Venous Vascular Closure System Versus Figure-of-Eight Suture Following Atrial Fibrillation Ablation - The STYLE-AF Study

BACKGROUND

Simplified ablation technologies for pulmonary vein isolation (PVI) are increasingly performed worldwide. One of the most common complications following PVI are vascular access-related complications. Lately, venous closure systems (VCS) were introduced into clinical practice, aiming to reduce the time of bedrest, to increase the patients' comfort and to reduce vascular access-related complications.

AIMS

To compare the safety and efficacy of using a VCS to achieve haemostasis following single shot PVI to the actual standard of care (figure-of-eight suture and manual compression (MC)).

METHODS

This is a prospective, multicentre, randomized, controlled, open-label trial performed at 3 German centres. Patients were randomized 1:1 to undergo haemostasis either by means of VCS (VCS group) or of a figure-of-eight suture and MC (F8 group). The primary efficacy endpoint was the time to ambulation, while the primary safety endpoint was the incidence of major periprocedural adverse events until hospital discharge.

RESULTS

A total of 125 patients were randomized. The baseline characteristics were similar between the groups. The VCS group showed a shorter time to ambulation (109.0 (82.0, 160.0) vs. 269.0 (243.8, 340.5) min; p<0.001), shorter time to haemostasis (1 (1, 2) vs. 5 (2, 10) min; p<0.001) and shorter time to discharge eligibility (270 (270, 270) vs. 340 (300, 458) min; p<0.001). No major vascular access related complication was reported in either group. A trend towards a lower incidence of minor vascular access related complications on the day of procedure was observed in the VCS group (7 (11.1%) vs. 15 (24.2%); p=0.063) as compared to the control group.

CONCLUSION

Following AF ablation, the use of a VCS results in a significantly shorter time to ambulation, time to haemostasis and time to discharge eligibility. No major vascular access related complications were identified. The use of MC and a figure-of-eight suture showed a trend towards a higher incidence of minor vascular access related complications.

Developing a Virtual Reality Simulation System for Preoperative Planning of Robotic-Assisted Thoracic Surgery

Background. Robotic-assisted thoracic surgery (RATS) is now standard for lung cancer treatment, offering advantages over traditional methods. However, RATS's minimally invasive approach poses challenges like limited visibility and tactile feedback, affecting surgeons' navigation through com-plex anatomy. To enhance preoperative familiarization with patient-specific anatomy, we devel-oped a virtual reality (VR) surgical navigation system. Using head-mounted displays (HMDs), this system provides a comprehensive, interactive view of the patient's anatomy pre-surgery, aiming to improve preoperative simulation and intraoperative navigation. Methods. We integrated 3D data from preoperative CT scans into Perspectus VR Education software, displayed via HMDs for in-teractive 3D reconstruction of pulmonary structures. This detailed visualization aids in tailored preoperative resection simulations. During RATS, surgeons access these 3D images through Tile-ProTM multi-display for real-time guidance. Results. The VR system enabled precise visualization of pulmonary structures and lesion relations, enhancing surgical safety and accuracy. The HMDs offered true 3D interaction with patient data, facilitating surgical planning. Conclusions. VR sim-ulation with HMDs, akin to a robotic 3D viewer, offers a novel approach to developing robotic surgical skills. Integrated with routine imaging, it improves preoperative planning, safety, and accuracy of anatomical resections. This technology particularly aids in lesion identification in RATS, optimizing surgical outcomes.

Impact of very wide antral pulmonary vein isolation on esophageal temperature changes during pulsed field ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Esophageal thermal injury (ETI) is a serious drawback of available energy sources for atrial fibrillation (AF) ablation, especially on the posterior left atrial (LA) wall. Pulsed field ablation (PFA) is a novel non-thermal energy source with promising safety advantages over existing methods due to its unique myocardial tissue specificity sparing the esophagus.

Objective

To evaluate esophageal temperature changes during very wide antral pulmonary vein isolation (PVI) using the PFA system.

