Publications by authors named "Tamas Szili-Torok"

176 Publications

Comparison of procedural efficacy and biophysical parameters between two competing cryoballoon technologies for pulmonary vein isolation: Insights from an initial multicenter experience.

J Cardiovasc Electrophysiol 2021 Mar 1;32(3):580-587. Epub 2021 Feb 1.

Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Karlsruhe, Germany.

Introduction: Recently a novel cryoballoon system (POLARx, Boston Scientific) became available for the treatment of atrial fibrillation. This cryoballoon is comparable with Arctic Front Advance Pro (AFA-Pro, Medtronic), however, it maintains a constant balloon pressure. We compared the procedural efficacy and biophysical characteristics of both systems.

Methods: One hundred and ten consecutive patients who underwent first-time cryoballoon ablation (POLARx: n = 57; AFA-Pro: n = 53) were included in this prospective cohort study.

Results: Acute isolation was achieved in 99.8% of all pulmonary veins (POLARx: 99.5% vs. AFA-Pro: 100%, p = 1.00). Total procedure time (81 vs. 67 min, p < .001) and balloon in body time (51 vs. 35 min, p < .001) were longer with POLARx. After a learning curve, these times were similar. Cryoablation with POLARx was associated with shorter time to balloon temperature -30°C (27 vs. 31 s, p < .001) and -40°C (32 vs. 54 s, p < .001), lower balloon nadir temperature (-55°C vs. -47°C, p < .001), and longer thawing time till 0°C (16 vs. 9 s, p < .001). There were no differences in time-to-isolation (TTI; POLARx: 45 s vs. AFA-Pro 43 s, p = .441), however, POLARx was associated with a lower balloon temperature at TTI (-46°C vs. -37°C, p < .001). Factors associated with acute isolation differed between groups. The incidence of phrenic nerve palsy was comparable (POLARx: 3.5% vs. AFA-Pro: 3.7%).

Conclusion: The novel cryoballoon is comparable to AFA-Pro and requires only a short learning curve to get used to the slightly different handling. It was associated with faster cooling rates and lower balloon temperatures but TTI was similar to AFA-Pro.
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http://dx.doi.org/10.1111/jce.14915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986676PMC
March 2021

Incremental Value of an Insertable Cardiac Monitor in Patients with Hypertrophic Cardiomyopathy with Low or Intermediate Risk for Sudden Cardiac Death.

Cardiology 2021 21;146(2):207-212. Epub 2021 Jan 21.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,

Aims: The aim of the present study was to compare the rate of actionable arrhythmic events between patients with hypertrophic cardiomyopathy (HCM) who are monitored with an insertable cardiac monitor (ICM) or Holter monitoring.

Methods: We studied 50 patients (mean age 52 years, 72% men) with HCM at low or intermediate risk for sudden cardiac death (SCD), of whom 25 patients received an ICM between November 2014 and February 2019. We retrospectively identified a control group of 25 patients who were matched on age, sex, and HCM Risk-SCD score category. The mean HCM Risk-SCD score was 3.41 ± 1.31 and 3.31 ± 1.43 for the ICM and Holter groups, respectively. The primary endpoint was an actionable event which was defined as an arrhythmic event resulting in a change in patient management. The secondary endpoint was the occurrence of ventricular tachycardia (VT).

Results: The cumulative actionable event rate at 30 months was higher in the ICM group (51 vs. 27%, log-rank p value <0.01). De novo atrial fibrillation requiring oral anticoagulation occurred only in the ICM group (n = 3). Overall, 4 implantable cardioverter-defibrillators were implanted for primary prevention (n = 2 in each group). The cumulative rate of VT episodes at 30 months was similar between groups (23% [ICM group] vs. 42% [Holter group], log-rank p value = 0.71). Furthermore, the characteristics of VT were similar between groups with regard to the number of beats and rate.

Conclusions: In adults with HCM, an ICM will detect more arrhythmic events requiring an intervention than a conventional Holter strategy. In contrast, the diagnostic yield of detecting VT seems similar for both groups.
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http://dx.doi.org/10.1159/000512656DOI Listing
January 2021

First Expert Evaluation of a New Steerable Catheter in an Isolated Beating Heart.

Cardiovasc Eng Technol 2020 Dec 18;11(6):769-782. Epub 2020 Nov 18.

BioMechanical Engineering, Delft University of Technology, Delft, Zuid-Holland, The Netherlands.

Purpose: In previous studies we developed two mechanical prototypes of steerable catheters: the Sigma, which uses joysticks to actuate two steerable tip segments, and the Epsilon, which has a handle that is an enlarged version of the tip. In this study, we present a first performance evaluation of the prototypes in the cardiac environment. The evaluation was carried out by an expert user, an electrophysiologist with over 20 years of experience, to obtain insight in clinically relevant factors.

Methods: Two experiments were conducted. In the first experiment, the Sigma was used in a passive beating heart setup connected to pumps with a saline solution and camera visualization, and compared with the expert's past experience with conventional steerable catheters. In the second experiment, the Sigma was used in an active beating heart setup with blood perfusion through the coronary arteries and echo visualization, and compared with the Epsilon prototype. The prototype was evaluated through questionnaires on task performance, catheter usability, and workload. After each of the experiments, the catheter characteristics were evaluated via a survey and followed by an in-depth interview.

Results & Conclusions: The expert user found the passive beating heart setup to more successful than the active beating heart setup for the purpose of this experiment, with insightful visualization while the heart was in beating condition. The steerability of the prototypes was experienced as useful and clinically relevant. Based on the questionnaires and interview we were able to identify future design improvements and developments for the steerable catheter prototypes.
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http://dx.doi.org/10.1007/s13239-020-00499-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7782459PMC
December 2020

Efficacy and safety of direct oral anticoagulants in patients undergoing elective electrical cardioversion: A real-world patient population.

