A prospective observational single-center study with a retrospective analysis of procedural data was conducted to assess the effects of ET thresholds on freeze termination rates. Data from the POLARx™ system (Group A) and the Arctic Front AdvancePro™ system (Group B) were compared. Procedures were guided by pulmonary vein angiography and intracardiac echocardiography, with cryo-dosing based on time-to-isolation (TTI). A standard freeze duration of 180 seconds was employed, with additional applications as necessary. Continuous monitoring of ET was performed using an S-CATH Esophageal Temperature Probe, and freeze applications were terminated when the ET dropped below 15°C. A hypothetical termination rate was calculated for the proposed cut-off of 20°C. From October 2018 to October 2024, a total of 1,757 patients (50.7% paroxysmal AF) were enrolled, with a mean age of 66.2 years. The cohort included 1,058 males (60.2%) and 699 females (39.8%). Three hundred thirty-patients (18.8%) were treated in group A, and 1,426 patients (81.2%) were assigned to group B. In group B, persistent AF was documented more frequently (55.0% vs. 22.7%, p<0.001). Significant procedural differences were noted, with Group A having lower median dose area products than Group B (701 cGy×cm² vs. 916 cGy×cm², p<0.001). Acute PVI was achieved in 7,116 veins (99.8%), with a median time to isolation of 37 seconds and a single-shot success rate of 91.0%. TTI was recorded in 73.1% of cases, with Group A showing a higher single-shot success rate (93.9% vs. 91.1%, p<0.001). Minimal esophageal temperatures were similar (34.4°C vs. 35.2°C, p=0.125), but minimal balloon temperatures were lower in Group A (-56.0°C vs. -49.0°C, p<0.001). Freeze termination rates due to low ET (<15°C) were equal in both groups (5.5% vs. 5.6%, p=1.0). Hypothetically increased thresholds (<20°C) for freeze termination showed no significant difference (10.8% vs. 10.2%, p=0.51). Freeze termination due to low ET occurred most frequently in the left inferior pulmonary vein (LIPV) (13.3%) and right inferior pulmonary vein (RIPV) (6.9%). Increased ET (<20°C) would significantly raise freeze terminations in the LIPV (23.6%) and RIPV (11.8%). Raising the ET threshold from 15°C to 20°C for freeze application termination in CBA significantly increases termination rates, especially in the LIPV and RIPV. No significant differences were found between the two available CBA systems regarding freeze terminations or procedural success. While a higher threshold may enhance safety by reducing the risk of AEF, it may also lead to more frequent freeze interruptions.

Atrial fibrillation (AF) is the most common arrhythmia, associated with increased risks of stroke and heart failure. Cryoballoon ablation (CBA) has emerged as a leading treatment for symptomatic AF, providing effective pulmonary vein isolation (PVI). While new technologies like pulsed field ablation are promising, long-term outcome data are limited. This study presents a 17-year longitudinal analysis of CBA outcomes at a high-volume center, assessing procedural success, complication rates, and long-term arrhythmia-free survival. A prospective observational single-center all-comer study was conducted to evaluate long-term efficacy and safety of CBA as the initial ablation approach for AF. Over the study period, various CB systems and protocols were employed. The majority was guided by PV angiography, intracardiac echocardiography, and esophageal temperature monitoring, with cryo-dosing based on time-to-isolation (TTI). A standard freeze duration of 180 seconds was applied, with an additional freeze if TTI was ≥45 seconds or if TTI data were unavailable. From 2007 to 2024, 4,167 CBA procedures were performed, including 424 repeat ablations among 3,937 consecutive patients. Of these, 46.2% had persistent AF. Mean patient age was 65±11 years, with 38.5% female. Key baseline characteristics included a mean left atrial diameter of 42±7 mm, BMI of 26.2 kg/m² [5.8], and a median CHA2DS2-VASc score of 3 [3]. Comorbidities included hypertensive heart disease (22.9%), moderate to severe mitral regurgitation (3.6%), and prior myocardial infarction (1.5%). Procedural data showed a median dose-area product of 1,313 cGy×cm² [1,802], median fluoroscopy time of 23 minutes [24], and procedural time of 95 minutes [30]. Various CB systems were used: first-generation ArcticFront™ (20.4%), second-generation ArcticFront Advance™ (31.8%), ArcticFront AdvanceST™ (6.4%), fourth-generation ArcticFront AdvancePro™ (33.7%), and POLARx/-Fit™ (7.6%). Acute PVI was achieved in all pulmonary veins. Complications occurred in 7.9% of cases. Major adverse cardiovascular and cerebrovascular events were recorded in 5 patients (0.01%), including 5 strokes with no associated deaths or myocardial infarctions. Major complications included persistent phrenic nerve palsy (0.6%) and pericardial effusion requiring intervention (0.1%). Minor complications affected 7.2% of patients, with transient phrenic nerve palsy in 3.8%. During a mean follow-up of 45 months, 30.1% of patients experienced arrhythmia recurrence, with no independent risk factors for AF or atrial tachycardia recurrence identified in multivariate analysis. This 17-year all-comer study of CBA as the initial ablation strategy for AF demonstrated effective long-term outcomes and a favourable safety profile. These results reinforce the role of CBA as a reliable approach for managing AF, highlighting its efficacy in optimizing patient outcomes amid evolving treatment technologies.

