Explore the vast range of titles available.

Despite substantial progress in recent years, graft survival beyond the first year still requires improvement. Since modern immunosuppression addresses mainly T-cell activation and proliferation, we studied macrophage infiltration into the allografts of 103 kidney transplant recipients during acute antibody and T-cell mediated rejection. Macrophage infiltration was correlated with both graft function and graft survival until month 36 after transplantation. Macrophage infiltration was significantly elevated in antibody-mediated and T-cell mediated rejection, but not in kidneys with established IFTA. Treatment of rejection with steroids was less successful in patients with more prominent macrophage infiltration into the allografts. Macrophage infiltration was accompanied by increased cell proliferation as well as antigen presentation. With regard to the compartmental distribution severity of T-cell-mediated rejection was correlated to the amount of CD68+ cells especially in the peritubular and perivascular compartment, whereas biopsies with ABMR showed mainly peritubular CD68 infiltration. Furthermore, severity of macrophage infiltration was a valid predictor of resulting creatinine values two weeks as well as two and three years after renal transplantation as illustrated by multivariate analysis. Additionally performed ROC curve analysis showed that magnitude of macrophage infiltration (below vs. above the median) was a valid predictor for the necessity to restart dialysis. Having additionally stratified biopsies in accordance to the magnitude of macrophage infiltration, differential CD68+ cell infiltration was reflected by striking differences in overall graft survival. The differences in acute allograft rejection have not only been reflected by different magnitudes of macrophage infiltration, but also by compartment-specific infiltration pattern and subsequent impact on resulting allograft function as well as need for dialysis initiation. There is a robust relationship between macrophage infiltration, accompanying antigen-presentation and resulting allograft function.

BackgroundEarly recurrence of atrial tachyarrhythmia (ERAT) is common after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF), but its clinical significance in patients with persistent AF remains unclear. We sought to determine the predictive value of ERAT for rhythm outcome after RFCA for persistent AF.MethodsThe study included 207 consecutive patients (mean age 66.4 ± 10.7 years, male 66.2%) with persistent and long-standing persistent AF undergoing de novo pulmonary vein isolation (± atrial substrate ablation). All patients remained off antiarrhythmic drugs. ERAT was defined as any atrial arrhythmia ≥ 30 s occurring within the first 30 days. Late recurrence (LR) was determined during follow-up visits scheduled 1, 3, 6 and 12 months post-ablation using 7-day Holter ECGs.ResultsERAT occurred in 143/207 (69.1%) patients as AF (60%) or atrial tachycardia (40%) and was persistent in 82% of cases. During a median follow-up of 22.2 months, LR occurred significantly more often in patients with ERAT than in patients without ERAT (92.3 vs. 43.8%, P < 0.001). The only independent predictors for LR were ERAT (OR 16.8, 95% CI 6.184–45.797, P < 0.001) and intraprocedural termination to sinus rhythm (OR 0.052, 95% CI 0.003–0.851, P = 0.038). Extending the blanking period from 30 to 90 days did not impact LR rates.ConclusionERAT following ablation of persistent AF is strongly associated with late arrhythmia recurrence, which challenges the assumption that ERAT represents merely a transient phenomenon. While limiting the blanking period to 30 days seems justified, the benefit of early re-ablations remains to be addressed in future studies.Graphic abstract

Apixaban is increasingly used for stroke prevention in patients with atrial fibrillation. Data about the safety of left atrial radiofrequency ablation procedures under continuous apixaban therapy are lacking. We performed a matched-cohort study of patients undergoing left atrium ablation procedures for atrial fibrillation or left atrial flutter. For each patient on apixaban, 2 patients on phenprocoumon were matched by age, gender, and type of arrhythmia. The primary safety end point was a composite of bleeding, thromboembolic events, and death. We identified 105 consecutive patients (35 women; mean age 63 years) on apixaban and matched 210 phenprocoumon patients (70 women, mean age 64 years). The primary end point was met in 11 patients of the apixaban group and 26 patients of the phenprocoumon group (10.5% vs 12.3%, p = 0.71). Major bleeding complications occurred in 1 patient of the apixaban group and 1 patient of the phenprocoumon group (1% vs 0.5%, p >0.99). Minor bleeding complications were observed in 10 patients of the apixaban group and 25 patients of the phenprocoumon group (9.5% vs 11.9%, p = 0.61). No patient in either group experienced a thromboembolic event and no patient died. In patients on apixaban, no clinical variable was predictive for bleeding complications. Left atrial ablation procedures under continuous oral anticoagulation with apixaban are feasible and as safe as under continuous oral anticoagulation with phenprocoumon.