Methods

Thirteen consecutive AF patients (62% with paroxysmal AF; age: 61 years; 70% male) underwent first-time PFA under deep sedation. Eight pulse trains (2kV/2.5 sec, bipolar, biphasic, 4x basket/flower configuration each) were delivered to each pulmonary vein (PV). Extra pulse trains in the flower configuration were added for very wide antral circumferential ablation (vWACA). Continuous intraluminal esophageal temperature (TESO) was monitored with an S-shaped esophageal temperature probe.

Results

A median of 32 (IQR 32;32) and 8 (IQR 8;9) pulse trains for PVI and vWACA with a procedural time and catheter dwell time of 67 min (IQR 61-69) and 17 min (IQR 16-18) were applied. PFA with vWACA resulted in consecutive posterior LA wall isolation in 11/13 patients. Fluoroscopically, the esophagus coursed near the right PVs in 2/13, left PVs in 8/13 and mid-posterior wall position in 3/13 patients. Maximum TESO increase from baseline was 0.8 ±0.9 °C. However, no clinically relevant TESO changes occurred (Table 1). On short-term, all patients remained asymptomatic for sore throat, cough, or other symptoms potentially related to ETI. No esophago-duodenoscopy was necessary.

Conclusion

PFA of the PVs and lesion extension to the posterior LA wall demonstrated clinically non-significant TESO changes and has the potential to eliminate the risk of a thermal damage to the esophagus.

Very high-power short-duration temperature-controlled ablation for cavotricuspid isthmus block : the Fast-and-Furious CTI study

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation for typical right atrial flutter (AFL) provides an effective treatment associated with encouraging clinical outcome. The novel micro-electrode ablation catheter allows very high-power short-duration (vHP-SD, 90 W/4 sec) ablation and potentially offers the ability to perform a safe, effective and faster cavotricuspid isthmus (CTI) ablation.

Aims

We evaluated feasibility and efficacy of a vHP-SD (90 W/4 sec) temperature-controlled radiofrequency (RF) CTI ablation for AFL using a novel contact force (CF) sensing ablation catheter with micro-electrodes.

Methods

Fifteen consecutive patients (median age 75 years (interquartile range, IQR: 67, 79), 67 % male) with documented typical AFL were prospectively enrolled and underwent vHP-SD based CTI ablation (90 W/4 sec). Durability of CTI block was proven by pacing maneuvers from both sides of the ablation line.

Results

Complete CTI block using vHP-SD ablation was achieved in all patients (Figure 1). At median 23 (IQR 20; 39) RF applications over a median RF ablation time of 92 (IQR 78, 154) seconds were applied. It was not necessary to switch to the standard temperature-controlled mode to achieve durable CTI block. No periprocedural complications, no charring and no steam pops were observed.

Conclusions

Very high-power short-duration (90 W/4 sec) CTI ablation for the treatment of typical AFL is feasible and efficient. Effective CTI block can be achieved in about 1.5 minutes of RF time.

Comparison of ostial versus very wide antral circumferential pulmonary vein isolation using pulsed field ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is the gold standard for first-time atrial fibrillation (AF) ablation procedures. Wide antral circumferential ablation (WACA) in comparison to ostial PVI has been attributed to an improved rhythm outcome after AF ablation. Pulsed field ablation (PFA) is a novel energy source with promising safety and efficacy advantages over existing ablation methods due to its unique myocardial tissue specificity. Feasibility of PFA for very WACA has not been investigated so far.

Objective

To evaluate procedural characteristics and lesion formation during wide antral circumferential PVI in comparison to ostial PVI using a PFA system.

Methods

Thirty-seven consecutive AF patients underwent first-time PFA under deep sedation. Patients eighter received ostial (ostial group; N = 15: 66 % paroxysmal AF; age: 69 years; 66 % male) or very wide antral (vWACA group; N = 22: 59 % paroxysmal AF; age: 62 years; 73 % male) PFA. Pre and post ablation LA voltage maps were acquired using a 20-pole spiral catheter together with a 3-dimensional electroanatomic mapping system (voltage cutoff ≤0.5 mV). On post ablation maps, lesion size by encircling the ablated area was measured. In all patients, 8 pulse trains (2kV/2.5 sec, bipolar, biphasic, 4x basket/flower configuration each) were delivered to each pulmonary vein (PV). In the vWACA-group, extra pulse trains in flower configuration were added to each PV in a wide antral position continuous intraluminal esophageal temperatures (TESO) were monitored with an S-shaped esophageal temperature probe.