Abstract The left atrial appendage (LAA) is an important part of the heart that can contribute to the formation of blood clots and the development of arrhythmias. Managing the LAA is crucial in clinical practice. Besides oral anticoagulation, one approach is LAA occlusion, which can reduce the risk of blood clots in selected patients. Another approach is LAA ablation, which has been proposed in addition to pulmonary vein isolation (PVI) and might improve the success of treating atrial fibrillation (AF). Different types of LAA morphology have been identified, and these differences can affect the choice of treatment and strategies for individual patients. To refine current classification system, a new approach has been proposed. The study utilized an observational single-center trial with blinded retrospective analysis of cardiac computed tomography angiography (CCTA) images from cryoballoon PVI patients. Statistical analysis included baseline characteristics and left atrium/LAA measurements. An LAA bounding box was introduced to enhance the current classification system, particularly focusing on distinguishing "chicken-wing" and "windsock," as well as "cauliflower" and "cactus" morphologies. From 2012 to 2016 a total of 1.103 patients underwent second generation cryoballoon PVI. Prior to PVI, CCTA was available for 725 (65.7%) patients with sufficient quality for measuring in 473 (65.2%). Mean age was 66.3±9.5 years; Paroxysmal AF was present in 277 (58.6%) participants. The distribution of LAA morphological types was as follows: "windsock" 51%, "chicken-wing" 20%, "cauliflower" 15%, and "cactus" 13%. Inter-rater reliability, assessed using Cohen's Kappa with Landis and Koch criteria, demonstrated substantial agreement (Kappa = 0.69; p<0.001). "Chicken-wing" morphology had the largest LAA volume at 9.9 (7.9; 12.8) mL, followed by "windsock" morphology with an LAA volume of 9.7 (7.7; 13.1) mL. "Cactus" and "cauliflower" morphologies had considerably smaller LAA volumes, measuring 5.4 (4.6; 7.5) mL and 5.6 (4.4; 7.6) mL, respectively. Bounding box parameters were utilized to distinguish between "windsock" and "chicken-wing" as well as "cauliflower" and "cactus" morphologies. "Windsock" had a maximal LAA depth of 44.3±7.1 mm, while "chicken-wing" measured 40.1±8.6 mm (p<0.001). The sinus values for the bounding box were 0.40±0.06 for "windsock" and 0.44±0.08 for "chicken-wing" (p<0.001). For "cauliflower," the LAA depth averaged 30.42±5.0 mm, whereas for "cactus," it measured 33.4±4.3 mm (p<0.001). The mean sinus of the bounding box was 0.48±0.08 for "cauliflower" and 0.44±0.07 for "cactus" (p<0.05). The utilization of novel bounding box parameters has the potential to aid in the differentiation between different LAA morphologies, such as 'chicken-wing' and 'windsock', as well as 'cactus' and 'cauliflower', especially in cases where the current classification system may not provide clear distinctions.

