Background: Cardiac sympathetic denervation as a treatment for drug-refractory ventricular arrhythmias (VAs) involves video-assisted thoracoscopic removal of the stellate ganglion (SG) and thoracic ganglia. A simplified approach sparing the SG and targeting left T2–T4 ganglia (left cardiac sympathetic denervation [LCSD]) may offer a less invasive alternative. Objective: This study aimed to evaluate the efficacy and safety of simplified SG-sparing LCSD as a bailout procedure for multimorbid patients with structural heart disease and recurrent VAs refractory to antiarrhythmic drugs and/or catheter ablation. Methods: All patients undergoing SG-sparing LCSD at our institution between June 2023 and June 2024 were included in this single-center retrospective study. Baseline demographics, procedural complications, and arrhythmia outcomes were analyzed. Results: LCSD was performed in 7 patients (mean age 75.9 ± 6.7 years, mean LVEF 30.7 ± 10.9%) with structural heart disease (nonischemic cardiomyopathy, n = 3; ischemic cardiomyopathy, n = 4) mostly 1 day (interquartile range 1–21) after admission with a procedure duration of 20.7 ± 5.3 minutes. Initially, 4 patients (57.1%) had electrical storm. Apart from 1 pleural effusion requiring drainage, no major complications or Horner’s syndrome occurred. During a follow-up of 7 ± 2.6 months, median VA episodes requiring implantable cardioverter-defibrillator therapy decreased from 14 to 2 (P = .021) and median implantable cardioverter-defibrillator shocks from 1.5 to 0 (P = .034). Three patients remained free of sustained VAs; 1 patient died of coronavirus disease 2019. Conclusion: In this case series of 7 patients, SG-sparing LCSD demonstrated promising results in terms of safety and efficacy for reducing VAs. Further studies are warranted to confirm long-term outcomes with this approach.

Background: Sedation with propofol (PFL) may complicate mapping and catheter ablation (CA) of ventricular premature contractions (PVC) due to suppression of PVCs. There might be different effects of sedation depth itself versus drug-induced effects of propofol on PVCs. Purpose: Aim of the study was to assess the impact of sedation depth monitored with electroencephalogram (EEG) processed signals and propofol (PFL) concentrations on changes in PVS during mapping and ablation of PVCs. Methods: The prospective study included 32 patients (pts) who underwent CA of PVCs between august 2015 and august 2016 (46.8% male, BMI 25.7±4.2 kg/m2, LVEF 51.3±9.6%, hypertension 51.1%, coronary heart disease 25.0%, 1.15±0.34 PVS morphologies/pt). No pharmacological or physical provocation was performed to induce PVCs. PVCs were analyzed over a 3 minute time interval, if a defined plasma PFL concentration was achieved. The defined plasma PFL target concentration (TC) was measured via a target controlled infusion system (TCI). Sedation was increased stepwise until defined PFL-TC levels (sedation levels, SL) were reached (SL 0) 0: no sedation; SL 1: 0.5 μcg/ml; SL 2: 1.5 μcg/ml; SL 3: 2,5 μcg/ml and SL 4 defined as PFL concentration >2.5 μcg/ml until first high frequency (HF) current impulse). Continuous measurement of sedation depth with processed EEG signals (bispectral index monitor, BIS; 0 complete cortical EEG suppression, 100 awake) was performed. BIS and PFL-TC were documented at 1st HF impulse and if PVCs were not present anymore before 1st HF impulse. Results: PVC burden prior to CA was 27.0±6.3%. PVC origin was left coronary cusp in 50.0%, right coronary cusp in 21.4% and in 28.6% right ventricular outflow tract. PFL-TC and BIS values were significantly correlated (r=-0.56, p<0,0001). Number of PVCs and BIS values correlated significantly (r=0,37, p<000,1) (Fig 1). No significant correlation was found between number of PVCs and PFL-TC (r=0.09, p=0.16). In 53.6% of all pts PVCs disappeared prior to 1st HF application at a mean BIS value of 45.7±15.1 and a PFL-TC of 3.2±1.7 μcg/ml. At time of 1st HF application number of PVCs was significantly lower, than without sedation (21.0±13.9 versus 5.2±7.6, p<0.0001) (Fig). Conclusion: At 1st HF impulse in more than 50% of pts with PFL sedation PVCs dissolved. Sedation depth measured with processed EEG signals had effects on number of PVCs, whereas PFL concentration did not correlate with number of PVCs. The use of BIS monitoring may provide individualized sedation protocol for better mapping and ablation of PVCs.