Int J Cardiol 2021 Mar 2;326:98-102. Epub 2020 Nov 2.

The Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.

Background: Direct oral anticoagulants (DOACs) have emerged as the preferred choice of oral anticoagulation in patients with atrial fibrillation. Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing electrical cardioversion (ECV); however, there is limited real-world data.

Objective: To evaluate the outcome of patients undergoing an elective ECV for atrial tachyarrhythmia in a tertiary referral center who were treated with DOAC or vitamin K antagonist (VKA) without routine trans esophageal echocardiography (TEE).

Methods: This was a retrospective single-center cohort study of consecutive patients undergoing an elective ECV for atrial tachyarrhythmia from January 2013 to February 2020. The primary endpoints were thromboembolism (composite of stroke, transient ischemic attack or systemic embolism) and major bleeding events within 60 days.

Results: A total of 1431 ECV procedures were performed in 920 patients. One-third of the procedures were performed under DOAC (N = 488, 34%) and the remainder of the procedures was performed under VKA (N = 943, 66%). There were no differences between groups with regard to demographic variables (mean age 62.4 ± 11.7, 72% men) and mean CHADS-VASc score (2.3 ± 1.6); however, the VKA group had a higher proportion of patients with co-morbidity. Thromboembolism occurred in 0.41% in the DOAC group versus 0.64% in the VKA group (P = 0.72). Major bleeding events occurred in 0.41% in the DOAC group versus 0.11% in the VKA group (P = 0.27).

Conclusion: In a real-world population, the rates of thromboembolism and major bleeding events were low after elective ECV in patients using DOAC or VKA, even without routine TEE.
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http://dx.doi.org/10.1016/j.ijcard.2020.10.070DOI Listing
March 2021

Efficacy and safety of transvenous lead extraction using a liberal combined superior and femoral approach.

J Interv Card Electrophysiol 2020 Oct 7. Epub 2020 Oct 7.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.

Purpose: During transvenous lead extraction (TLE), the femoral snare has mainly been used as a bail-out procedure. The purpose of the present study is to evaluate the efficacy and safety of a TLE approach with a low threshold to use a combined superior and femoral approach.

Methods: This is a single-center observational study including all TLE procedures between 2012 till 2019.

Results: A total of 264 procedures (median age 63 (51-71) years, 67.0% male) were performed in the study period. The main indications for TLE were lead malfunction (67.0%), isolated pocket infection (17.0%) and systemic infection (11.7%). The median dwelling time of the oldest targeted lead was 6.8 (4.0-9.7) years. The techniques used to perform the procedure were the use of a femoral snare only (30%), combined rotational powered sheath and femoral snare (25%), manual traction only (20%), rotational powered sheath only (17%) and locking stylet only (8%). The complete and clinical procedural success rate was 90.2% and 97.7%, respectively, and complete lead removal rate was 94.1% of all targeted leads. The major and minor procedure-related complication rates were 1.1% and 10.2%, respectively. There was one case (0.4%) of emergent sternotomy for management of cardiac avulsion. Furthermore, there were 5 in-hospital non-procedure-related deaths (1.9%), of whom 4 were related to septic shock due to a Staphylococcus aureus endocarditis after an uncomplicated TLE with complete removal of all leads.

Conclusion: An effective and safe TLE procedure can be achieved by using the synergy between a superior and femoral approach.
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http://dx.doi.org/10.1007/s10840-020-00889-6DOI Listing
October 2020

Emerging electromagnetic interferences between implantable cardioverter-defibrillators and left ventricular assist devices: Authors' reply.

Europace 2020 12;22(12):1911-1912

Department of Cardiology, Thorax Center, Erasmus Medical Center, Room RG 431, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.

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http://dx.doi.org/10.1093/europace/euaa240DOI Listing
December 2020

Elimination of Benign Ventricular Premature Beats or Ventricular Tachycardia with Catheter Ablation versus Two Different Optimal Antiarrhythmic Drug Treatment Regimens (Sotalol or Verapamil/Flecainide).

Cardiology 2020 25;145(12):795-801. Epub 2020 Aug 25.

Isala Heart Center, Zwolle, The Netherlands,

Background: Symptomatic idiopathic ventricular arrhythmias (VA), including premature beats (VPB) and nonsustained ventricular tachycardia (VT) are commonly encountered arrhythmias. Although these VA are usually benign, their treatment can be a challenge to primary and secondary health care providers. Mainstay treatment is comprised of antiarrhythmic drugs (AAD) and, in case of drug intolerance or failure, patients are referred for catheter ablation to tertiary health care centers. These patients require extensive medical attention and drug regimens usually have disappointing results. A direct comparison between the efficacy of the most potent AAD and primary catheter ablation in these patients is lacking. The ECTOPIA trial will evaluate the efficacy of 2 pharmacological strategies and 1 interventional approach to: suppress the VA burden, improve the quality of life (QoL), and safety.

Hypothesis: We hypothesize that flecainide/verapamil combination and catheter ablation are both superior to sotalol in suppressing VA in patients with symptomatic idiopathic VA.

Study Design: The Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment (ECTOPIA) trial is a randomized, multicenter, prospective clinical trial to compare the efficacy of catheter ablation versus optimal AAD treatment with sotalol or flecainide/verapamil. One hundred eighty patients with frequent symptomatic VA in the absence of structural heart disease or underlying cardiac ischemia who are eligible for catheter ablation with an identifiable monomorphic VA origin with a burden ≥5% on 24-h ambulatory rhythm monitoring will be included. Patients will be randomized in a 1:1:1 fashion. The primary endpoint is defined as >80% reduction of the VA burden on 24-h ambulatory Holter monitoring. After reaching the primary endpoint, patients randomized to one of the 2 AAD arms will undergo a cross-over to the other AAD treatment arm to explore differences in drug efficacy and QoL in individual patients. Due to the use of different AAD (with and without β-blocking characteristics) we will be able to explore the influence of alterations in sympathetic tone on VA burden reduction in different subgroups. Finally, this study will assess the safety of treatment with 2 different AAD and ablation of VA.
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http://dx.doi.org/10.1159/000509661DOI Listing
August 2020

Extensive scar modification for the treatment of intra-atrial re-entrant tachycardia in patients after congenital heart surgery.