Results

A median of 8 [IQR 8;8] and 10 [IQR 10;11] pulse trains per PV for ostial and vWACA PVI were applied. vWACA PFA resulted in significant larger lesion formation (47.3 cm2 [IQR 39.1; 52.0]) in comparison to ostial PFA (35.5 cm2 [IQR 30.3; 38.1], p=0.013) with consecutive posterior LA wall isolation in 19/22 (86 %) patients (Figure 1). In the vWACA group, median TESO increased by 0.7 °C (TESOmax 36.5 °C [IQR 36.0;36.9]). However, the vWACA approach was not associated with a significant increase in procedure time, sedation dosage or exposure to radiation.

Conclusion

Very wide antral circumferential PFA of the PVs is feasible and was associated with significant larger lesion formation in comparison to conventional ostial PFA. Concomitant posterior LA wall isolation occurred in the majority of patient and did not result in a clinically significant increase of intraluminal esophageal temperatures, procedure time, sedation and radiation dosage.

Removal of a foreign body by rigid bronchoscope after virtual reality-aided presurgical planning: A case report

Flexible bronchoscopy is becoming increasingly important for the removal of airway foreign bodies. However, in cases of risk of coughing during the procedure, rigid bronchoscopic intervention should be performed under general anesthesia. A 22-year-old man presented with history of several episodes of fever, for which he was administered antibiotics at a private clinic. In an annual chest X-ray and chest computed tomography examination, a foreign body, which appeared to be an orthodontic appliance, was discovered in the left main bronchus. It was deemed difficult to remove the foreign body using flexible bronchoscopy because of granulation tissue formation. Therefore, the patient was referred to our institution. We simulated the clinical situation using virtual reality, which indicated that the proximal and distal metallic parts of the appliance had grown into the bronchial mucosa. First, we inserted a rigid bronchoscope under general anesthesia and cut the granulation tissue using an insulation-tipped diathermic knife. Thereafter, we removed the appliance with grasping forceps under rigid bronchoscope guidance. In cases of risk of foreign body encroachment into the bronchial mucosa or granulation tissue development, rigid bronchoscopic intervention is effective. Furthermore, a VR-based intervention may be a useful option in such cases.

•

Virtual reality provides depth perception and spatial understanding for planning.

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A rigid bronchoscope can remove foreign bodies better than a flexible one.

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Cutting tracheal mucosa by an IT knife may be required in some cases.

Immersive 3-Dimensional Virtual Reality Modeling for Case-Specific Presurgical Discussions in Cerebrovascular Neurosurgery

BACKGROUND

Adequate surgical planning includes a precise understanding of patient-specific anatomy and is a necessity for neurosurgeons. Although the use of virtual reality (VR) technology is emerging in surgical planning and education, few studies have examined the effectiveness of immersive VR during surgical planning using a modern head-mounted display.

OBJECTIVE

To investigate if and how immersive VR aids presurgical discussions of cerebrovascular surgery.

METHODS

A multiuser immersive VR system, BananaVisionTM, was developed and used during presurgical discussions in a prospective patient cohort undergoing cerebrovascular surgery. A questionnaire/interview was administered to multiple surgeons after the surgeries to evaluate the effectiveness of the VR system compared to conventional imaging modalities. An objective assessment of the surgeon's knowledge of patient-specific anatomy was also conducted by rating surgeons' hand-drawn presurgical illustrations.

RESULTS

The VR session effectively enhanced surgeons' understanding of patient-specific anatomy in the majority of cases (83.3%). An objective assessment of surgeons' presurgical illustrations was consistent with this result. The VR session also effectively improved the decision-making process regarding minor surgical techniques in 61.1% of cases and even aided surgeons in making critical surgical decisions about cases involving complex and challenging anatomy. The utility of the VR system was rated significantly higher by trainees than by experts.