ObjectivesThe occurrence of sudden cardiac death (SCD) in competitive athletes has led to a discussion about appropriate preparticipation screening models. The role of an electrocardiogram (ECG) in routine testing remains controversial in current guidelines. Furthermore, data on cardiac findings and the prognostic utility of screening strategies in young female elite ice hockey is scarce.MethodsFemale elite ice hockey players were enrolled in the open prospective “General Evaluation Program for Arrhythmia-Related Death in Athletes” (GEPARD) registry from 2008 to 2018. A staged preparticipation screening was performed. The main goal was to determine the prevalence of SCD conditions and identify effective screening tools. The secondary aim was to study baseline results and follow-ups on a unique subgroup of young female ice hockey players.ResultsA total of 88 female ice hockey players, mean age 16 ± 1 years, were prospectively enrolled. The prevalence of conditions potentially leading to SCD during competition was 3.4% (3/88). The 12-lead ECG led to the diagnosis of one congenital long QT and one acute myocarditis and showed a number needed to screen of 44, with a specificity of 98%. One athlete demonstrated a relevant pericardial effusion on echocardiography, which was related to acute toxoplasmosis. No cases of SCD occurred during long-term follow-up.ConclusionThe subgroup of young female ice hockey players showed a notable prevalence of athletes “at risk” of 3.4%, which indicates the importance of preparticipation screening that features a 12-lead ECG as the most important component.

: Given its increasing prevalence, atrial fibrillation (AF) requires increasing attention from general practitioners, internists and cardiologists. It is therefore essential to provide information about the latest advances in AF treatment. The treatment strategy anchored in the guidelines along the CC-to-ABC scheme (Confirm, Characterize - to - Anticoagulation, Better Symptom Control, Comorbidities Management) should also include early rhythm control. Catheter ablation has been established as a safe and effective therapy for restoring and maintaining sinus rhythm. Several studies have shown its superiority over antiarrhythmic drug therapy. By rhythm control, catheter ablation has the potential to improve patients´ quality of live and left ventricular function, as well as reduce the risk of stroke. For selected patients, particularly those with heart failure, catheter ablation is the first-line treatment. Successful AF treatment requires a proactive approach. Thus, it is important to become familiar with the CC-to-ABC scheme, as well as catheter ablation, as effective strategies for treating AF and improve patient prognosis.

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Catheter ablation of symptomatic atrial fibrillation (AF) is an established treatment option. Cryoballoon (CBA) and radiofrequency ablation (RFA) have demonstrated comparable high rates of freedom from atrial arrhythmia recurrence. Comparative data on quality of life (QoL) outcomes with respect to the used energy source are scarce. Purpose To compare QoL changes following CBA versus RFA in symptomatic AF. Methods This is a sub-analysis of the prospective multi-center FREEZE Cohort Study (ClinicalTrials.gov, NCT01360008). QoL changes were assessed by EQ-5D-3L self-report questionnaire and by EHRA symptom score at baseline and follow-up. Five dimensions of QoL were compared between the treatment groups: "mobility", "self-care", "usual activities", "pain/discomfort", and "anxiety/depression". Changes of Visual Analogue Scale (EQ-VAS) and general physical condition (GPC) were assessed. Results From 2011 to 2016, a total of N=4,189 patients were included, and N=2,110 (50.4%) - CBA N=1,590 (75%) and RFA N=529 (25%) - completed all QoL questionnaires. Differences between groups were observed. Mean age was 61.4±10.4 (CBA) and 63.2±10.4 (RFA) years (p<0.001), and 72.8%, and 65.4% of patients demonstrated paroxysmal AF (p<0.01), respectively. EHRA symptom score was >/= II in 89.7% versus 92.9% of patients in CBA and RFA group at baseline (p<0.0001). The median follow-up duration was 422 (CBA) and 482 days (RFA), p<0.0001. At follow-up, atrial arrhythmia recurrence was documented in 45.0% and 56.9% of patients in the CBA and RFA group (p<0.0001), and EHRA Score >/= II was documented in 23.7% and 32.0% of patients (p<0.001), respectively. Repeat ablation was less frequently performed in the CBA group (7.9% vs. 22.3%, p<0.001). Ablation was rated as „overall successful" by 69.5% and 53.7% of the patients in in the CBA and RFA group, respectively (p<0.0001). Significant differences in QoL dimensions from baseline to follow-up were observed between the groups (see Figure): Patients in the CBA group showed a statistically significant greater improvement for the QoL dimension "pain/discomfort", „general physical condition", EQ-VAS, and EQ-5D-Score as compared to the RFA group (all p<0.001). No differences between the groups were found for the dimensions "mobility", "self-care", "usual activities", and "anxiety/depression". Conclusion Catheter ablation in symptomatic AF was associated with a significant improvement of AF symptoms, "pain/discomfort", "anxiety/depression", and GPC in both groups. However, there was only a small benefit of ablation on „mobility", „self-care", and „usual activities". Interestingly, in the CBA group patients reported significantly more frequently amelioration of "pain/discomfort" and „general physical condition". This finding was confirmed by a higher EQ-VAS and EQ-5D-Score as well as a higher level of satisfaction in the CBA group, and might be related to the lower recurrence rate.