Cardiol Young 2020 Sep 23;30(9):1231-1237. Epub 2020 Jul 23.

Department of Clinical Electrophysiology, Erasmus Medical Center, Rotterdam, The Netherlands.

Background: Catheter ablation is an important therapeutic option for atrial tachycardias in patients with CHD. As a result of extensive scarring and surgical repair, multiple intra-atrial re-entrant tachycardia circuits develop and serve as a substrate for arrhythmias. The best ablation approach for patients with multiple intra-atrial re-entrant tachycardias has not been investigated. Here, we compared substrate-based ablation using extensive scar modification to conventional ablation.

Methods: The present study included patients with surgically corrected CHD that underwent intra-atrial re-entrant tachycardia ablation. Extensive scar modification was defined as substrate ablation based on a dense voltage map, aimed to eliminate all potentials in the scar region. The control group had activation mapping-based ablation. A clinical composite endpoint was assessed. Points were given for type, number, and treatment of intra-atrial re-entrant tachycardia recurrence.

Results: In 40 patients, 63 (extensive scar modification 13) procedures were performed. Acute procedural success was achieved in 78%. Procedural duration was similar in both groups. Forty-nine percent had a recurrence within 1 year. During a 5-year follow-up (2.5-7.5 years), 46% required repeat catheter ablation. Compared to baseline, clinical composite endpoint significantly decreased by 46% after 12 months (p = 0.001). Acute procedural success, procedural parameters, recurrence and repeat ablation were similar between extensive scar modification and activation mapping-based ablation.

Conclusion: Catheter ablation using extensive scar modification for intra-atrial re-entrant tachycardias occurring after surgically corrected CHD illustrated similar short- and long-term outcomes and procedural efficiency compared to catheter ablation using activation mapping-based ablation. The choice of ablation approach for multiple intra-atrial re-entrant tachycardia should remain at the discretion of the operator.
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http://dx.doi.org/10.1017/S1047951120001900DOI Listing
September 2020

Vulnerability for ventricular arrhythmias in patients with chronic coronary total occlusion.

Expert Rev Cardiovasc Ther 2020 Aug 1;18(8):487-494. Epub 2020 Aug 1.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands.

Introduction: The presence of a chronic total occlusion (CTO) is associated with an increased risk of ventricular arrhythmias.

Areas Covered: This review provides an overview of the relationship between CTO and ventricular arrhythmias, arrhythmogenic mechanisms, and the effect of revascularization.

Expert Opinion: Studies in recipients of an implantable cardioverter-defibrillator (ICD) have shown that a CTO is an independent predictor of appropriate ICD therapy. The myocardial territory supplied by a CTO is a pro-arrhythmogenic milieu characterized by scar tissue, large scar border zone, hibernating myocardium, residual ischemia despite collaterals, areas of slow conduction, and heterogeneity in repolarization. Restoring coronary flow by revascularization might be associated with electrical homogenization as reflected by a decrease in QT(c) dispersion, decrease in T wave peak-to-end interval, reduction of late potentials, and decrease in scar border zone area. Future research should explore whether CTO revascularization results in a lower burden of ventricular arrhythmias. Furthermore, risk stratification of CTO patients without severe LV dysfunction is interesting to identify potential ICD candidates. Potential tools for risk stratification are the use of electrocardiographic parameters, body surface mapping, electrophysiological study, and close rhythm monitoring using an insertable cardiac monitor.
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http://dx.doi.org/10.1080/14779072.2020.1793671DOI Listing
August 2020

Pathophysiological Mechanisms of Premature Ventricular Complexes.

Front Physiol 2020 13;11:406. Epub 2020 May 13.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.

Premature ventricular complexes (PVCs) are the most common ventricular arrhythmia. Despite the high prevalence, the cause of PVCs remains elusive in most patients. A better understanding of the underlying pathophysiological mechanism may help to steer future research. This review aims to provide an overview of the potential pathophysiological mechanisms of PVCs and their differentiation.
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http://dx.doi.org/10.3389/fphys.2020.00406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247859PMC
May 2020

Statin Use Is Prospectively Associated With New-Onset Diabetes After Transplantation in Renal Transplant Recipients.

Diabetes Care 2020 08 22;43(8):1945-1947. Epub 2020 May 22.

Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

Objective: New-onset diabetes after transplantation (NODAT) is frequent and worsens graft and patient outcomes in renal transplant recipients (RTRs). In the general population, statins are diabetogenic. This study investigated whether statins also increase NODAT risk in RTRs.

Research Design And Methods: From a prospective longitudinal study of 606 RTRs (functioning allograft >1 year, single academic center, follow-up: median 9.6 [range, 6.6-10.2] years), 95 patients using statins were age- and sex-matched to RTRs not on statins (all diabetes-free at inclusion).

Results: NODAT incidence was 7.2% (73.3% of these on statins). In Kaplan-Meier (log-rank test, = 0.017) and Cox regression analyses (HR 3.86 [95% CI 1.21-12.27]; = 0.022), statins were prospectively associated with incident NODAT, even independent of several relevant confounders including immunosuppressive medication and biomarkers of glucose homeostasis.

