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Notizen: Introduction: Focally induced atrial fibrillation (AF) often is due to ectopic activity in the pulmonary veins (PV). Although initial approaches were aimed at ablating only the ectopic foci, more extensive ablation approaches have evolved that isolate all PVs empirically and/or create circumferential ablation lines in the left atrium (LA). These techniques last longer and may be associated with more risks. We retrospectively evaluated the outcome and risks of ablation for focally induced AF in a single-center patient population. Methods and Results: We report on 47 patients (32 men and 15 women; age 47 ± 10 years) in whom 52 ablations were performed. In 19 patients (22 sessions), ablation was directed at the site(s) of overt ectopic activity (“selective” group), whereas in 28 patients (30 sessions) without sufficient ectopy to determine the culprit PV a mean of 3.5 PVs were empirically targeted for bidirectional disconnection from the LA (“extensive” group). On a preprocedural Holter recording, the “selective” group had significantly more isolated atrial ectopy (3,276 ± 2,933 vs 620 ± 937 beats/24 hours) and runs of atrial tachycardia (330 ± 202 vs 53 ± 87 runs/24 hours) than the “extensive” group (P 〈 0.01 for both). Only 11% had persistent AF before ablation. Acute procedural success was 81% (elimination of all ectopy) and 83%, respectively (bidirectional and fully circumferential isolation of all targeted PVs). Procedure and fluoroscopy times were significantly shorter in the “selective” group. There were no major complications, but 7 minor complications and 2 acute PV stenoses 〉 50% in the 30 “extensive” procedures were observed. Mean follow-up was 8.4 ± 8.5 months (median 6.9). Kaplan-Meier analysis, excluding recurrences during only the first month (“delayed cure”), showed AF recurrence in 45% after 6 months and in 55% after 1 year. Outcome was not dependent on ablation approach (“selective” or “extensive”) nor was time to first AF (22 ± 64 days and 30 ± 69 days). AF recurrence tended to be higher in patients with larger LA (P = 0.08), underlying heart disease or hypertension (P = 0.08), and those “extensive” patients in whom not all 4 PVs were targeted (P = 0.07). Conclusion: Trigger-directed ablation for focally induced AF is associated with a relatively high recurrence rate during follow-up. Apart from recurrence of the ectopic trigger, this may point to underlying structural changes in the atrial substrate not addressed by the ablation. Prospective evaluation of the risk-to-benefit profile of any technique (selective, extensive, including linear lines) is required. (J Cardiovasc Electrophysiol, Vol. 15, pp. 200-205, February 2004)

Notizen: Ischemia Does Not Alter APD Shortening Dynamics. Introduction: After an abrupt increase in heart rate, action potential duration (APD) will shorten. To assess the effect of ischemia on APD shortening dynamics, we compared right ventricular (RV) and left ventricular (LV) APD shortening induced by an abrupt decrease in pacing cycle length (PCL) during control and LV ischemia. Methods and Results: In eight anesthetized AV block dogs, endocardial LV and RV APD were determined simultaneously after an abrupt PCL decrease from 800 to 350 msec. Measurements were repeated during left anterior descending coronary artery (LAD) occlusion. During control, LV and RV APD shortened 97 ± 27 and 71 ± 14 msec, respectively (P 〈 0.05). Shortening was pronounced in a short initial phase and gradual in the longer secondary phase. Linear regression analysis revealed very high uniformity of LV and RV APD shortening dynamics (r2= 0.96 ± 0.01). During repeated LAD occlusion, ischemia induced a gradual LV APD shortening from 314 ± 25 msec to a new steady-state value of 251 ± 23 msec, whereas RV APD remained stable at 289 ± 28 msec. The additional PCL decrease resulted in LV and RV APD shortening of 72 ± 8 and 68 ± 15 msec, respectively, with the same high uniformity of shortening dynamics as seen during control (r2= 0.94 ± 0.03). Conclusion: There is a pronounced difference in APD shortening dynamics induced by an abrupt decrease in PCL compared with ischemia. LV shortening dynamics induced by a decrease in PCL are not affected by LV ischemia, preserving a high interventricular uniformity of repolarization dynamics.