Background Pulmonary vein isolation (PVI) is recommended to treat paroxysmal and persistent atrial fibrillation (AF). This analysis aimed to assess the hospital efficiency of single-shot cryoballoon ablation (CBA) and point-by-point radiofrequency ablation (RFA). Methods The discrete event simulation used PVI procedure times from the FREEZE Cohort study to establish the electrophysiology (EP) lab occupancy time. 1000 EP lab days were simulated according to an illustrative German hospital, including 3 PVI cases per day using CBA at one site and RFA at the other. Results The analysis included 1560 CBA patients and 1344 RFA patients from the FREEZE Cohort. Some baseline patients’ characteristics were different between groups (age, AF type, and some concomitant diseases), without being statistically associated to ablation procedure time. Mean procedure time was 122.2 ± 39.4 min for CBA and 160.3 ± 53.5 min for RFA ( p < 0.0001). RFA was associated with a more than five-fold increase of cumulative overtime compared to CBA over the simulated period (1285 h with RFA and 253 h with CBA). 70.7% of RFA lab days included overtime versus 25.7% for CBA. CBA was associated with more days with an additional hour at the end of the EP lab shift compared to RFA (47.8% vs 11.5% days with one hour left, respectively). Conclusion CBA is faster and more predictable than point-by-point RFA, and enables improvements in EP lab efficiency, including: fewer cumulative overtime hours, more days where overtime is avoided and more days with remaining time for the staff or for any EP lab usage. Clinical trial registration NCT01360008 (first registration 25/05/2011).

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein isolation (PVI) is an effective treatment strategy in symptomatic atrial fibrillation (AF) patients. However, this approach shows worse long-term results in individuals suffering from persistent compared to the paroxysmal type. Purpose The objective was to investigate differences of left atrial (LA) as well as left atrial appendage (LAA) anatomy in persistent AF (persAF) and paroxysmal (PAF) and patients. Methods An observational single center study with a blinded retrospective analysis of cardiac computed tomography angiography (CCTA) images was conducted. Dimensions of LA, posterior wall box, pulmonary veins (PV) as well as LAA size and morphology were assessed and statistically analyzed. All important measures are depicted in the attached figure. Results From 2012 to 2016 a total of 1.103 patients underwent second generation cryoballoon PVI. Prior to PVI, CCTA was available for 725 (65.7%) patients with sufficient quality for measuring in 473 (65.2%). Mean age was 66.3±9.5 years; PAF was present in 277 (58.6%) participants. In persAF LA volume [mL] (111.8; 128.8; p<0.001), posterior wall box area [cm2] (11.9; 13.3; p<0.001) and pulmonary vein ostial dimensions were significantly larger compared to PAF. LAA volume [mL] (9.0; 10.0; p=0.01) and LAA ostial perimeters (66.5; 70.0; p=0.003) were also identified to be larger in persAF. However, there was no difference in LAA morphology (overall distribution: "windsock" 51%; "chicken-wing" 20%; "cauliflower" 15% and "cactus" 13%). Conclusion Compared to PAF, persAF patients had significantly larger LA volumes, posterior wall box areas, PV ostial dimensions as well as LAA volumes and LAA ostial perimeters. LAA morphological types were distributed equally in both groups.

