12 months). The primary outcome was a composite of major/clinically relevant non-major bleeding (CRNM) within 12 months. The composite efficacy endpoint consisted of cardiovascular death, stroke, systemic embolic events, myocardial infarction (MI), and definite stent thrombosis.

Results: Major/CRNM bleeding event rates were 20.7%/year and 25.6%/year with edoxaban and warfarin, respectively (HR [95% CI]: 0.83 [0.654-1.047]). The event rates of composite outcome were 7.26%/year and 6.86%/year, respectively (HR [95% CI]): 1.06 [0.711-1.587]), and of overall net clinical benefit were 12.48%/year and 12.80%/year, respectively (HR [(95% CI]: 0.99 [(0.730; 1.343]). Increasing CHADS-VASc score was associated with increased rates of all outcomes. CHADS-VASc score ≥ 5 was a marker for stent thrombosis. Paroxysmal AF was associated with a higher occurrence of MI (4.87% versus 2.01%, p = 0.0024).

Conclusion: After PCI in AF patients, increasing CHADS-VASc score was associated with increased bleeding rates and CHADS-VASc score (≥ 5) predicted the occurrence of stent thrombosis. Paroxysmal AF was associated with MI. These findings may have important clinical implications in AF patients.
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http://dx.doi.org/10.1007/s00392-020-01760-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166657PMC
June 2021

Antiarrhythmic Effect of Ranolazine in Combination with Selective NCX-Inhibition in an Experimental Model of Atrial Fibrillation.

Pharmaceuticals (Basel) 2020 Oct 20;13(10). Epub 2020 Oct 20.

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

The aim of this study was to investigate the effects of a combination of ranolazine with different selective inhibitors of the Na/Ca-exchanger (NCX) in an established experimental model of atrial fibrillation (AF). Eighteen hearts of New Zealand white rabbits were retrogradely perfused. Atrial catheters were used to record monophasic action potentials (aPRR). Hearts were paced at three different cycle lengths. Thereby, atrial action potential durations (aAPD), atrial effective refractory periods (aERP) and atrial post-repolarization refractoriness were obtained. Isoproterenol and acetylcholine were employed to increase the occurrence of AF. Thereafter, the hearts were assigned to two groups = 9 each group) and additionally perfused with a combination of 10 µM ranolazine and 1 µM of the selective NCX-inhibitor ORM-10103 (group A: Rano-ORM) or 10 µM ranolazine and 1 µM of another NCX-inhibitor, SEA0400 (group B: Rano-SEA). The infusion of Iso/ACh led to a shortening of aAPD, aERP, aPRR and the occurrence of AF episodes was significantly increased. Additional perfusion with ranolazine and ORM-10103 (group A) significantly prolonged the refractory periods and aPRR and AF episodes were effectively reduced. In group B, Rano-SEA led to a slight decrease in aAPD while aERP and aPRR were prolonged. The occurrence of AF episodes was consecutively reduced. To our knowledge, this is the first study investigating the effect of ranolazine combined with different selective NCX-inhibitors in an isolated whole-heart model of AF. Both combinations prolonged aERP and aPRR and thereby suppressed the induction of AF.
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http://dx.doi.org/10.3390/ph13100321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7589655PMC
October 2020

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

Distribution and impact of age in patients with implantable cardioverter-defibrillators regarding early complications and 1-year clinical outcome: results from the German Device Registry.

J Interv Card Electrophysiol 2020 Sep 22. Epub 2020 Sep 22.

Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg- Essen, Essen, Germany.

Background: Patients receiving implantable-cardioverter-defibrillators (ICD) in clinical practice are often older or younger than in clinical trials. Whether older patients benefit from ICD-therapy in a similar way as younger patients is under debate. The objective of this study was to provide real-world data regarding outcomes with respect to age in a large cohort in the German Device Registry.

Methods: Within the registry data from 50 German centers were collected between January 2007 and February 2014.

Results: Our analysis included 3239 ICD patients representing a group of young (28%; group I: < 58 years), intermediate aged (50%; group II: 58-74 years), and elderly patients (22%; group III: 75-92 years). Intergroup comparison of all groups was performed followed by individual comparison vs. group II serving as age-reference group. Procedure-related complications did not differ between all groups. Analysis of the primary endpoint, 1-year all-cause mortality, revealed an increased mortality in the elderly and a decreased mortality in the young cohort vs. the reference group II (group I 2.1%, group II 6.2%, group III 13.2%; p < 0.001). While all-cause rehospitalizations did not differ, we observed a difference in reported device revisions showing more device revisions required in younger patients (group I 8.9%, group II 6.8%, group III 4.0%; p = 0.001).