Notizen: Anatomic Nomenclature of the AV Junctions. Current nomenclature for the AV junctions derives from a surgically distorted view, placing; the valvar rings and the triangle of Koch in a single plane with anteroposterior and right-left lateral coordinates. Within this convention, the aorta is considered to occupy an anterior position, whereas the mouth of the coronary sinus is shown as being posterior. Although this nomenclature has served its purpose for the description and treatment of arrhythmias dependent on accessory pathways and AV nodal reentry, it is less than satisfactory for the description of atrial and ventricular mapping. To correct these deficiencies, a consensus document has been prepared by experts from the Working Group of Arrhythmias of the European Society of Cardiology and from the North American Society of Pacing and Electrophysiology. It proposes a new, anatomically sound, nomenclature that will be applicable to all chambers of the heart. In this report, we discuss its value for description of the A V junctions and establish the principles of this new nomenclature.

Notizen: Irrigated Tip Catheter for Ablation of Resistant VT. Introduction: Radiofrequency (RF) catheter ablation of ventricular tachycardia (VT) may fail if the critical isthmus is located intramyocardially or epicardially. The design of a saline-irrigated tip (SIT) catheter (Thermo-Cool™, Cordis-Webster) involves active cooling of the tip electrode, which allows creation of larger ablation lesions. Methods and Results: Eight patients (6 men, age 59 ± 12 years) in whom the clinical target VT (cycle length 430 ± 97 msec) could not be ablated using a conventional 4-mm tip RF ablation catheter underwent additional attempts to ablate this VT using a SIT catheter. Six patients had an old myocardial infarction, 1 patient had a dilated cardiomyopathy, and 1 patient had a structurally normal heart. Ablation of the clinical target VT using a SIT catheter was attempted from the left ventricle in 6 (septal, posterobasal, and inferior: 2 each) and from the right ventricle in 2 patients (both septal), by entrainment (n = 6), activation (n = 1), or pace mapping (n = 1). A mean of 6 ± 5 (range 2 to 15) pulses were delivered. Target VT ablation was successful in 5 patients (63%). After successful ablation, at a mean follow-up of 6.5 ± 4 months and while taking antiarrhythmic drugs, all 5 patients were free of VT recurrences. Conclusion: The clinical target VT could be ablated using a SIT catheter in 5 (63%) of the 8 patients in whom ablation using a conventional RF catheter was unsuccessful. In the 2 patients with septal VT, a biventricular approach to mapping and ablation was required.

Notizen: Flagella-specific proteins of Leishmania have been identified employing the monoclonal antibody technique. Six monoclonal antibodies recognized 3 different proteins. A doublet of protein of Mr 69,000 and 74,000 Da identified by monoclonal antibodies F-3, F-4 and F-6 is continuously distributed along the flagellum by immunofluorescence. Immunocytochemical electron microscopic studies localize these molecules to the paraxial rod of the flagellum. A single protein of Mr 13,200 Da is recognized by monoclonal antibodies F-1, F-2 and F-5. The distribution of the Mr 13,200 protein appears irregular, occurring in localized patches along the length of the flagellum, especially at the flagellar tip. Immunocytochemical electron microscopic experiments show that the Mr 13,200 molecule is associated with the membrane of the flagellum. Indirect immunofluorescence experiments demonstrated these monoclonal antibodies cross-reacted with members of the Kinetoplastida family (Endotrypanum, Trypanosoma, Leishmania) suggesting that these molecules may be evolutionarily conserved.

Notizen: Introduction: A short atrioventricular decrementally conducting accessory pathway is an uncommon variant of preexcitation. Available data from small series suggest that their decremental properties might not be caused by A-V nodal-like tissue. Methods: We compared clinical, electrocardiographic and electrophysiologic parameters in two groups of patients: 8 patients with a short A-V Mahaim pathway (Group A), and 33 patients with atriofascicular pathways (Group B). Radiofrequency catheter ablation was carried out guided by activation mapping at the annulus in Group A patients and targeting the “M” potential in Group B patients. Results: After ablation of all associated rapidly conducting bypass tracts, 7 of the 8 Group A patients showed clear preexcitation. In only 1 of 8 patients the short A-V Mahaim fiber was actively engaged in a reentrant tachycardia circuit. During radiofrequency catheter ablation an automatic rhythm occurred in 4 of 8 patients. Intravenous adenosine caused conduction a block in the Mahaim fiber in 3 of the 5 patients tested. In group B, no patient showed clear preexcitation (P 〈 00001) while 72% had a minimal preexcitation pattern. Twenty-nine of the 33 patients had a circus movement tachycardia with AV conduction over the atriofascicular fiber. During radiofrequency catheter ablation 30 of 33 patients showed accessory pathway automaticity. Adenosine caused transient block at the atriofascicular pathway in 11 (92%) of the 12 patients tested. Conclusions: While short decrementally conducting right-sided accessory pathways show a typical ECG pattern different from atriofascicular pathways, their electrophysiologic properties do not seem to be uniform. Those pathways can be successfully interrupted by catheter ablation.

