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IntroductionThe aim of this study was to compare second-generation cryoballoon and contact-force radiofrequency point-by-point pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients with regard to pulmonary vein reconnection and arrhythmia-free survival.Methods and resultsAltogether, 269 consecutive patients with drug-refractory AF undergoing PVI were included and randomly allocated to second-generation cryoballoon or contact-force point-by-point radiofrequency ablation. Median follow-up duration was 389 days (interquartile range 219–599). Mean age was 59 years (71% male); 136 patients underwent cryoballoon and 133 patients underwent radiofrequency ablation. Acute electrical PVI was 100% for both techniques. Procedure duration was significantly shorter in cryoballoon vs radiofrequency (166.5 vs 184.13 min P = 0.016). Complication rates were similar (6.0 vs 6.7%, P = 1.00). Single procedure freedom of atrial arrhythmias was significantly higher in cryoballoon as compared to radiofrequency (75.2 vs 57.4%, P = 0.013). In multivariate analysis, persistent AF, AF duration, and cryoballoon ablation were associated with freedom of atrial tachyarrhythmias. The number of repeat ablation procedures was significantly lower in the cryoballoon compared to radiofrequency (15.0 vs 24.3%, P = 0.045). At repeat ablation, pulmonary vein reconnection rate was significantly lower after cryoballoon as compared to radiofrequency ablation (36.8 vs 58.1%, P = 0.003).ConclusionsImproved arrhythmia-free survival and more durable pulmonary vein isolation is seen after PVI using second-generation cryoballoon as compared to contact-force radiofrequency, in patients with drug-refractory paroxysmal AF. Complication rates for both ablation techniques are low.

BackgroundRenal nerve stimulation (RNS) is used to localize sympathetic nerve tissue for selective renal nerve sympathetic denervation (RDN). Examination of heart rate variability (HRV) provides a way to assess the state of the autonomic nervous system. The current study aimed to examine the acute changes in HRV caused by RNS before and after RDN.Methods and results30 patients with hypertension referred for RDN were included. RNS was performed under general anesthesia before and after RDN. Heart rate (HR) and blood pressure (BP) were continuously monitored. HRV characteristics were assessed 1 min before and after RNS and RDN. RNS before RDN elicited a maximum increase in systolic BP of 45 (± 22) mmHg which was attenuated to 13 (± 12) mmHg (p < 0.001) after RDN. RNS before RDN decreased the sinus cycle length from 1210 (± 201) ms to 1170 (± 203) ms (p = 0.03), after RDN this effect was blunted (p = 0.59). The LF/HF ratio in response to RNS changed from ∆ + 0.448 (± 0.550) before RDN to ∆ − 0.656 (± 0.252) after RDN (p = 0.02). Selecting patients off beta-blockade (n = 11), the RNS-induced changes in HRV components before versus after RDN were more pronounced (LF/HF ratio ∆ + 0.900 ± 1.171 versus ∆ − 0.828 ± 0.519, p = 0.01), whereas changes in HRV parameters in patients on beta-blockade (n = 19) were no longer significant. In patients with diabetes mellitus (n = 7), RNS induced no changes in HRV parameters (LF/HF ratio ∆ − 0.039 ± 0.103 versus ∆ − 0.460 ± 0.491, p = 0.92).ConclusionRNS induces changes in HRV suggesting increased sympathetic activity. Conversely, after RDN, the RNS-induced changes in HRV suggesting a lower sympathetic autonomic balance. These changes were most pronounced in beta-blocker naïve patients and not present in patients with diabetes mellitus. These findings could support RNS-guided RDN to optimize results.

BackgroundRenal nerve denervation (RDN) is developed as a potential treatment for hypertension. Recently, we reported the use of renal nerve stimulation (RNS) to localize sympathetic nerve tissue for subsequent selective RDN. The effects of RNS on arterial pressure dynamics remain unknown. The current study aimed to describe the acute changes in arterial pressure dynamics response to RNS before and after RDN.Methods and resultsTwenty six patients with drug-resistant hypertension referred for RDN were included. RNS was performed under general anesthesia before and after RDN. We continuously monitored heart rate (HR) and invasive femoral blood pressure (BP). Augmentation pressure (AP) and index (Aix), pulse pressure (PP), time to reflected wave, maximum systolic BP and dicrotic notch were calculated. Systolic and diastolic BP at site of maximum response significantly increased in response to RNS (120 ± 16/62 ± 9 to 150 ± 22/75 ± 15 mmHg) (p < 0.001/< 0.001), whereas after RDN no RNS-induced BP change was observed (p > 0.10). RNS increased Aix (29 ± 11 to 32 ± 13%, p = 0.005), PP (59 ± 14 to 75 ± 17 mmHg, p < 0.001), time to reflected wave (63 ± 18 to 71 ± 25 ms, p = 0.004) and time to maximum systolic pressure (167 ± 36 to 181 ± 46 ms, p = 0.004) before RDN, whereas no changes were observed after RDN (p > 0.18). All changes were BP dependent. RNS had no influence on HR or the time to dicrotic notch (p > 0.12). ConclusionRNS induces temporary rises in Aix, PP, time to maximum systolic pressure and time to reflected wave. These changes are BP dependent and were completely blunted after RDN.