Conclusions: This study demonstrates that statin use is prospectively associated with the development of NODAT in RTRs independent of other recognized risk factors.
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http://dx.doi.org/10.2337/dc19-1212DOI Listing
August 2020

Contact feedback improves 1-year outcomes of remote magnetic navigation-guided ischemic ventricular tachycardia ablation.

Int J Cardiol 2020 09 12;315:36-44. Epub 2020 May 12.

Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands. Electronic address:

Introduction: Remote magnetic navigation (RMN)-guided catheter ablation (CA) is a feasible treatment option for patients presenting with ischemic ventricular tachycardia (VT). Catheter-tissue contact feedback, enhances lesion formation and may consequently improve CA outcomes. Until recently, contact feedback was unavailable for RMN-guided CA. The novel e-Contact Module (ECM) was developed to continuously monitor and ensure catheter-tissue contact during RMN-guided CA.

Objective: The present study aims to evaluate the effect of ECM implementation on acute and long-term outcomes in RMN-guided ischemic VT ablation.

Method: This retrospective, two-center study included consecutive ischemic VT patients undergoing RMN-guided CA from 2010 to 2017. Baseline clinical data, procedural data, including radiation times, and acute success rates were compared between CA procedures performed with ECM (ECM+) and without ECM (ECM-). One-year VT-free survival was analyzed using Cox-proportional hazards models, adjusting for potential confounders: age, left ventricular function, VT inducibility at baseline and substrate based ablation strategy.

Results: The current study included 145 patients (ECM+ N = 25, ECM- N = 120). Significantly lower fluoroscopy times were observed in the ECM+ group (9.5 (IQR 5.3-13.5) versus 12.5 min (IQR 8.0-18.0), P = 0.025). Non-inducibility of the clinical VT at the end of procedure was observed in 92% ECM+ versus 72% ECM- patients (P = 0.19). ECM guidance was associated with significantly lower VT-recurrence rates during 1-year follow-up (16% ECM+ versus 40% ECM-; multivariable HR 0.29, 95%-CI 0.10-0.69, P = 0.021, reference group: ECM-).

Conclusion: Contact feedback by the ECM further decreases fluoroscopy exposure and improves VT-free survival in RMN-guided ischemic VT ablation.
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http://dx.doi.org/10.1016/j.ijcard.2020.05.028DOI Listing
September 2020

Outcome of Insertable Cardiac Monitors in Symptomatic Patients with Brugada Syndrome at Low Risk of Sudden Cardiac Death.

Cardiology 2020 22;145(7):413-420. Epub 2020 Apr 22.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,

Introduction: There is limited data on the experience with insertable cardiac monitors (ICMs) in patients with Brugada syndrome.

Objective: To evaluate the outcome of ICM in symptomatic patients with Brugada syndrome who are at suspected low risk of sudden cardiac death (SCD).

Methods: We conducted a prospective single-center cohort study including all symptomatic patients with Brugada syndrome who received an ICM (Reveal LINQ) between July 2014 and October 2019. The main indication for monitoring was to exclude ventricular arrhythmias as the cause of symptoms and to establish a symptom-rhythm relationship.

Results: A total of 20 patients (mean age, 39 ± 12 years; 55% male) received an ICM during the study period. Nine patients (45%) had a history of syncope (presumed nonarrhythmogenic), and 5 patients had a recent syncope (<6 months). During a median follow-up of 32 months (interquartile range, 11-36 months), 3 patients (15%) experienced an episode of nonsustained ventricular arrhythmia. No patient died suddenly or experienced a sustained ventricular arrhythmia, and no patient had a recurrence of syncope. Overall, 17 patients (85%) experienced symptoms during follow-up, of whom 10 patients had an ICM-detected arrhythmia. In 4 patients (20%), the ICM-detected arrhythmia was an actionable event. ICM-guided management included antiarrhythmic drug therapy for symptomatic ectopic beats (n = 3), pulmonary vein isolation, and oral anticoagulation for atrial fibrillation (n = 1), electrophysiological study for risk stratification (n = 1), and pacemaker implantation for atrioventricular block (n = 1).

Conclusions: An ICM can be used to exclude ventricular arrhythmias in symptomatic patients with Brugada syndrome at low risk of SCD. Furthermore, an ICM-detected arrhythmia changed clinical management in 20% of patients.
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http://dx.doi.org/10.1159/000507075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592947PMC
April 2021

Reducing radiation exposure in second-generation cryoballoon ablation without compromising clinical outcome.

J Interv Card Electrophysiol 2021 Mar 13;60(2):287-294. Epub 2020 Apr 13.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.

Purpose: Pulmonary vein isolation (PVI) using cryoballoon (CB) ablation is associated with an increased radiation exposure compared with radiofrequency ablation. Previous studies showed that radiation exposure in CB PVI can be reduced by optimizing the fluoroscopy protocol without comprising acute efficacy and safety. We evaluated the mid-term outcome of a modified fluoroscopy protocol in patients undergoing CB PVI.

Methods: The study population comprised 90 consecutive patients who underwent second-generation CB-based PVI. The first 46 patients underwent CB PVI with conventional fluoroscopy settings (group A, historic control group). In the following 44 patients (group B), a modified fluoroscopy protocol was applied consisting of (1) visualization of degree of PV occlusion only by fluoroscopy (no cine runs); (2) increased radiation awareness. Primary endpoints were the total dose area product (DAP), fluoroscopy time, and freedom from documented recurrence of atrial fibrillation (AF) after a single procedure.

Results: Group B had a lower median DAP (1393 cGycm vs. 3232 cGycm, P < 0.001) and median fluoroscopy time (20 min vs. 24 min, P < 0.001) as compared with group A. The 1-year freedom from documented recurrence of AF after a single procedure was similar among groups (74% in group A vs. 77% in group B, P = 0.71). There were no significant differences between both groups for the secondary endpoints, including procedure duration, proportion of patients with complete electrical isolation, and complications.