The role of catheter ablation in patients with ventricular tachycardia (VT) has evolved over the last two decades into an established treatment option. In patients with idiopathic VT catheter ablation is the gold standard treatment option with high effectiveness and low risk of complications. Due to the high risk of side effects the use of antiarrhythmic drugs is only indicated in exceptional cases. In patients with structural heart diseases, such as ischemic and dilated cardiomyopathy, VT is the most frequent cause of death. Furthermore, recurrent shocks from implantable cardioverter defibrillators (ICD) are one of the main reasons for the high morbidity and mortality; however, in these patients a complex myocardial substrate is present and consequently there is a relevant risk of recurrence after VT ablation. A periprocedural mortality of approximately 3% must be considered in these often severely ill patients. Nevertheless, there is no reasonable alternative to catheter ablation, particularly in patients who continue to have VT episodes even under therapy with amiodarone. Questions with respect to the optimal procedural technique for VT ablation, the endpoint and optimal timing of ablation need to be clarified in clinical trials.

The use of non-vitamin K antagonists (NOACs), uninterrupted (uVKA) and interrupted vitamin K antagonists (iVKA) are common periprocedural oral anticoagulation (OAC) strategies for atrial fibrillation (AF) ablation. Comparative data on complication rates resulting from OAC strategies for solely persistent AF (persAF) undergoing ablation are sparse. Thus, we sought to determine the impact of these OAC strategies on complication rates among patients with persAF undergoing catheter ablation.

Genetische Aortensyndrome (GAS) wie das Marfan-Syndrom führen unbehandelt zu einem frühen Tod aufgrund von Aortendissektion und -ruptur. Des Weiteren besteht eine hohe kardiovaskuläre Morbidität und Mortalität durch Arrhythmien, Herzinsuffizienz und Herzklappenerkrankungen mit einem Risiko für den plötzlichen Herztod von bis zu 4 %.

Die Katheterablation ist neben der frequenzkontrollierenden oder rhythmuserhaltenden medikamentösen Therapie integraler Bestandteil der Behandlung von Patienten mit Vorhofflimmern (VHF). Ein weiterer Eckpfeiler der Therapie von VHF ist die adäquate orale Antikoagulation. Neben den Vitamin-K-Antagonisten (VKA) Phenprocoumon und Warfarin sind zur oralen Antikoagulation bei VHF auch die direkten oralen Antikoagulanzien (DOAK) Apixaban, Dabigatran und Rivaroxaban zugelassen. Entsprechend ergeben sich prä-, peri- und postablativ verschiedene Antikoagulationsmöglichkeiten. Durch die zunehmende klinische Erfahrung mit den DOAK und die weltweit ansteigende Anzahl von VHF-Ablationen unterliegen insbesondere die periinterventionellen Therapieregime einem ständigen Wandel, sodass die vorliegende Arbeit den aktuellen Stand aufzeigt und praktische Hinweise gibt.