Purpose:Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation in persistent AF (persAF), and cryoballoon PVI emerged as an initial ablation strategy. Symptomatic atrial arrhythmia recurrence following successful PVI in persAF is observed more frequently than in paroxysmal AF. Predictors for arrhythmia recurrence following cryoballoon PVI for persAF are not well described, and the role of left atrial appendage (LAA) anatomy is uncertain.Methods:Patients with symptomatic persAF and pre-procedural cardiac computed tomography angiography (CCTA) images undergoing initial second-generation cryoballoon (CBG2) were enrolled. Left atrial (LA), pulmonary vein (PV) and LAA anatomical data were assessed. Clinical outcome and predictors for atrial arrhythmia recurrence were evaluated by univariate and multivariate regression analysis.Results:From May 2012 to September 2016, 488 consecutive persAF patients underwent CBG2-PVI. CCTA with sufficient quality for measurements was available in 196 (60.4%) patients. Mean age was 65.7 ± 9.5 years. Freedom from arrhythmia was 58.2% after a median follow-up of 19 (13; 29) months. No major complications occurred. Independent predictors for arrhythmia recurrence were LAA volume (HR 1.082; 95% CI, 1.032 to 1.134; p = 0.001) and mitral regurgitation ≥ grade 2 (HR, 2.49; 95% CI 1.207 to 5.126; p = 0.013). LA volumes ≥110.35 ml [sensitivity: 0.81, specificity: 0.40, area under the curve (AUC) = 0.62] and LAA volumes ≥9.75 ml (sensitivity: 0.56, specificity 0.70, AUC = 0.64) were associated with recurrence. LAA-morphology, classified as chicken-wing (21.9%), windsock (52.6%), cactus (10.2%) and cauliflower (15.3%), did not predict outcome (log-rank, p = 0.832).Conclusion:LAA volume and mitral regurgitation were independent predictors for arrhythmia recurrence following cryoballoon ablation in persAF. LA volume was less predictive and correlated with LAA volume. LAA morphology did not predict the clinical outcome. To improve outcomes in persAF ablation, further studies should focus on treatment strategies for persAF patients with large LAA and mitral regurgitation.

Background: To investigate gender differences in epicardial adipose tissue (EAT) and plaque composition by coronary CT angiography (CCTA) and the association with cardiovascular outcome. Methods: Data of 352 patients (64.2 ± 10.3 years, 38% female) with suspected coronary artery disease (CAD) who underwent CCTA were retrospectively analyzed. EAT volume and plaque composition from CCTA were compared between men and women. Major adverse cardiovascular events (MACE) were recorded from follow-up. Results: Men were more likely to have obstructive CAD, higher Agatston scores, and a larger total and non-calcified plaque burden. In addition, men displayed more adverse plaque characteristics and EAT volume compared to women (all p < 0.05). After a median follow-up of 5.1 years, MACE occurred in 8 women (6%) and 22 men (10%). In multivariable analysis, Agatston calcium score (HR 1.0008, p = 0.014), EAT volume (HR 1.067, p = 0.049), and low-attenuation plaque (HR 3.82, p = 0.036) were independent predictors for MACE in men, whereas only low-attenuation plaque (HR 2.42, p = 0.041) showed predictive value for events in women. Conclusion: Women demonstrated less overall plaque burden, fewer adverse plaque characteristics, and a smaller EAT volume compared to men. However, low-attenuation plaque is a predictor for MACE in both genders. Thus, a differentiated plaque analysis is warranted to understand gender differences of atherosclerosis to guide medical therapy and prevention strategies.