IntroductionPatients with persistent atrial fibrillation (AF) may additionally suffer from a concealed sinus node disease. We sought to determine the incidence, indications and predictors of acute pacemaker [PM] implantation within 1 week after the ablation of persistent AF.Methods and resultsWe performed a retrospective analysis of patients, who had had an ablation of persistent AF at our center. Between 01/2011 and 08/2016, 1234 patients (mean age 65 ± 10 years, 66.7% male) without prior PM implantation underwent an ablation of persistent AF. Pulmonary vein isolation (PVI) was performed in 1158 (93.8%), the additional ablation of complex fractionated atrial electrograms (CFAE) in 1109 (89.9%) and linear ablation in 524 (42.5%) patients. Temporary cardiac pacing was necessary in 27 (2.2%) patients. The temporary PM was removed in 15 patients (1.2%) because sinus node recovered after a median of 1.0 (minimum 0.1−maximum 2.0) day. The remaining 12 (1.0%) patients required the implantation of a permanent PM. Another 13 (1.1%) patients required permanent PM implantation without prior temporary pacing. In a multivariable regression model, age [OR 1.07 (1.02–1.12), p = 0.006], sinus pauses prior to ablation [OR 7.97 (2.36–26.88), p = 0.001] and atria with low voltage [OR 2.83 (1.31–6.11), p = 0.008] were identified as significant predictors for acute cardiac pacing.ConclusionAcute cardiac pacing within 1 week after the ablation of persistent AF was necessary in 40 (3.2%) patients. Age, sinus pauses in history prior to ablation and the existence of low-voltage areas in the atria were identified as relevant risk factors.

Data about the safety of edoxaban in patients who underwent left atrial (LA) radiofrequency (RF) ablation procedures are lacking. This study sought to compare the safety of uninterrupted edoxaban with uninterrupted phenprocoumon administration during LA RF ablation for atrial fibrillation and atrial tachycardia. In total, 231 patients (mean age 64 ± 11years, male 71%) who underwent LA RF ablation under continuous oral anticoagulation (OAC) with edoxaban or phenprocoumon were included in the study. Patients on uninterrupted edoxaban (60 mg or 30 mg/day for at least 4 weeks) were matched for gender, age and type of arrhythmia with 2 patients on uninterrupted phenprocoumon (international normalized ratio 2 to 3). We identified 77 consecutive patients on edoxaban and n = 154 patients on phenprocoumon. Heparin was administered periprocedurally to achieve an activated clotting time of 280 to 300 seconds. No protamine was administered periprocedurally. The primary end point was a composite of bleeding, thromboembolic events, and death. The primary end point was met in 9 patients in the edoxaban group and in 22 patients in the phenprocoumon group (p = 0.69). No patient in either group died or had a thromboembolic complication. No major bleeding complication was observed in the edoxaban group, whereas one was found in 1 patient in the phenprocoumon group (p ≥0.99). Minor bleeding complications occurred in 9 patients (12%) in the edoxaban group and in 21 patients (14%) in the phenprocoumon group (p = 0.84). Uninterrupted OAC with edoxaban appeared to be as safe as uninterrupted OAC with phenprocoumon in patients who underwent LA RF ablation procedures.

Background The need for pre‐ or peri‐procedural imaging to rule out the presence of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation (AF) is unclear in the era of uninterrupted direct oral anticoagulant (DOAC) regimen. We sought to examine the safety of catheter ablation in appropriately selected patients with paroxysmal AF without performing screening for left atrial thrombus. Patients and Methods Consecutive patients planned for radiofrequency AF catheter ablation between January 2016 and June 2020 were enrolled, and prospectively studied. All subjects were receiving uninterrupted anticoagulation with DOACs for at least 4 weeks before the procedure. All subjects were in sinus rhythm the day of the procedure. The primary outcome of the study was ischemic stroke or transient ischemic attack (TIA) during at 30 days. Results A total of 451 patients (age 59.7 ± 10.2 years, 289 males) with paroxysmal AF were included in the study. The mean CHA2DS2‐VASc score was 1.4 ± 1.2. The mean left ventricular ejection fraction and left atrial diameter were 60 ± 5% and 39.3 ± 4 mm, respectively. Regarding the anticoagulation regimen, apixaban was used in 197 (43.6%) patients, rivaroxaban in 148 (32.8%) patients, and dabigatran in 106 (23.5%) patients. None of the patients developed clinical ischemic stroke or TIA during the 30‐day post‐discharged period. Conclusions Catheter ablation can be safely performed in low‐risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation. Catheter ablation can be safely performed in low‐risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation.