The name of the author Jaap Jan J. Smit was rendered wrongly in the original publication. The original article has been corrected.

Although prevalence of heart failure increases with age, in most clinical trials of cardiac resynchronization therapy (CRT), older patients are not included. Observational studies of effects of CRT in older patients had a small sample size. In the present study, the clinical and echocardiographic response to CRT in a larger group of elderly (age >75 years) patients was evaluated. In this prospective observational study of 266 consecutive patients, CRT was performed in 107 elderly patients (40%) and 159 (60%) younger patients (age ≤75 years). Echocardiographic and clinical parameters were evaluated at baseline and at 3, 12, and 24 months. In the elderly group, mean age was 79 years compared with 67 years in patients aged ≤75 years. Clinical baseline characteristics between the 2 groups were comparable. During follow-up, there was a comparable and sustained improvement in both groups according to New York Heart Association (NYHA) class, quality of life score, and left ventricular (LV) ejection fraction. Clinical response, defined as survival with improvement (≥1 score) of NYHA class without hospital admittance for heart failure, was seen in 67% and 69% (group aged ≤75 years) versus 65% and 60% (group aged >75 years) after 3 months and 1 year, respectively. Reverse LV remodeling defined as LV end-systolic volume reduction ≥10% was seen in 79% and 87% (group aged ≤75 years) versus 71% and 79% (group aged >75 years) after 3 months and 1 year, respectively. Hospitalization for heart failure decreased significantly in both groups in the year after CRT. A subgroup analysis of 39 octogenarians (>80 years) also showed a significant improvement in NYHA class and LV ejection fraction in this subgroup. Also, LV reverse remodeling occurred in a similar extent (75% and 84%) after 3 months and 1 year, respectively. This study shows a clinical and echocardiographic improvement of CRT in patients aged >75 years and even so in octogenarians.

Purpose For patients with symptomatic atrial fibrillation (AF), a curvilinear multi-electrode ablation (MEA) catheter has been reported to be successful to achieve pulmonary vein (PV) isolation. However, this approach has not been compared prospectively with conventional PV isolation (CPVI) using a standard circular mapping catheter and 3D electro-anatomic mapping. In this prospective non-randomized study, we compared the efficacy of these two techniques. Methods Of 185 consecutive patients, age 54.6 ± 10.1 years, with symptomatic paroxysmal AF (PAF), 96 patients underwent PV isolation by CPVI and 89 patients underwent MEA to isolate the PVs. CPVI was performed by encircling the left- and right-sided PVs. During MEA, the PV ablation catheter (Medtronic, USA) was used to isolate PVs with duty-cycled radiofrequency energy. Results The mean procedure time was 171.73 ± 52.87 min for CPVI and 133.25 ± 37.99 min for MEA, respectively ( P  < 0.001). The mean fluoroscopy time was 31.07 ± 14.97 for CPVI and 30.07 ± 11.45 min for MEA ( P  = 0.651). At 12 months, 80% of patients who underwent CPVI and 82% of patients who underwent MEA were free of symptomatic PAF off antiarrhythmic drug therapy ( P  = 0.989). Among the variables of age, gender, duration and frequency of PAF, left ventricular ejection fraction, left atrial size, structural heart disease, and the ablation technique, only an increased left atrial size was an independent predictor of recurrent PAF. Left atrial flutter occurred after CPVI in two patients and after MEA ablation in three patients. Conclusion In patients undergoing catheter ablation for PAF, MEA and CPVI proved equally efficacious.

AimsIn the SCALAF trial, catheter-based pulmonary vein isolation (PVI) was as effective in long-term prevention of atrial fibrillation (AF) as minimally invasive thoracoscopic PVI and left atrial appendage ligation (MIPI). Catheter ablation (CA) resulted in significantly less major complications as compare to MIPI. We report quality of life (QOL) outcome in these patients.MethodsIn this study, 52 patients with symptomatic paroxysmal or early persistent AF were randomized to either MIPI or CA. QOL was assessed at baseline, 3, 6, and 12 months follow-up using the SF-36 Health Survey Questionnaire. AF-related symptoms were quantified at each follow-up visit using the European Heart Rhythm Association (EHRA) score.ResultsMedian age was 57 years and 78% was male. Paroxysmal AF was present in 74%. At 3 months follow-up, physical role limitations (88.2 ± 29.5; versus 40.9 ± 44.0; P = 0.001, respectively) and bodily pain scores (95.5 ± 8.7; versus 76.0 ± 27.8; P = 0.021, respectively) were significantly higher after CA compared to MIPI, indicating less limitation in daily activity caused by physical problems and less pain after CA than after MIPI. AF symptoms assessed by the EHRA scores improved significantly at 3, 6, 12, and 24 months compared to baseline in both treatment groups (P < 0.001), with no significant differences between treatment groups.ConclusionsCA and MIPI ablation of AF both resulted in an improvement in several QOL measurements, although CA resulted in significantly less physical problems and bodily pain 3 months after treatment compared to MIPI.Clinical trial numberClinicalTrials.gov identifier: NCT00703157.Graphic abstract