CONCLUSION

Although rated as more useful by trainees than by experts, immersive 3D VR modeling increased surgeons' understanding of patient-specific anatomy and improved surgical strategy in certain cases involving challenging anatomy.

Developing a virtual reality simulation system for preoperative planning of thoracoscopic thoracic surgery

Background

Video-assisted thoracoscopic surgery (VATS) has become a standard approach for the treatment of lung cancer. However, its minimally invasive nature limits the field of view and reduces tactile feedback. These limitations make it vital that surgeons thoroughly familiarize themselves with the patient’s anatomy preoperatively. We have developed a virtual reality (VR) surgical navigation system using head-mounted displays (HMD). The aim of this study was to investigate the potential utility of this VR simulation system in both preoperative planning and intraoperative assistance, including support during thoracoscopic sublobar resection.

Methods

Three-dimensional (3D) polygon data derived from preoperative computed tomography data was loaded into BananaVision software developed at Colorado State University and displayed on an HMD. An interactive 3D reconstruction image was created, in which all the pulmonary structures could be individually imaged. Preoperative resection simulations were performed with patient-individualized reconstructed 3D images.

Results

The 3D anatomic structure of pulmonary vessels and a clear vision into the space between the lesion and adjacent tissues were successfully appreciated during preoperative simulation. Surgeons could easily evaluate the real patient’s anatomy in preoperative simulations to improve the accuracy and safety of actual surgery. The VR software and HMD allowed surgeons to visualize and interact with real patient data in true 3D providing a unique perspective.

Conclusions

This initial experience suggests that a VR simulation with HMD facilitated preoperative simulation. Routine imaging modalities combined with VR systems could substantially improve preoperative planning and contribute to the safety and accuracy of anatomic resection.

P1438Predictors and clinical impact of bleeding events after left atrial appendage closure in patients with high risk or a history of bleeding

Background

Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation and may be especially attractive in patients with high risk or a history of bleeding. However, data of clinical benefit and incidence of post-procedural bleeding in patients with both high risk of bleeding and ischemic cerebral stroke after LAAC are lacking.

Objectives

This study sought to identify predictors and the prognostic impact of post-LAAC bleeding in patients at high risk and/or history of bleeding in the direct oral anticoagulant therapy (DOAC) era.

Methods and results

We retrospectively enrolled a total of 195 patients (75 ± 8.7 years, 38% female, 47% with previous major bleeding, mean CHA2DS2-VASc score 4.3 ± 1.6 and mean HAS-BLED score 2.7 ± 1.1) undergoing endocardial (91%) or epicardial (9%) LAAC during a mean follow-up of 339 ± 319 days. Twenty-three (11.9%) patients developed procedure-unrelated bleeding events after a median of 147 (43, 362) days after LAAC, in 12/23 (52%) patients under single antiplatelet therapy (SAPT), 6/23 (26%) dual antiplatelet therapy (DAPT), 1/23 (4%)  DOAC, 1/23 (4%) VKA, 2/23 (9%) dual therapy (SAPT and DOAC/VKA) and 1/23 (4%) triple therapy (DAPT and DOAC/VKA). (Figure) Diabetes mellitus and previous major bleeding were identified as the independent predictors of post-LAAC bleeding (Odds ratio 2.65 [95% CI:1.04-6.73], p = 0.041, and 5.50 [95% confidence interval:1.72-17.5], p = 0.004). Post-LAAC bleeding was associated with all-cause death (9/23 [39%] vs 18/171 [11%], p = 0.001), but not ischemic stroke/TIA (1/23 [4%] vs 6/171 [4%], p = 0.593) nor device thrombus (2/23 [9%] vs 3/171 [2%], p = 0.108). Kaplan-Meier curve estimated that patients with post-LAAC bleeding had a worse mortality than those without post-LAAC bleeding (3-year mortality; 35.6% [95%CI; 11.6-61.0%] vs 68.7% [45.0-83.8], p = 0.029)

Conclusions

In AF patients with high bleeding risk or history of bleeding undergoing LAAC, bleeding events are common and may occur even after long-term duration after LAAC. Previous major bleeding history strongly predicts subsequent bleeding events following LAAC and is associated with unfavorable mortality. Further investigations are required to identify optimal post-procedural antithrombotic strategies for patients undergoing LAAC with previous major bleeding.