Die Behandlung von Patienten mit Herzrhythmusstörungen ist von zunehmender Bedeutung. Neben der symptomatischen Therapie kann heute auch eine Senkung der Sterblichkeit durch die Behandlung von Herzrhythmusstörungen erzielt werden. Die Vorbereitung, Durchführung und Nachbereitung elektrophysiologischer Eingriffe und Implantation aktiver Herzrhythmusimplantate sowie die Nachsorge der Patienten erfolgt im Team bestehend aus Assistenz‑, Pflegepersonal und Ärzteschaft. Das vorliegende Weiterbildungscurriculum „Fachassistenz Spezielle Rhythmologie“ soll die Qualität in der Patientenversorgung sichern und optimieren und dem medizinischen nichtärztlichen Personal ein strukturiertes Weiterbildungsprogramm nach den Maßstäben des kontinuierlichen Lernens anbieten. Es soll eine objektivierbare Qualifizierungsmöglichkeit bieten, welche Aufstieg und Karriere im Bereich der Assistenz- und Pflegeberufe unterstützt. Dabei soll Transparenz und Bewusstsein für die notwendigen Kompetenzen des Assistenz- und Pflegepersonals im Gebiet „Spezielle Rhythmologie“ geschaffen und das Berufsfeld bekannter und attraktiver gemacht werden. Neben der fachlichen Qualifikation werden auch persönliche, kommunikative, methodische sowie soziale Kompetenzen vermittelt. Das Weiterbildungscurriculum ist die inhaltliche Grundlage und der Leitfaden für Anbieter von Weiterbildungskursen und beschreibt die Voraussetzungen, die erfüllt werden müssen, um das Zertifikat „Fachassistenz Spezielle Rhythmologie“ der Deutschen Gesellschaft für Kardiologie zu erlangen. Das Curriculum soll neben der Verbesserung der Qualitätskriterien mittelfristig auch zum Ziel haben, eine entsprechend der Qualifizierung höhere Eingruppierung des Assistenz- und Pflegepersonals zu ermöglichen.

Cryoballoon ablation (CBA) aiming at pulmonary vein isolation (PVI) became a standardized atrial fibrillation (AF) ablation procedure. Life‐threatening complications like cardiac tamponade exist. Intracardiac echocardiography (ICE) usage is associated with superior safety in radiofrequency ablation. It is unclear if ICE has an impact on safety of CBA.

Registry data add important information to randomized controlled trials (RCT) on real‐life aspects of implantable cardioverter‐defibrillator (ICD) patients with and without cardiac resynchronization therapy (CRT‐D). This analysis of the prospectively conducted German Device Registry aims at comparing mortality rates, comorbidities, complication rates to results from RCT.

BACKGROUND:Cryoballoon ablation (CBA) for pulmonary vein isolation (PVI) is a standard in atrial fibrillation (AF) ablation but might not be enough in complex atrial arrhythmias (AA). An open three-dimensional wide-band dielectric imaging system (3D-WBDIS) has been introduced to guide CBA.MATERIAL AND METHODS:Pilot study evaluating feasibility and safety of 3D-WBDIS in combination with CBA and optional radiofrequency ablation (RFA) in patients with complex AA defined as (1) history of persistent AF, (2) additional atrial tachycardia/flutter, or (3) previous left atrial ablation.RESULTS:Prospectively, seventeen patients, 68.9 ± 12.2 years of age, with complex AA were enrolled. In 70 pulmonary veins (PV), balloon positioning maneuvers (n = 129) were guided additionally by the occlusion tool (1.84/PV). Compared to angiography, its sensitivity and specificity was 94.5, and 85%, respectively. CBA-PVI was achieved in 100% of PVs including variants. In 68 maps, the median number of mapping points was 251.0 (interquartile range (IQR) 298.0) with a median map volume of 52.8 (IQR 83.9) mL. Following CBA, six additional arrhythmias (two right and two left atrial flutter, one left atrial appendage tachycardia, and one atrioventricular nodal reentry tachycardia) were identified and successfully ablated by means of RFA in five patients (29.4%). Left atrial and fluoroscopy times were 88 (IQR 40) and 20 (IQR 10) minutes, respectively. Dose area product was 1,100 (IQR 1252) cGyxcm2. Freedom from AA after 6 months follow-up time and 90 days blanking period was documented in 10/17 (59%) patients, and 8/17 (47%) without a blanking period. No major complication was observed.CONCLUSION:The combined use of CBA with optional RFA guided by a novel 3D-WBDIS is feasible and safe in patients suffering from complex AA. The occlusion tool shows high sensitivity and specificity for assessment of the balloon occlusion. Additional arrhythmias were successfully mapped and ablated. Short-term outcome is promising, and subsequent prospective, larger outcome studies are necessary to confirm our observations.

