Pulmonalvenenisolation mit multipolaren Ablationskathetern zur Behandlung von paroxysmalem Vorhofflimmern

Atrial fibrillation (AFIB) is the most common atrial rhythm disease and is associated with an increased risk of thrombembolic and cardiac complications. Different therapies are used in clinical routine: frequency control with anticoagulants and rhythm control. In patients with paroxysmal AFIB but without structural heart disease, antiarrhythmic drug therapy was previously first priority; however, pulmonary vein catheter ablation is becoming more important. “Single tip” systems, ultrasound, and various balloon techniques have been used in clinical routine. New radiofrequency systems with multipolar radiofrequency ablation catheters, however, give hope for better outcomes with fewer intraprocedural complications, as well as shorter procedure and fluoroscopy times.     

Therapeutic drug monitoring of tricyclic antidepressants in everyday clinical practice

Data about therapeutic drug monitoring (TDM) of psychotropic medications are often obtained from samples of highly selected individuals, who may not be representative for the average psychiatric patient. These data therefore may have limitations with regard to their transferability to everyday clinical practice. Therefore studies under naturalistic conditions are important to clarify the full clinical relevance of TDM. We retrospectively evaluated all TDM-analyses of the tricyclic antidepressants (TCA) amitriptyline and clomipramine during a 12-month period in an unselected sample of patients in a standard clinical setting. We especially examined the relationship between serum levels on one hand and clinical response and adverse effects on the other hand. In patients with amitriptyline, responders showed a significantly higher serum level than non-responders, whereas in patients with clomipramine a serum level within the recommended therapeutic range was associated with clinical response. We also found significantly higher serum concentrations in patients with adverse effects compared to patients without adverse effects in the clomipramine group. No such relationship could be shown in patients treated with amitriptyline. Our results suggest that therapeutic ranges in naturalistic settings in some ways differ from those obtained in controlled clinical settings and that TDM studies in everyday clinical practice are necessary and beneficial.     

Prevalence of late potentials in high frequency signal-averaged electrocardiography and arrhythmias in long-term ECG in healthy probands]

In a prospective study 79 symptom-free persons (41 females; 38 males) with an age range of 22-69 (mean 44) years were investigated by 48-h continuous ambulatory electrocardiography and by the signal-averaging ECG according to Simson's technique after having normal findings with echocardiography, standard ECG at rest and exercise stress test. Late potentials were defined according to Denes criteria (40 Hz highpass-filter); at least two out of the following three criteria had to be fulfilled for a correct positive finding: 1) QRS duration (QRSdur) greater than 120 ms; 2) root mean square of the last 40 ms (RMS 40) less than 20 microV; 3) mean duration of terminal low-amplitude signals (LAdur) greater than 39 ms. With long-term ECG 25% of the test subjects had no ventricular extrasystoles (VES), 28% had uniform VES, 33% multiform VES, 10% couplets, and 4% short runs of ventricular tachycardia during 48-hour recordings. Only 19% of them showed more than 48 VES/48 h. Individuals of advanced age demonstrated arrhythmias of higher Lown classes, as well as more frequent VES. By applying the signal-averaging technique 12.6% of the apparently healthy individuals showed late potentials, but none had LAdur greater than 45 ms. Individuals of higher age had not more late potentials than the younger ones. However, individuals with incomplete right bundle branch block pattern (n = 6) demonstrated with 50% significantly more often later potentials in comparison to 9.6% of those without this pattern (n = 73) (P less than 0.05). There was no correlation between late potentials and spontaneous arrhythmias, neither with regard to Lown classes, nor with regard to the frequency of VES. In conclusion, late potentials may occur in some individuals without apparent cardiovascular disease; they are unrelated to age as well as to spontaneous ventricular arrhythmias in normals.     

Long-term electrocardiography: value and reliability of various systems

25 years after the introduction of ambulatory electrocardiography four concepts are available: the conventional Holter-ECG, computer-based systems, entire ECG recording in miniaturized form and the event recorder. In contrast to visual analysis with the aid of an arrhythmia computer a more precise and quantitative evaluation of long-term ECG is possible. The reliability of a computer-based system is indicated by its sensitivity, positive predictive accuracy and reproducibility of automatic analysis. Only few of the computerized systems have been repeatedly tested on a company independent basis using these criteria in a representative number of patients, with frequent arrhythmias, and with a separate documentation of false negative, false positive and true positive events. Data available so far show that a reasonable reliability is possible, but 100% remains the exception to the rule. Thus, there is no complete automatic analysis of cardiac arrhythmias, and corrections by the physician are mandatory. This is further emphasized by the fact that only a part of all possible arrhythmias may be identified by computer whereas the other part has to be evaluated by visual control. In this context entire ECG recording is helpful, as an isolated method, however, it cannot be recommended, since the miniaturized ECG prevents analysis of subtle details and provides no quantitative data. Event recorders rely exclusively on the accuracy of the portable arrhythmia detector. Due to the concept of discontinuous ECG recording evaluation of this accuracy is pronounced problematic. Only by changing to the continuous recording mode does validation of the event recorder become possible. The first data demonstrate that the reliability of real-time analysis by the portable arrhythmia detector is not superior to highspeed analysis by the arrhythmia computer. Thus, quality control is necessary when using the event recorder as it is with continuous long-term ECG. However, there are significant limitations: with discontinuous ECG recording false negative events are not documented, separation of false positive from correct positive findings is restricted to the limited recording capacity (12-120 min real time) and the short ECG samples (6-12s) do not allow verification of sustained arrhythmias. Furthermore, questions regarding arrhythmias, ST-segment changes and pacemaker dysfunctions unidentifiable by computer remain unanswered with the use of the event recorder. For these reasons, continuous ambulatory electrocardiography providing complete data for every kind of analysis is still the standard method.(ABSTRACT TRUNCATED AT 400 WORDS)