Conclusions: One-year mortality was doubled in elderly ICD patients probably due to non-cardiac causes. These results further underpin the need for re-evaluating the primary prevention ICD indication in octo- and nonagenarians. Young patients show lower mortality rates but seem to bear higher risk of device-related complications, which highlights the need for improved measures to reduce device-related complications in the young.
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http://dx.doi.org/10.1007/s10840-020-00876-xDOI Listing
September 2020

The ECG in sarcoidosis - a marker of cardiac involvement? Current evidence and clinical implications.

J Cardiol 2021 Feb 8;77(2):154-159. Epub 2020 Sep 8.

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

Sarcoidosis is a multisystem granulomatous disease of unknown etiology characterized by noncaseating granulomas. Cardiac involvement is often limiting patients' prognosis. Cardiac sarcoidosis can manifest with variant cardiac arrhythmias, of which atrioventricular (AV)-block-related bradycardia and ventricular tachycardias are the most common. Although cardiac sarcoidosis remains a histopathological diagnosis, the significance of imaging modalities, especially cardiac magnetic resonance imaging is increasing rapidly but mainly remains reserved for patients with a high suspicion due to a previous arrhythmia or unknown cardiomyopathy. Thus, there is a need for screening in daily clinical practice so that possible characteristic electrocardiographic (ECG) findings may guide the way to detect the disease. We therefore evaluated the ECG as a potential tool for screening of cardiac sarcoidosis and present different electrophysiological manifestations of cardiac sarcoidosis based on a literature review. The ECG is a valuable tool for screening of cardiac involvement in patients with sarcoidosis. Several parameters have been shown to be associated with cardiac involvement in sarcoidosis such as higher-degree AV-block, QRS complex fragmentation and widening, as well as certain T wave abnormalities that may indicate cardiac involvement, of which the latter two are most promising and specific. However, prospective studies examining a large number of trials are desirable.
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http://dx.doi.org/10.1016/j.jjcc.2020.07.006DOI Listing
February 2021

Outcomes of ablation in Wolff-Parkinson-White-syndrome: Data from the German Ablation Registry.

Int J Cardiol 2021 01 2;323:106-112. Epub 2020 Sep 2.

Department of Medicine I, University Hospital, LMU Munich, Germany; German Centre for Cardiovascular Research (DZHK); Partner Site: Munich Heart Alliance, Munich, Germany. Electronic address:

Aims: Catheter ablation is recommended for symptomatic WPW-syndrome. Commonly perceived low recurrence rates were challenged recently. We sought to identify patient strata at increased risk.

Method: Of 12,566 patients enrolled at 52 German Ablation Registry sites from 2007 to 2010, 789 were treated for WPW-syndrome. Patients were included for symptomatic palpitations and tachycardia documentation. Follow-up duration was one year. Overall complications were defined as serious, access-related, and ablation-related. We adjudicated WPW-recurrence for re-ablation during follow-up. Risk strata included: admission for repeat ablation at registry entry; accessory pathway localization; antiarrhythmic medical treatment before the ablation.

Results: WPW-syndrome patients were 42.8 ± 16.2 years on average; 39.9% were women. A majority of 95.9% was symptomatic; in 84.4%, a tachycardia was documented. Seventy-six (9.6%) patients presented for repeat procedures. Accessory pathways were located in the left atrium (71.4%), right atrium (21.1%), septum (4.4%), or coronary sinus diverticula (2.1%). Prior antiarrhythmic medication was used in 43.7% of patients. No serious events occurred. The overall complication rate was 2.5% (ablation related 1.2%, access-related 1.3%). Major determinants for complications were presentation for re-ablation as registry index procedure (6.9% vs 2.2%; p = 0.016) and septal pathway location (left 2.0% vs septal 9.1%, p = 0.014). The overall re-ablation rate was 9.7%. Usage of prior antiarrhythmic medication was associated with higher recurrence rates (12.2% vs. 7.6%; p = 0.035).

Conclusions: Patients at higher complication risk may be identified by repeat procedure and septal pathway location. Prior antiarrhythmic medication was associated with higher recurrence rates. Our findings may help improving peri-procedural patient management and information.
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http://dx.doi.org/10.1016/j.ijcard.2020.08.102DOI Listing
January 2021