Abstract Figure. The association between time to bleeding

P2846Focal impulse and rotor modulation ablation versus pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation (FIRMAP AF study)

Background

Based on the assumption of trigger elimination, pulmonary vein isolation (PVI) currently presents the gold standard of atrial fibrillation (AF) ablation. Recently, rapidly spinning rotors or focal impulse formation has been raised as a crucial sustaining mechanism of AF. Ablation of these rotors may potentially obviate the need for trigger elimination with PVI.

Purpose

This study sought to compare the safety and effectiveness of Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation only with the gold standard of pulmonary vein isolation (PVI) in patients with paroxysmal AF.

Methods

This was a post-market, prospective, single-blinded, randomized, multi-center trial. Patients were enrolled at three centers and equally (1:1) randomized between those undergoing conventional RF ablation with PVI (PVI group) vs. those treated with FIRM-guided RF ablation without PVI (FIRM group). Data was collected at enrollment, procedure, and at 7-day, 3-month, 6-month, and 12-month follow-up visits. The study was closed early by the sponsor. At the time of study closure, any pending follow-up visits were waived.

Results

From February 2016 until February 2018, a total of 51 (out of a planned 170) patients (mean age 63±10.6 years, 57% male) were enrolled and randomized. Four patients withdrew from the study prior to treatment, resulting in 23 patients allocated to the FIRM group and 24 in the PVI group. Only 13 patients in the FIRM group and 11 patients in the PVI group completed the 12-month follow-up. Statistical analysis was not completed given the small number of patients.

Single-procedure effectiveness (freedom from AF/atrial tachycardia recurrence after blanking period) was 52.9% (9/17) in the FIRM group and 85.7% (12/14) in the PVI group at 6 months; and 31.3% (5/16) in the FIRM group and 80% (8/10) in the PVI group at 12 months. Repeat procedures were performed in 45.8% (11/24) patients in the FIRM group and 7.4% (2/27) in the PVI group.

The acute safety endpoint [freedom from procedure-related serious adverse events (SAE)] was achieved in 87% (20/23) of FIRM group patients and 100% (24/24) of PVI group patients. Procedure related SAEs occurred in three patients in the FIRM group: 1 femoral artery aneurysm and 2 injection site hematomas. No additional procedure-related SAEs were reported >7 days post-procedure.

Conclusions

These partial study effectiveness results reinforce the importance of PVI in paroxysmal atrial fibrillation patients and suggest that FIRM-guided ablation alone (without PVI) is not an effective strategy for treatment of paroxysmal AF in most patients. Further study is needed to understand the effectiveness of adding FIRM-guided ablation as an adjunct to PVI in this patient group.

Acknowledgement/Funding

Abbot

P343Comparison of Focal Impulse and Rotor Modulation Ablation (FIRM) only versus second-generation cyroballoon ablation in patients with paroxysmal atrial fibrillation

Background

Rotors have been postulated to be a major driver of atrial fibrillation (AF). Initial studies demonstrated, that focal impulse and rotor modulation (FIRM) might be an effective therapy for the treatment of paroxysmal AF (PAF). However, data about FIRM-guided ablation strategies without PVI is sparse.

Objective

To compare the safety and efficacy of FIRM-guided catheter ablation (without PVI; FIRM arm) and second generation cryoballoon (CB2, CB2 arm) based PVI in patients with paroxysmal atrial fibrillation (PAF) and de-novo catheter ablation of AF.