Background and aims: We aimed to evaluate the association of epicardial adipose tissue (EAT) with coronary CT angiography (CCTA) plaque parameters on cardiovascular outcome in patients with and without diabetes mellitus. Methods: Data of 353 patients (62.9 +/- 10.4 years, 62% male), who underwent CCTA as part of their clinical workup for the evaluation of suspected or known CAD, were retrospectively analyzed. EAT volume and plaque parameters from CCTA were compared in patients with diabetes (n = 63) and without diabetes (n = 290). Follow-up was performed to record adverse cardiovascular events. The predictive value to detect adverse cardiovascular events was assessed using concordance indices (CIs) and multivariable Cox proportional hazards analysis. Results: In total, 33 events occurred after a median follow-up of 5.1 years. In patients with diabetes, EAT volume and plaque parameters were significantly higher than in patients without diabetes (all p < 0.05). A multivariable model demonstrated an incrementally improved C-index of 0.84 (95%CI 0.80-0.88) over the Framingham risk score and single measures alone. In multivariable Cox regression analysis EAT volume (Hazard ratio[HR] 1.21, p = 0.022), obstructive CAD (HR 1.18, p = 0.042), and >= 2 high-risk plaque features (HR 2.13, p = 0.031) were associated with events in patients with diabetes and obstructive CAD (HR 1.88, p = 0.017), and Agatston calcium score (HR 1.009, p = 0.039) in patients without diabetes. Conclusions: EAT, as a biomarker of inflammation, and plaque parameters, as an extent of atherosclerotic CAD, are higher in patients with diabetes and are associated with increased adverse cardiovascular outcomes. These parameters may help identify patients at high risk with need for more aggressive therapeutic and preventive care.

Supraventrikuläre Tachykardien (SVT) sind häufige und in vielen Fällen (hoch)symptomatische Herzrhythmusstörungen. Die neuen ESC-Leitlinien zum Management der SVT stellen die aktuellen Empfehlungen zur Diagnostik und Behandlung supraventrikulärer Tachykardien vor. Die im Vergleich zu den letzten Leitlinien aus dem Jahr 2003 wesentlichste Änderung in den neuen Leitlinien 2019 ist für viele Formen die deutliche Präferenz der nichtmedikamentösen Behandlung durch die Katheterablation vor der medikamentösen antiarrhythmischen Therapie zur Langzeitbehandlung. Die Katheterablation wird für fast alle Indikationen als Klasse-I-Indikation geführt, Ausnahmen sind die inadäquate Sinustachykardie, multifokale atriale Tachykardien und seltene SVT bei Erwachsenen mit angeborenen Herzfehlern (EMAH). Die elektrische Kardioversion bleibt Methode der ersten Wahl zur Akuttherapie hämodynamisch relevanter Tachykardien. Zur medikamentösen Akuttherapie werden überwiegend Adenosin, Betarezeptorenblocker und Kalziumantagonisten vom Typ Verapamil/Diltiazem empfohlen. Auch aufgrund der äußerst limitierten Daten zur Effektivität und Behandlungssicherheit der medikamentösen antiarrhythmischen Langzeittherapie von SVT wurden die Empfehlungen und Evidenzgrade für die pharmakologische Behandlung teilweise deutlich herabgestuft.