Conclusion: Using a modified fluoroscopy protocol and increased radiation awareness, radiation exposure can be significantly reduced in CB PVI with a similar 1-year clinical outcome.
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http://dx.doi.org/10.1007/s10840-020-00737-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925495PMC
March 2021

Contact-Force-Sensing-Based Radiofrequency Catheter Ablation in Paroxysmal Supraventricular Tachycardias (COBRA-PATH): a randomized controlled trial.

Trials 2020 Apr 9;21(1):321. Epub 2020 Apr 9.

Thoraxcenter, Department of Clinical Electrophysiology, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000, CA, Rotterdam, The Netherlands.

Background: Multiple studies have demonstrated the importance of adequate catheter-tissue contact in the creation of effective lesions during radiofrequency catheter ablation. The development of contact force (CF)-sensing catheters has contributed significantly to improve clinical outcomes in atrial fibrillation. However, CF-sensing technology is not used in the ablation of paroxysmal supraventricular tachycardia (PSVT). The possible reason for this is that PSVT ablation with the conventional approach (i.e. nonirrigated, non-CF-sensing catheters) is considered a relatively low-risk procedure with fairly high success rates (short and long term). The aim of this study is to determine whether CF sensing can further improve the outcomes of PSVT ablation.

Methods/design: The COBRA-PATH study is a single-center, two-armed, randomized controlled trial. Patients without structural heart disease being referred for electrophysiology study, because of PSVT and potential treatment with radiofrequency (RF) catheter ablation, will be randomly assigned to either manual ablation with standard nonirrigated ablation catheters or manual ablation with an open-irrigated ablation catheter equipped with CF sensing (used in a virtual nonirrigated modus). The primary study endpoint is the difference in the number of RF applications during the ablation of atrioventricular nodal re-entry tachycardia, and that of Wolff-Parkinson-White syndrome and atrioventricular re-entrant tachycardia. Secondary outcome parameters include acute and long-term procedural success rates, overall duration of RF applications, procedure/fluoroscopy durations and safety parameters.

Discussion: We expect to see a reduced number/duration of RF applications required to achieve effective lesion creation, and consequently a decrease in total procedure/fluoroscopy times. Although a significant improvement in procedural success rates (acute/long term) might not be feasible to demonstrate (given the relatively high success rate of the standard ablation method), the possible decrease in procedure duration and the consequential reduction of radiation exposure has important clinical implications for both operators and patients undergoing the procedure.

Trial Registration: ClinicalTrials, NCT04078685. Retrospectively registered on 2 September 2019.
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http://dx.doi.org/10.1186/s13063-020-4219-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147009PMC
April 2020

High-Density Lipoprotein Particles and Their Relationship to Posttransplantation Diabetes Mellitus in Renal Transplant Recipients.

Biomolecules 2020 03 21;10(3). Epub 2020 Mar 21.

Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands.

High concentrations of high-density lipoprotein (HDL) cholesterol are likely associated with a lower risk of posttransplantation diabetes mellitus (PTDM). However, HDL particles vary in size and density with yet unestablished associations with PTDM risk. The aim of our study was to determine the association between different HDL particles and development of PTDM in renal transplant recipients (RTRs). We included 351 stable outpatient adult RTRs without diabetes at baseline evaluation. HDL particle characteristics and size were measured by nuclear magnetic resonance (NMR) spectroscopy. During 5.2 (IQR, 4.1‒5.8) years of follow-up, 39 (11%) RTRs developed PTDM. In multivariable Cox regression analysis, levels of HDL cholesterol (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.40-0.94 per 1SD increase; = 0.024) and of large HDL particles (HR 0.68, 95% CI 0.50-0.93 per log 1SD increase; = 0.017), as well as larger HDL size (HR 0.58, 95% CI 0.36-0.93 per 1SD increase; = 0.025) were inversely associated with PTDM development, independently of relevant covariates including, age, sex, body mass index, medication use, transplantation-specific parameters, blood pressure, triglycerides, and glucose. In conclusion, higher concentrations of HDL cholesterol and of large HDL particles and greater HDL size were associated with a lower risk of PTDM development in RTRs, independently of established risk factors for PTDM development.
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http://dx.doi.org/10.3390/biom10030481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175217PMC
March 2020

Early detection of ventricular arrhythmias in adults with congenital heart disease using an insertable cardiac monitor (EDVA-CHD study).

Int J Cardiol 2020 04 4;305:63-69. Epub 2020 Feb 4.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands. Electronic address:

Background: Sudden cardiac death (SCD) due to ventricular arrhythmias (VA) is an important mode of death in adults with congenital heart disease (CHD). Risk stratification is difficult in this heterogeneous population. Insertable cardiac monitors (ICM) may be useful for risk stratification. The purpose of the present study was to evaluate the use of ICM for the detection of VA in adults with CHD.

Methods: In this prospective single-center observational study we included consecutive adults with CHD deemed at risk of VA who received an ICM between March 2013 and February 2019. The decision to implant an ICM was made in a Heart Team consisting of a cardiac electrophysiologist and a cardiologist specialized in CHD.

Results: A total of 30 patients (mean age, 38 ± 15 years; 50% male) received an ICM. During a median follow-up of 16 months, 8 patients (27%) had documented nonsustained VA. Of these 8 patients, 3 (10%) received a prophylactic ICD. Furthermore, ICM-detected arrhythmias were present in 22 patients (73%) leading to a change in clinical management in 16 patients (53%). Besides the patients receiving an ICD, 10 patients (33%) had a change in their antiarrhythmic drugs, 6 patients (20%) underwent an electrophysiology study, and 1 patient (3%) received a pacemaker.