PurposeThis study was designed to evaluate the electromagnetic interference (EMI) effects and safety of the new security screening millimetre wave body scanners (MWBSs) for patients with rare cardiac implantable electronic devices (CIEDs).MethodsWe identified 73 patients with either entirely subcutaneous implantable cardioverter-defibrillators (S-ICD) or leadless pacemakers (LPM) attending routine device follow-up. CIED programming was optimised for the detection of EMI occurrence, and high-voltage therapy was disabled. Patients then underwent millimetre wave body scans under continuous ECG monitoring. Scanning was performed at the recommended distance as well as in close proximity to the scanner emulating accidental exposure. CIED function was observed for EMI effects.ResultsThere were no episodes of inhibition of pacing in the leadless pacemaker subgroup, no oversensing in the S-ICD subgroup and no spontaneous device reprogramming in any group. There was no change in pacing or sensing thresholds, and S-ICD vector eligibility remained unchanged after scanning with the MWBS. No CIEDs were identified by the MWBS during the study.ConclusionNo EMI events were detected during the use of MWBSs by patients with either S-ICDs or LPMs. This data should be reassuring for patients suggesting that they can undergo security body scans without worries or disclosure of their CIED status.

BackgroundThe prevalence of atrial fibrillation (AF) is significantly higher in adults with congenital heart disease (ACHD) compared to patients without congenital heart disease (CHD). As AF in ACHD patients might have significant hemodynamic consequences, rhythm control is particularly desirable but rarely achieved by antiarrhythmic drugs. The aim of this study was to investigate safety and long-term outcome of AF ablation in ACHD patients.MethodsAll ACHD patients (n = 46) that underwent AF ablation at our centre from 2013 to 2017 were included in the study. CHD was classified as simple (46%), moderate (41%) or complex (13%). The majority of patients (61%) suffered from persistent AF (paroxysmal AF 39%). Persistent AF was present in 57% of patients with simple, in 58% of patients with moderate and 83% of patients with complex CHD. All patients underwent radiofrequency (RF) ablation on uninterrupted oral anticoagulation. Pulmonary vein isolation (PVI) was performed in patients with paroxysmal AF, whereas patients with persistent AF underwent PVI and ablation of complex fractionated atrial electrograms (CFAE).ResultsNo major complications occurred. Single-procedure success after 18 months off antiarrhythmic drugs was 61% for paroxysmal AF and 29% for persistent AF (p = 0.003). Multiple procedures (mean 2.1 ± 1.4) increased long-term success to 82% for paroxysmal AF and 48% for persistent AF (p = 0.05). Long-term ablation success was 64% for simple, 62% for moderate and 50% for complex CHD patients.ConclusionsAF ablation in ACHD patients is feasible and safe regardless of CHD complexity. Success rates in patients with paroxysmal AF are high and comparable to patients without CHD. In ACHD patients with persistent AF, success rates of ablation are markedly reduced which might be due to a different and/or more extensive (bi-)atrial substrate. In the cohort of complex ACHD patients with persistent AF as the dominant AF type, long-term success of AF ablation is limited.

Right bundle branch block (RBBB) configuration is an unexpected finding during right ventricular (RV) pacing that raises the suspicion of inadvertent left ventricular lead positioning. The aim of this study was to evaluate the prevalence of paced RBBB pattern in relation to RV lead location. This is a secondary analysis of a prospective, multicenter study, which randomized implantable cardioverter defibrillator recipients to an apical versus midseptal defibrillator lead positioning. A 12-lead electrocardiogram was recorded during intrinsic rhythm and RV pacing. Paced RBBB–like pattern was defined as positive (>0.05 mV) net amplitude of QRS complex in leads V1 and/or V2. In total, 226 patients (65.6 ± 12.0 years, 20.8% women, 53.1% apical site) were included in the study. The prevalence of paced RBBB pattern in the total population was 15.5%. A significantly lower percentage of patients in the midseptal group demonstrated RBBB-type configuration during RV pacing compared with the apical group (1.9% vs 27.5%, p <0.001). Baseline RBBB, prolonged QRS duration during intrinsic rhythm, and reduced ejection fraction were not associated with increased likelihood of paced RBBB. In the subgroup of patients with RBBB type during pacing, 91.4% of patients had a paced QRS axis from −30° to −90°, whereas 100% of patients displayed a negative QRS vector at lead V3. In conclusion, RBBB configuration is encountered in a considerable percentage of device recipients during uncomplicated RV pacing. Midseptal lead positioning is associated with significantly lower likelihood of paced RBBB pattern compared with apical location.