Identification of patients who will benefit from cardiac resynchronization therapy (CRT) is challenging. “Apical rocking” is frequently observed in asynchronously contracting ventricles and small studies suggested that it may predict CRT response. We assessed the predictive value of LV apical rocking on echocardiographic and clinical response to CRT in a large cohort of patients treated with CRT. Echocardiography was performed in 137 consecutive patients prior to CRT, and repeated during follow-up. Apical rocking was defined as motion of the left ventricular (LV) apical myocardium perpendicular to the LV long axis. Echocardiographic response to CRT was defined as a reduction in LV end-systolic volume ≥15 % and clinical response as survival without heart failure hospitalization. All echocardiograms were assessed by independent cardiologists, blinded for baseline, clinical and follow-up data. Multivariable analyses were performed to adjust for potential confounders. Mean echocardiographic and clinical follow-up was 22 ± 8 and 57 ± 12 months respectively. Apical rocking was present in 49 % of the patients. Apical rocking was more common in females, younger patients, and in patients with non-ischemic cardiomyopathy. Echocardiographic response to CRT was observed in 69 %, clinical response in 77 % of the patients. Apical rocking was associated with both echocardiographic response (OR 10.77, 95 % CI 4.12–28.13) and clinical response to CRT (HR 2.73, 95 % CI 1.26–5.91). Also after multivariable analyses, apical rocking was associated with both echocardiographic (OR 9.97, 95 % CI 3.48–28.59) and clinical response to CRT (HR 2.13, 95 % CI 0.94–4.83). Apical rocking is independently associated with both echocardiographic and clinical response to CRT.

Echocardiographic assessment of left ventricular (LV) dyssynchrony is used to predict response to cardiac resynchronization therapy (CRT). However, the association between reduction in the extent of speckle tracking based LV-dyssynchrony and echocardiographic response to CRT has not been explored yet. The aim of this study was to assess the changes in the extent of LV dyssynchrony as a result of CRT and its association with echocardiographic response to CRT in a large consecutive series of patients. We studied 138 patients with standard CRT indication. Time-based speckle tracking longitudinal strain (maximal delay between 6-segments in 4-chamber view) was performed to assess LV-dyssynchrony at baseline and after a mean follow-up of 22 ± 8 months. Echocardiographic CRT response was defined as a reduction in LV end-systolic volume ≥15 %. Mean age was 68 ± 8 years (30 % female). Mean LV ejection fraction (LVEF) was 26 ± 7 %. Ninety six patients (70 %) were classified as echocardiographic responders. In the total study group, LV-dyssynchrony decreased from 196 ± 89 ms at baseline to 180 ± 105 ms during follow-up, P  = 0.01. Of note, in responders there was a pronounced reduction in LV dyssynchrony (198 ± 88 ms at baseline vs 154 ± 50 ms after CRT, P  < 0.001), whereas in non-responders there was a significant increase (191 ± 92 ms at baseline vs 243 ± 160 ms after CRT, P  = 0.04). After multivariate analysis, decreased in LV-dyssynchrony, wider QRS duration and non-ischemic etiology were independently and significantly associated with CRT response. Changes in the extent of LV dyssynchrony as measured by speckle tracking after CRT are independently associated with response to CRT.

BackgroundHypertension is an important, modifiable risk factor for the development of atrial fibrillation (AF). Even after pulmonary vein isolation (PVI), 20–40% experience recurrent AF. Animal studies have shown that renal denervation (RDN) reduces AF inducibility. One clinical study with important limitations suggested that RDN additional to PVI could reduce recurrent AF.ObjectiveThe goal of this multicenter randomized controlled study is to investigate whether RDN added to PVI reduces AF recurrence.MethodsThe main end point is the time until first AF recurrence according to EHRA guidelines after a blanking period of 3 months. Assuming a 12-month accrual period and 12 months of follow-up, a power of 0.80, a two-sided alpha of 0.05 and an expected drop-out of 10% per group, 69 patients per group are required. We plan to randomize a total of 138 hypertensive patients with AF and signs of sympathetic overdrive in a 1:1 fashion. Patients should use at least two antihypertensive drugs. Sympathetic overdrive includes obesity, exercise-induced excessive blood pressure (BP) increase, significant white coat hypertension, hospital admission or fever induced AF, tachycardia induced AF and diabetes mellitus. The interventional group will undergo PVI + RDN and the control group will undergo PVI.ResultsPatients will have follow-up for 1 year, and continuous loop monitoring is advocated.ConclusionThis randomized, controlled study will elucidate if RDN on top of PVI reduces AF recurrence.