In addition to treatment with drugs to control the rate and rhythm, the method of catheter ablation is a cornerstone in the treatment of atrial fibrillation. Another crucial part in treating patients with atrial fibrillation is an adequate oral anticoagulation. Apart from the vitamin K antagonists (VKA) phenprocoumon and warfarin, the direct oral anticoagulants (DOAC) apixaban, dabigatran and rivaroxaban have been approved for oral anticoagulation of patients with atrial fibrillation. As a result there are different potential treatment possibilities for pre-interventional, peri-interventional and post-interventional anticoagulation in the setting of catheter ablation for atrial fibrillation. Due to increasing clinical experience with DOAC and the increasing number of atrial fibrillation ablations worldwide, peri-interventional treatment strategies are continuously changing. Therefore, the current article discusses current standards and gives practical guidance.

Objectives: The frequency of and risk factors for ventricular arrhythmia are unknown in patients with FBN1 gene mutations.

Die Katheterablation bei Vorhofflimmern (VHF) wird mittlerweile sehr häufig angewandt. Lesen Sie, über welche Komplikationen die Patienten aufzuklären sind und welche Rolle dabei die Erfahrung eines kardiologischen Zentrums spielt.

Die Einführung des implantierbaren Kardioverter-Defibrillators (ICD) in die klinische Routine der Primär- und Sekundärprävention ventrikulärer Arrhythmien hat zu einer deutlichen Reduktion der Mortalität von Patienten mit hochgradig eingeschränkter linksventrikulärer Funktion geführt. Trotz des immensen Benefits dieser Therapie stellt im klinischen Alltag neben den adäquaten ICD-Therapien vor allem der hohe Anteil inadäquater Therapien ein großes Problem dar. Tachykard übergeleitetes Vorhofflimmern ist dabei neben supraventrikulären Tachykardien, Artefaktsensing und elektromagnetischen Interferenzen die häufigste Ursache für inadäquate ICD-Schocks. Da sowohl adäquate als auch inadäquate ICD-Schocks paradoxerweise die Mortalität erhöhen, kommt der Vermeidung von ICD-Therapien eine entscheidende Bedeutung zu. Neben den klassischen erweiterten Detektionskritieren (Stabilität, Onset und Morphologie des Kammerkomplexes) sowie den firmenspezifischen Zweikammer-ICD-Algorithmen gelingt eine Therapiereduktion vor allem durch Erhöhung der Detektionsfrequenz für ventrikuläre Tachykardien und Programmierung einer langen Detektionsdauer. Dies konnte eindrucksvoll in den neueren Studien wie MADIT-RIT, ADVANCE-III und PROVIDE gezeigt werden. Ein erhöhtes Risiko für Synkopen ist durch die Therapiereduktion nicht zur befürchten. Zusätzlich zur optimierten Programmierung kann der Anteil von adäquaten ICD-Therapien durch Antiarrhythmika und durch eine Katheterablation beeinflusst werden.

Background: Catheter ablation (CA) for atrial fibrillation (AF) is an effective therapeutic option for the treatment of symptomatic drug-refractory AF. According to current guidelines, the prevention of stroke and embolism is the most important therapeutic goal in AF and the recommendations for anticoagulation (OAC) after successful CA are based upon the CHA(2)DS(2)-VASc-Score [3]. The aim of this study was to evaluate the use of OAC in patients with a high risk for thromboembolic events 1 year after CA and to identify predictor variables for discontinuation of OAC.Methods: Between January 2007 and January 2010 13092 patients were enrolled in the study. A total of 52 German electrophysiological centers agreed to participate in this prospective multicenter registry. 41 centers included patients undergoing CA for AF. Analysis included patients who were discharged with OAC after CA and had a CHA2DS2-VASc-Score >= 2. A centralized 1 year follow-up (FU) was conducted via telephone.Results: 1300 patients fulfilled the inclusion criteria. One year after CA 51.8 % of these patients were on OAC. Factors significantly associated with discontinuation of OAC included no AF recurrence in FU (adjusted odds ratio (OR): 2.14, [95% confidence interval (CI): 1.73-2.66], P < 0.001) and paroxysmal AF (OR: 1.53 [95 % CI: 1.29-1.81], P < 0.001). Factors associated with continuation of OAK were patient age (OR per 10 years: 0.79 [95% CI: 0.68-0.91], P = 0.002), valvular heart disease (OR: 0.67 [95 % CI: 0.48-0.92], P = 0.013), an implanted pacemaker, defibrillator or a cardiac resynchronization therapy system (OR: 0.55 [95 % CI: 0.41-0.74], P < 0.001) and neurological events in hospital or during FU (OR: 0.40 [95 % CI: 0.18-0.88], P < 0.022).Conclusion: Almost half of the patients with an indication for OAC are not adequately anticoagulated one year after CA for AF. Paroxysmal AF or freedom from AF is significantly associated with discontinuation of OAC.