Methods

In this retrospective single-center study patients with PAF undergoing de-novo ablation of PAF between February 2016 and January 2017 were enrolled. Patients treated with FIRM-guided AF ablation as a standalone therapy without PVI were included and compared with patients undergoing CB2 based PVI. All patients in the FIRM arm were part of the randomized multicenter FIRMAP AF trial (results of this trial will be presented at this meeting). In patients undergoing FIRM-guided ablation, 3D electroanatomical mapping of both atria was performed. Rotor mapping using FIRM technology was conducted in spontaneous or induced AF. The procedural endpoint was the elimination of all rotors and focal impulses; no PVI was performed in those patients. In the CB2 arm, CB based PVI with the procedural endpoint of isolation of all veins was performed. Procedural data and arrhythmia-free survival after 12 months were compared.

Results

FIRM-guided and CB2 based AF ablation was performed in 22 and 86 patients, respectively. Follow up was completed in 20 and 79 patients LA diameter differed between groups. Otherwise, baseline characteristics did not differ between the FIRM group (mean age 60±11 years, 59.1% males) and the CB2 group (mean age 62±13, 62.4% male).

Arrhythmia-free survival including a 90-day blanking period was 25.0% (15/20) in the FIRM group and 86.1% (11/79) in the CB2 PVI group (p=0.000; Figure 1). Procedure duration was significantly longer in the FIRM group (152 [120; 176] minutes) compared to the CB2 PVI group (122 [110; 145] minutes) (p=0.031), whereas radiation dose was lower in the FIRM group (1266 [1027; 2281] cGy·cm2 vs. 3020 [1677; 4215] cGy·cm2). Adverse events (groin complications) occurred in 1 patient (1.2%) in the CB2 PVI group and 5 patients (22.7%) in the FIRM group.

Figure 1. Kaplan-Meier-survival curve dem

Conclusion

De novo ablation of PAF using a FIRM-guided AF ablation only (without PVI) is associated with poor arrhythmia-free survival after 12 months compared to CB2 PVI. These results underline the importance of PVI as the first-line approach in catheter ablation of AF.

[Ablation of supraventricular tachycardias : Complications and emergencies]

Catheter ablation is an established treatment of supraventricular tachycardias (SVT) with high success rates of > 95 %. Complication rates range from 3 to 5 %, with serious complications occurring in about 0.8 %. There are general complications caused either by the vascular access or the catheters (e. g. hematomas, hemo-pneumothorax, embolism, thrombosis and aspiration) und specific ablation related complications (e. g. AV block during ablation of the slow pathway). The complication risk is elevated in elderly and multimorbid patients. Furthermore, the experience of the treating physician and the respective team plays an essential role. The purpose of this article is to give an overview on incidences, causes and management as well as prevention strategies of complications associated with catheter ablation of SVT.

Left ventricular global function index assessed by cardiovascular magnetic resonance for the prediction of cardiovascular events in ST-elevation myocardial infarction

BACKGROUND

The left ventricular performance index (LVGFI) as a comprehensive marker of cardiac performance integrates LV structure with global function within one index. In a prospective cohort study of healthy individuals the LVGFI demonstrated a superior prognostic value as compared to LV ejection fraction (LVEF). In patients after ST-segment elevation myocardial infarction (STEMI), however, the role of the LVGFI is unknown. Aim of this study was to investigate the relationship between the LVGFI and infarct characteristics as well as prognosis in a large multicenter STEMI population.

METHODS

In total 795 STEMI patients reperfused by primary angioplasty (<12 h after symptom onset) underwent cardiovascular magnetic resonance (CMR) at 8 centers. CMR was completed within one week after infarction using a standardized protocol including LV dimensions, mass and function for calculation of the LVGFI. The primary clinical endpoint of the study was the occurrence of major adverse cardiac events (MACE).

RESULTS

The median LVGFI was 31.2 % (interquartile range 25.7 to 36.6). Patients with LVGFI < median had significantly larger infarcts, less myocardial salvage, a larger extent of microvascular obstruction, higher incidence of intramyocardial hemorrhage and more pronounced LV dysfunction (p < 0.001 for all). MACE and mortality rates were significantly higher in the LVGFI < median group (p < 0.001 and p = 0.003, respectively). The LVGFI had an incremental prognostic value in addition to LVEF for prediction of all-cause mortality.