Die neuen Leitlinien der ESC zur Diagnose und Behandlung von Vorhofflimmern setzen die vorhandenen Evidenzen aus den Ergebnissen klinischer Studien in eine klare Perspektive zur klinischen Anwendung um. Deutlich wird der generelle Trend zu einer intensiveren individuellen und personalisierten Betrachtung der Patienten mit Vorhofflimmern insbesondere in 2 Bereichen: durch die Einführung der Charakterisierung von Vorhofflimmern mit dem 4S-Schema (Einbeziehung von Schlaganfallrisiko, Symptome, Vorhofflimmerlast, Substrat) als präzisere Methode im Vergleich zur seit vielen Jahren gelebten „PPP“-Klassifizierung (paroxysmal, persistierend, permanent). Dieser Zugang wird auch in den Ablationsempfehlungen sichtbar, in denen geraten wird, die Rezidivrisiken für das Wiederauftreten von Vorhofflimmern nach einer Ablationsbehandlung bereits vor der Intervention intensiv mit in die Überlegungen einzubeziehen. Wie schon in den 2016 ESC-Leitlinien wird die integrierte Behandlung von Patienten mit Vorhofflimmern betont und mit dem ABC-Behandlungspfad ein einfacher und intuitiver Weg aufgezeigt, um die wesentlichen Behandlungsschritte klar darzustellen: A für „anticoagulation/avoid stroke“, B für „better symptoms“, und C für „comorbidities“. Außerdem werden erstmalig Empfehlungen für Qualitätsindikatoren und für Behandlungsbewertungen durch Patienten (sog. PROs = „patient reported outcomes“) vorgestellt. Im Bereich der Antikoagulation zur Schlaganfallprävention stärken die Leitlinien den Einsatz der Nicht-Vitamin-K-Antikoagulanzien entsprechend dem individuellen Schlaganfallrisiko nach CHA2DS2-VASc, empfehlen aber auch die intensivere Beachtung der Blutungsrisiken. Aufgrund fehlender neuer Studiendaten gibt es keine Änderung der Empfehlungen für den interventionellen Vorhofohrverschluss – es bleibt bei IIb („kann erwogen werden“). Im Bereich der frequenzregularisierenden Behandlung bleiben Kalziumantagonisten und Betablocker ggf. in Kombination mit Digitalis die erste Wahl. In der Rhythmuskontrolle findet sich für den Bereich der medikamentösen Therapie eine nachvollziehbare Abwertung für Sotalol aufgrund der bekannten Behandlungsrisiken. Die kurz nach Veröffentlichung der Leitlinien vorgestellte EAST-Studie wird im Hinblick auf die Bedeutung einer antiarrhythmischen Therapie in diesem Kommentar besonders diskutiert. Aufgewertet wird die Katheterablation von Vorhofflimmern in den Leitlinien insbesondere für Patienten mit Tachykardie-induzierter schwerer Herzinsuffizienz (IB-Empfehlung), aber auch für Patienten mit Vorhofflimmern und HFrEF bei strukturellen Herzerkrankungen (IIa-Empfehlung).

PurposeTo investigate the long-term prognostic value of coronary CT angiography (cCTA)-derived plaque information on major adverse cardiac events (MACE) in patients with and without diabetes mellitus. Methods64 patients with diabetes (63.3±10.1 years, 66% male) and suspected coronary artery disease (CAD) who underwent cCTA were matched with 297 patients without diabetes according to age, sex, cardiovascular risk factors, statin and antithrombotic therapy. Major adverse cardiac events (MACE) were recorded. cCTA-derived risk scores and plaque measures were assessed. The discriminatory power to identify MACE was evaluated using multivariable regression analysis and concordance indices (CIs).ResultsAfter a median follow-up of 5.4 years, MACE occurred in 31 patients (8.6%). In patients with diabetes, cCTA risk scores and plaque measures were significantly higher compared to non-diabetic patients (all p <0.05). The following plaque measures were predictors of MACE using multivariable Cox regression analysis (hazard ratio [HR]) in patients with diabetes: segment stenosis score (HR 1.20, p <0.001), low-attenuation plaque (HR 3.47, p =0.05), and in non-diabetic patients: segment stenosis score (HR 1.92, p <0.001), Agatston score (HR 1.0009, p =0.04), and low-attenuation plaque (HR 4.15, p =0.04). A multivariable model showed significantly improved C-index of 0.96 (95% CI 0.94-0.0.97) for MACE prediction, when compared to single measures alone.ConclusionDiabetes is associated with a significantly higher extent of CAD and plaque features, which have independent predictive values for MACE. cCTA-derived plaque information portends improved risk stratification of patients with diabetes beyond assessment of obstructive stenosis on cCTA alone.

The objective was to analyze the impact of patient age on clinical characteristics, procedural results, safety, and outcome of cryoballoon ablation (CBA) as the primary approach in the interventional treatment of symptomatic atrial fibrillation (AF).