Introduction Catheter ablation for idiopathic ventricular arrhythmia is well established but epicardial origin, proximity to coronary arteries, and limited accessibility may complicate ablation from the venous system in particular from the great cardiac vein (GCV). Methods Between April 2009 and October 2010 14 patients (56 ± 15 years; 9 male) out of a total group of 117 patients with idiopathic outflow tract tachycardias were included undergoing ablation for idiopathic VT or premature ventricular contractions (PVC) originating from GCV. All patients in whom the PVC arose from the GCV were subject to the study. In these patients angiography of the left coronary system was performed with the ablation catheter at the site of earliest activation. Results Successful ablation was performed in 6/14 (43%) and long-term success was achieved in 5/14 (36%) patients. In 4/14 patients (28.6%) ablation was not performed. In another 4 patients (26.7%), ablation did not abolish the PVC/VT. In the majority, the anatomical proximity to the left coronary system prohibited effective RF application. In 3 patients RF application resulted in a coronary spasm with complete regression as revealed in repeat coronary angiography. Conclusion A relevant proportion idiopathic VT/PVC can safely be ablated from the GCV without significant permanent coronary artery stenosis after RF application. Our data furthermore demonstrate that damage to the coronary artery system is likely to be transient.

Recently, significant progress has been made treating atrial fibrillation (AF) with catheter ablation emerging as an increasingly important technique. Electrical disconnection of the pulmonary veins (PV) is a widely accepted endpoint for interventional treatment of paroxysmal AF (PAF). According to the current guidelines, catheter ablation can be considered as a therapeutic option in patients who failed antiarrhythmic drug treatment for PAF. The procedural endpoint for PVI is achievement of permanent electrical isolation of the PVs, which in the vast majority of patients harbor triggered electrical activity inducing and maintaining PAF. The success rate of this approach in patients with PAF ranges between 60 and 80% after a single procedure and augments to > 80 % in patients undergoing a repeat procedure to abolish recovered PV connection. However, it is now evident that persistent or long-standing persistent AF may not be successfully treated by PVI alone since the majority of patients have AF maintaining substrate beyond the PV. From a pathophysiological perspective this is explained by structural and electrical remodeling of the atrial myocardium in patients with persistent AF. Therefore, it is today widely accepted that additional substrate modification is required to effectively address persistent AF using catheter ablation. It has been shown that a combined approach of PV isolation, ablation of fractionated atrial electrograms and application of lines to treat atrial macro-reentrant tachycardias ("stepwise approach") aiming for restoration of sinus rhythm is a favorable strategy to treat persistent AF. However, significant expertise is needed to accomplish all steps within these complex procedures. Therefore, catheter ablation for persistent AF cannot yet be considered "clinically established" and should only be performed in high volume centers. Additional data is needed to verify the beneficial effect of this strategy and determine "predictors" identifying patients profiting most from these ablation strategies. In patients with PAF, catheter ablation has emerged as an established therapy also in comparison to antiarrythmic drug treatment. Recent studies have shown that catheter ablation for PAF is superior to antiarrhythmic drug treatment with regard to mid-term suppression of any atrial arrhythmia. Overall, catheter ablation for AF has still to be considered as a symptomatic treatment since evidence for beneficial effects with regard to more robust clinical endpoints such as death, rehospitalization and ischemic cerebral events are not yet available.