Conclusions: The detection of VA by the ICM contributed to the clinical decision to implant a prophylactic ICD. Furthermore, ICM-detected arrhythmias led to important changes in the clinical management. Therefore, long-term arrhythmia monitoring by an ICM seems valuable for risk stratification in adults with CHD.
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http://dx.doi.org/10.1016/j.ijcard.2020.02.009DOI Listing
April 2020

Emerging electromagnetic interferences between implantable cardioverter-defibrillators and left ventricular assist devices.

Europace 2020 04;22(4):584-587

Department of Cardiology, Erasmus MC University Medical Center, Room RG 431, Dr Molewaterplein 40, Rotterdam, The Netherlands.

Aims: To investigate the prevalence of electromagnetic interference (EMI) between left ventricular assist devices (LVADs) and implantable cardioverter-defibrillators (ICDs)/pacemakers (PMs).

Methods And Results: A retrospective single-centre study was conducted, including all patients undergoing HeartMate II (HMII) and HeartMate 3 (HM3) LVAD implantation (n = 106). Electromagnetic interference was determined by the inability to interrogate the ICD/PM. Overall, 85 (mean age 59 ± 8, 79% male) patients had an ICD/PM at the time of LVAD implantation; 46 patients with HMII and 40 patients with HM3. Among the 85 LVAD patients with an ICD's/PM's, 11 patients (13%) experienced EMI; 6 patients (15%) with an HMII and 5 patients (11%) with an HM3 (P = 0.59). Electromagnetic interference from the HMII LVADs was only present in patients with a St Jude/Abbott device; 6 of the 23 St Jude/Abbott devices. However, in the HM3 patients, EMI was mainly present in patients with Biotronik devices: 4 of the 18 with only one (1/25) patient with a Medtronic device. While initial interrogation of these devices was not successful, none of the 11 cases experienced pacing inhibition or inappropriate shocks.

Conclusion: In summary, the prevalence of EMI between ICDs in the older and newer type of LVAD's remains rather high. While HMII patients experienced EMI with a St Jude/Abbott device (which was already known), HM3 LVAD patients experience EMI mainly with Biotronik devices. Prospective follow-up, preferably in large registries, is warranted to investigate the overall prevalence and impact of EMI in LVAD patients.
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http://dx.doi.org/10.1093/europace/euaa006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132535PMC
April 2020

The Role of Atrial Fibrosis Detected by Delayed - Enhancement MRI in Atrial Fibrillation Ablation.

Curr Med Imaging Rev 2020 ;16(2):135-144

Department of Clinical Electrophysiology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands.

Introduction: Atrial Fibrillation (AF) is associated with remodeling of the atrial tissue, which leads to fibrosis that can contribute to the initiation and maintenance of AF. Delayed- Enhanced Cardiac Magnetic Resonance (DE-CMR) imaging for atrial wall fibrosis detection was used in several studies to guide AF ablation. The aim of present study was to systematically review the literature on the role of atrial fibrosis detected by DE-CMR imaging on AF ablation outcome.

Methods: Eight bibliographic electronic databases were searched to identify all published relevant studies until 21st of March, 2016. Search of the scientific literature was performed for studies describing DE-CMR imaging on atrial fibrosis in AF patients underwent Pulmonary Vein Isolation (PVI).

Results: Of the 763 citations reviewed for eligibility, 5 articles (enrolling a total of 1040 patients) were included into the final analysis. The overall recurrence of AF ranged from 24.4 - 40.9% with median follow-up of 324 to 540 days after PVI. With less than 5-10% fibrosis in the atrial wall there was a maximum of 10% recurrence of AF after ablation. With more than 35% fibrosis in the atrial wall there was 86% recurrence of AF after ablation.

Conclusion: Our analysis suggests that more extensive left atrial wall fibrosis prior ablation predicts the higher arrhythmia recurrence rate after PVI. The DE-CMR imaging modality seems to be a useful method for identifying the ideal candidate for catheter ablation. Our findings encourage wider usage of DE-CMR in distinct AF patients in a pre-ablation setting.
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http://dx.doi.org/10.2174/1573405614666180806130327DOI Listing
January 2020

Conductor cable externalization in an atrial hemodynamic sensor lead in a patient presenting with inappropriate shocks.

HeartRhythm Case Rep 2019 Dec 10;5(12):582-585. Epub 2019 Sep 10.

Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1016/j.hrcr.2019.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926221PMC
December 2019

Combining left atrial appendage closure and catheter ablation for atrial fibrillation: 2-year outcomes from a multinational registry.

Europace 2020 02;22(2):225-231

Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands.

Aims: Clinical practice guidelines do not recommend discontinuation of long-term oral anticoagulation in patients with a high stroke risk after catheter ablation for atrial fibrillation (AF). Left atrial appendage closure (LAAC) with Watchman has emerged as an alternative to long-term anticoagulation for patients accepting of the procedural risks. We report on the long-term outcomes of combining catheter ablation procedures for AF and LAAC from multicentre registries.

Methods And Results: Data were pooled from two prospective, real-world Watchman LAAC registries running in parallel in Europe/Middle-East/Russia (EWOLUTION) and Asia/Australia (WASP) between 2013 and 2015. Of the 1140 patients, 142 subjects at 11 centres underwent a concomitant AF ablation and LAAC procedure. The mean CHA2DS2-VASc score was 3.4 ± 1.4 and HAS-BLED score 1.5 ± 0.9. Successful LAAC was achieved in 99.3% of patients. The 30-day device and/or procedure-related serious adverse event rate was 2.1%. After a mean follow-up time of 726 ± 91 days, 92% of patients remained off oral anticoagulation. The rates of the composite endpoint of ischaemic stroke/transient ischaemic attack/systemic thromboembolism were 1.09 per 100 patient-years (100-PY); and for non-procedural major bleeding were 1.09 per 100-PY. These represent relative reductions of 84% and 70% vs. expected rates per risk scores.