Notizen: Atrial Channel and VT Therapy in ICD. Introduction: Performance of dual chamber implantable cardioverter defibrillator (ICD) systems bas been judged based on functioning of the ventricular tachycardia:supraventricular tachycardia (VT:SVT) discrimination criteria and DDD pacing. The purpose of this study was to evaluate the use of dual chamber diagnostics to improve the electrical and antiarrhythmic therapy of ventricular arrhythmias. Methods and Results: Information about atrial and ventricular rhythm in relation to ventricular arrhythmia occurrence and therapy was evaluated in 724 spontaneous arrhythmia episodes detected and treated by three types of dual chamber K Ds in 41 patients with structural heart disease. Device programming was based on clinically documented and induced ventricular arrhythmias. In ambulatory patients, sinus tachycardia preceded ventricular arrhythmias more often than in the hospital during exercise testing. The incidence of these VTs could be reduced by increasing the dose of a beta-blocking agent in only two patients. In five patients in whom sinus tachycardia developed after onset of hemodynamic stable VT, propranolol was more effective than Class III antiarrhythmics combined with another beta-blocking agent with regard to the incidence of VT and pace termination. In all but three cases, atrial arrhythmias were present for a longer time before the onset of ventricular arrhythmias. During atrial arrhythmias, fast ventricular rates before the onset of ventricular rate were observed more often than RR irregularities and short-long RR sequences. Dual chamber diagnostics allowed proper interpretation of detection and therapy outcome in patients with different types of ventricular arrhythmia. Conclusion: The advantages of the dual chamber ICD system go further than avoiding the shortcomings of the single chamber system. Information from the atrial chamber allows better device programming and individualization of drug therapy for ventricular arrhythmia.

Notizen: Atrial Arrhythmias in ICD Patients. Introduction: Devices capable of monitoring and treating atrial taihyarrhythmias provide information about the natural history of the arrbythmias and potentially can influence their natural course by electrical therapy early after onset.Methods and results: Types of atrial arrhythmias and efficacy of device therapies were evaluated in 30 patients implanted with the Medtronic model 7250 Jewel AF implantable cardioverter defibrillator (ICD). All patients had structural heart disease and documented sustained ventricular and atrial arrhythmias (27 with atrial fibrillation [AF]) before implant. Twenty patients were taking amiodarone, and three were taking sotalol. During 20 ± 10 months of follow-up, 600 atrial arrhythmia recurrences were documented in 50% of patients. AF was diagnosed in 19%. fast polymorphic atrial tacbycardia (AT) in 20%, fast monomorpbic AT in 57%. and slow AT in 4% of episodes. The two adaptive pacing therapies, burst and ramp, together with the 50-Hz burst, were successful in 57% of delected atrial arrhythmias. Burst and ramp were responsible for 49% and 50-Hz burst for 51% of successfully treated arrbytbmias; 33% of the episodes terminated spontaneously. No ventricular proarrbythmia was observed due to atrial pacing therapies. In 30% of episodes, dual chamber pacing was required due to post termination bradycardia. Atrial arrhythmia recurrences in patients with dilated cardiomyopathy were not amenable to pacing therapies. Several aspects of atrial arrhythmia diagnosis, therapy, and documentation that are specific for functioning of the Jewel AF arc discussed.Conclusion: Atrial arrhythmias in ICD patients with diseased hearts who are taking Class III antiarrbythmics frequently had longer cycle lengths than AF. Half of these arrhythmias could be terminated with pacing therapies; one third terminated spontaneously.