CONCLUSIONS

The LVGFI strongly correlates with markers of severe myocardial and microvascular damage in patients with STEMI, offering prognostic information beyond traditional cardiac risk factors including the LVEF.

TRIALS REGISTRATION

ClinicalTrials.gov: NCT00712101.

Embryonic GABA(B) receptor blockade alters cell migration, adult hypothalamic structure, and anxiety- and depression-like behaviors sex specifically in mice

Neurons of the paraventricular nucleus of the hypothalamus (PVN) regulate the hypothalamic- pituitary-adrenal (HPA) axis and the autonomic nervous system. Females lacking functional GABA_B receptors because of a genetic disruption of the R1 subunit have altered cellular characteristics in and around the PVN at birth. The genetic disruption precluded appropriate assessments of physiology or behavior in adulthood. The current study was conducted to test the long term impact of a temporally restricting pharmacological blockade of the GABA_B receptor to a 7-day critical period (E11–E17) during embryonic development. Experiments tested the role of GABA_B receptor signaling in fetal development of the PVN and later adult capacities for adult stress related behaviors and physiology. In organotypic slices containing fetal PVN, there was a female specific, 52% increase in cell movement speeds with GABA_B receptor antagonist treatment that was consistent with a sex-dependent lateral displacement of cells in vivo following 7 days of fetal exposure to GABA_B receptor antagonist. Anxiety-like and depression-like behaviors, open-field activity, and HPA mediated responses to restraint stress were measured in adult offspring of mothers treated with GABA_B receptor antagonist. Embryonic exposure to GABA_B receptor antagonist resulted in reduced HPA axis activation following restraint stress and reduced depression-like behaviors. There was also increased anxiety-like behavior selectively in females and hyperactivity in males. A sex dependent response to disruptions of GABA_B receptor signaling was identified for PVN formation and key aspects of physiology and behavior. These changes correspond to sex specific prevalence in similar human disorders, namely anxiety disorders and hyperactivity.

Management of patients pre-, per- and postcatheter ablation procedures: how to minimize complications?

Catheter ablation using radiofrequency energy has become an accepted and safe treatment of cardiac arrhythmias. Nevertheless, it is important to determine the risk-to-benefit ratio of a specific procedure, especially when treating subjects with non-life-threatening cardiac arrhythmias, such as AV-nodal reentrant tachycardia or atrial fibrillation, and efforts have to be made to reduce the incidence of complications associated with these procedures, which are in the vast majority of cases not directly attributable to RF energy application but rather with obtaining peripheral vascular access or intracardiac catheter manipulation. Although complication rates in atrial fibrillation (AF) ablation have decreased with improvements of the ablation technique and a change of ablation concepts since the introduction of this technique, the risk of complication is still considerable and significantly higher compared to ablation procedures of other supraventricular tachycardia, including potentially life-threatening events. The higher incidence of AF ablation associated complications may be explained by the complex technique, the need for trans-septal puncture or extensive manipulation in the thin walled left atrium, as well as possible adverse effects of sedation. Even "new" complications associated with AF catheter ablation were identified, such as pulmonary vein stenosis or atrio-esophageal fistula formation. This article will review general risks and complications that can occur during RF catheter ablation procedures and conscious sedation with a particular attention on AF ablation procedures.

[Atrial fibrillation. New aspects for diagnosis and follow-up]

Continuous rhythm monitoring is the gold standard of objective rhythm assessment in patients with atrial fibrillation, thus, facilitating accurate detection of symptomatic and asymptomatic atrial fibrillation. This is of scientific and clinical interest for the understanding of this arrhythmia, the establishment of evidence-based therapeutic approaches, the definition of clinically indicated monitoring strategies, and for decision-making about oral anticoagulation. This article illustrates the importance of continuous monitoring of atrial fibrillation and presents developing technologies with their advantages and limitations as well as initial clinical experience.