Conclusion: The long-term outcomes from these international, multicentre registries show efficacy for all-cause stroke prevention and a significant reduction in late bleeding events in a population of high stroke risk post-ablation patients who have been withdrawn from oral anticoagulation.
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http://dx.doi.org/10.1093/europace/euz286DOI Listing
February 2020

Catheter steering in interventional cardiology: Mechanical analysis and novel solution.

Proc Inst Mech Eng H 2019 Dec 3;233(12):1207-1218. Epub 2019 Oct 3.

BioMechanical Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands.

In recent years, steerable catheters have been developed to combat the effects of the dynamic cardiac environment. Mechanically actuated steerable catheters appear the most in the clinical setting; however, they are bound to a number of mechanical limitations. The aim of this research is to gain insight in these limitations and use this information to develop a new prototype of a catheter with increased steerability. The main limitations in mechanically steerable catheters are identified and analysed, after which requirements and solutions are defined to design a multi-steerable catheter. Finally, a prototype is built and a proof-of-concept test is carried out to analyse the steering functions. The mechanical analysis results in the identification of five limitations: (1) low torsion, (2) shaft shortening, (3) high unpredictable friction, (4) coupled tip-shaft movements, and (5) complex cardiac environment. Solutions are found to each of the limitations and result in the design of a novel multi-steerable catheter with four degrees of freedom. A prototype is developed which allows the dual-segmented tip to be steered over multiple planes and in multiple directions, allowing a range of complex motions including S-shaped curves and circular movements. A detailed analysis of limitations underlying mechanically steerable catheters has led to a new design for a multi-steerable catheter for complex cardiac interventions. The four integrated degrees of freedom provide a high variability of tip directions, and repetition of the bending angle is relatively simple and reliable. The ability to steer inside the heart with a variety of complex shaped curves may potentially change conventional approaches in interventional cardiology towards more patient-specific and lower complexity procedures. Future directions are headed towards further design optimizations and the experimental validation of the prototype.
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http://dx.doi.org/10.1177/0954411919877709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6859597PMC
December 2019

HDL Cholesterol Efflux Predicts Incident New-Onset Diabetes After Transplantation (NODAT) in Renal Transplant Recipients Independent of HDL Cholesterol Levels.

Diabetes 2019 10 2;68(10):1915-1923. Epub 2019 Aug 2.

Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

In renal transplant recipients (RTRs), new-onset diabetes after transplantation (NODAT) is a frequent and serious complication limiting survival of graft and patient. However, the underlying pathophysiology remains incompletely understood. In vitro and in preclinical models, HDL can preserve β-cell function, largely by mediating cholesterol efflux, but this concept has not been evaluated in humans. This study investigated whether baseline cholesterol efflux capacity (CEC) in RTRs is associated with incident NODAT during follow-up. This prospective longitudinal study included 405 diabetes-free RTRs with a functioning graft for >1 year. During a median (interquartile range) follow-up of 9.6 (6.6-10.2) years, 57 patients (14.1%) developed NODAT. HDL CEC was quantified using incubation of human macrophage foam cells with apolipoprotein B-depleted plasma. Baseline CEC was significantly lower in patients developing NODAT during follow-up (median 6.84% [interquartile range 5.84-7.50%]) compared with the NODAT-free group (7.44% [6.46-8.60%]; = 0.001). Kaplan-Meier analysis showed a lower risk for incident NODAT with increasing sex-stratified tertiles of HDL efflux capacity ( = 0.004). Linear regression analysis indicated that CEC is independently associated with incident NODAT ( = 0.04). In Cox regression analyses, CEC was significantly associated with NODAT (hazard ratio 0.53 [95% CI 0.38-0.76]; < 0.001), independent of HDL cholesterol levels ( = 0.015), adiposity ( = 0.018), immunosuppressive medication ( = 0.001), and kidney function ( = 0.01). Addition of CEC significantly improved the predictive power of the Framingham Diabetes Risk Score ( = 0.004). This study establishes HDL CEC as a strong predictor of NODAT in RTRs, independent of several other recognized risk factors.
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http://dx.doi.org/10.2337/db18-1267DOI Listing
October 2019

Left-sided phrenic nerve injury during redo pulmonary vein isolation long after a previous contralateral self-limiting phrenic nerve palsy.

Clin Case Rep 2019 Jul 11;7(7):1391-1394. Epub 2019 Jun 11.

Department of Cardiology, Erasmus MC University Medical Center Rotterdam The Netherlands.

We present a unique case of a left-sided phrenic nerve injury (PNI) long after a previous contralateral PNI following pulmonary vein isolation (PVI) procedures. Firstly, right-sided PNI after cryoballoon ablation, and secondly a left-sided PNI was observed following a redo PVI extended with box-lesion and left atrial appendage isolation (LAAI).
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http://dx.doi.org/10.1002/ccr3.2199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637336PMC
July 2019

Robotic navigation shows superior improvement in efficiency for atrial fibrillation ablation.

J Atr Fibrillation 2019 Feb-Mar;11(5):2108. Epub 2019 Feb 28.

Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.

Background: Because of the expanding atrial fibrillation (AF) burden, AF catheter ablation (CA) techniques have to become more efficient. Efficient AF CA procedures are characterized by successful pulmonary vein isolation (PVI) within reasonable procedure time. Currently there are many PVI techniques available and all show substantial improvements over time. However, the magnitude of improvement in procedural efficiency has not yet been compared between different techniques. The aim of this study was to compare efficiency improvement between manually (MAN) guided, cryoballoon (CB) and remote magnetic navigation (RMN) guided PVI.

Methods: A total of 221 patients were included in this retrospective study. Procedural parameters of 115 patients treated with first-generation PVI techniques (MAN-1, CB-1, RMN-1) performed in 2010, were compared to 106 patients who were treated with the latest, second generation techniques (MAN-2, CB-2, RMN-2). Efficiency was characterized by the following parameters: total ablation time, total procedure time, first pass isolation (FPI) (i.e. successful isolation after the first pulmonary vein (PV) encirclement) and touch-up rates.

Results: Every technique showed significant improvement of procedure times from the first to the second generation (P<0.001). In-between second generation techniques, the procedure times were comparable. The greatest magnitude of procedure time improvement was observed within the RMN groups (∆-180min), which was significantly greater compared to CB (∆-48 min, P<0.001) and MAN (∆-98min, P=0.011) groups. The highest FPI rates were observed in RMN-2 (78% and 74%; left and right PVs respectively), which was significantly higher compared to other techniques (MAN-2: 24% and 24%; CB-2: 50% and 48%; P<0.001).

Conclusions: The highest magnitude of efficiency improvement was detected in RMN guided PVI.
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http://dx.doi.org/10.4022/jafib.2108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533826PMC
February 2019

Remote magnetic navigation-guided ventricular tachycardia ablation with continuous-flow mechanical circulatory support.

HeartRhythm Case Rep 2019 Apr 25;5(4):217-220. Epub 2019 Jan 25.

Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1016/j.hrcr.2019.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453544PMC
April 2019

Multiplane/3D transesophageal echocardiography monitoring to improve the safety and outcome of complex transvenous lead extractions.

Echocardiography 2019 May 24;36(5):980-986. Epub 2019 Mar 24.

Cardiology, Erasmus MC, Rotterdam, The Netherlands.

Both transesophageal echocardiography (TEE) and intracardiac echocardiography have been used to assist transvenous lead extractions. The clinical utility of continuous echocardiographic monitoring during the procedure is still debated, with different reports supporting opposite findings. In cases where the procedure is expected to be difficult, we propose adding a continuous TEE monitoring using a static 3D/multiplane probe in mid-esophageal position, with digital remote manipulation of the field of view. This approach may improve the chances of a successful extraction, increase safety, or even guide the entire intervention. We present here a short case series where continuous monitoring by TEE played an important role.
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http://dx.doi.org/10.1111/echo.14318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593712PMC
May 2019

Predicting defibrillator benefit in patients with cardiac resynchronization therapy: A competing risk study.

Heart Rhythm 2019 07 31;16(7):1057-1064. Epub 2019 Jan 31.

Department of Cardiology, University Hospital, University of Basel, Basel, Switzerland. Electronic address:

Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected heart failure patients, but decision-making regarding selection of CRT-defibrillator or CRT-pacemaker is an ongoing debate.

Objective: The purpose of this study was to construct predictive models and scoring systems for implantable cardioverter-defibrillator (ICD) therapy and death without ICD therapy (prior death).

Methods: We pooled 2 prospective cohorts of CRT-D patients with primary prevention indication and used Fine and Gray models to develop independent prognostic models for time to first ICD therapy (event of interest) or death without prior ICD therapy (competing event). We defined CRT-D benefit as a high probability of ICD therapy combined with moderate/low probability of prior death.

Results: Seven hundred twenty patients were included. Median follow-up was 7.2 years, and 247 patients (34%) died. Cumulative incidence of ICD therapy/prior death at 5 years was 24%/17%. In multivariable models, higher New York Heart Association classes, diuretic use, and ischemic cardiomyopathy were predictors of ICD therapy (hazard ratio 1.89 [1.30-2.75], 1.91 [1.12-3.24], and 1.40[1.02-1.92], respectively) but not of prior death. Males with comorbidities (cancer, renal failure, peripheral artery disease, body mass index >30) or systolic blood pressure ≤100 were at higher risk for prior death. Higher age was associated with lower risk of ICD therapy but higher risk of prior death. One-quarter of patients had low predicted benefit from CRT-D implantation using a scoring system for the dual prediction of appropriate ICD therapy and death without appropriate ICD-therapy.

Conclusion: Different factors predict ICD therapy or prior death in CRT-D patients using competing risk models. Scoring allows identifying patients with predicted low benefit of CRT-D (low chance of ICD therapy, high chance of prior death).
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http://dx.doi.org/10.1016/j.hrthm.2019.01.033DOI Listing
July 2019

Insertable cardiac monitors: current indications and devices.

Expert Rev Med Devices 2019 01 11;16(1):45-55. Epub 2018 Dec 11.

a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands.

Introduction: Recurrent unexplained syncope is a well-established indication for an insertable cardiac monitor (ICM). Recently, the indications for an ICM have been expanded.

Areas Covered: This review article discusses the current indications for ICMs and gives an overview of the latest generation of commercially available ICMs.

Expert Commentary: The 2018 ESC Syncope guidelines have expanded the indications for an ICM to patients with inherited cardiomyopathy, inherited channelopathy, suspected unproven epilepsy, and unexplained falls. ICMs are also increasingly used for the detection of subclinical atrial fibrillation (AF) in patients with cryptogenic stroke. Whether treatment of subclinical AF (SCAF) with oral anticoagulation prevents recurrent stroke is yet unknown. The current generation of ICMs are smaller, easier to implant, have better diagnostics, and are capable of remote monitoring. The Reveal LINQ (Medtronic) is the smallest ICM and has the most extensive performance and clinical data. The BioMonitor 2 (Biotronik) is the largest ICM but has excellent R-wave amplitudes, longest longevity, and reliable remote monitoring. The Confirm Rx (Abbott) is capable to provide mobile data transmission enabled by a smartphone app. Future generation of ICMs will incorporate heart failures indices to facilitate remote monitoring of heart failure patients.
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http://dx.doi.org/10.1080/17434440.2018.1557046DOI Listing
January 2019