Cardiac arrhythmia –
Heart Rhythm Academy

Cardiac arrhythmias are quite common and can have very different underlying causes. The spectrum ranges from occasional extra beats to life-threatening ventricular fibrillation. It is therefore not easy to understand whether your own condition is just annoying or (in the long run) life-threatening. And regardless of the severity of the condition, our experience shows that.
Anyone who understands what is going on in their body has less anxiety and feels better. Our Heart Rhythm Academy was developed based on this knowledge. It offers you an encyclopedic insight into the extensive and medically fascinating topic of cardiac arrhythmias – and helps you feel more confident.

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Diagnosis  
of cardiac arrhythmias

To assess cardiac arrhythmias, it is almost always necessary to conduct a comprehensive diagnostic investigation to determine the cause. This includes, e.g., the clarification of a structural heart disease such as

  • coronary heart disease (i.e. vascular heart disease)
  • a heart valve defect or
  • a disease of the heart muscle.

In young people, cardiac arrhythmias often have a genetic cause.
A careful case history provides up to 80% of the diagnosis and is therefore particularly important. For many years, we have successfully used a 12-question catalog for this purpose, which you should answer in advance before visiting our rhythm consultation.

Diagnosis

Electrocardiogram

The electrocardiogram (also known as a standard ECG or 12-lead ECG)has been the standard for diagnosing cardiac arrhythmias for over 100 years. ECG diagnostics are readily available and can be performed quickly and repeatedly. Most arrhythmias can be detected and classified. The ECG provides clues as to the origin and possible severity of the arrhythmia. In combination with the patient’s medical history, an expert evaluation of the ECG (electrocardiogram) can be used to make initial treatment decisions.
The resting ECG is less suitable for documenting sporadic arrhythmia episodes. Much better are methods that continuously record the heart rhythm over a longer period of time or can be activated as needed:

The long-term ECG (also known as Holter ECG monitoring or 24-hour ECG) allows continuous monitoring of the heart rhythm over a period of usually 24-72 hours – with modern devices even over a week or more.
It is important to keep a diary carefully noting down any symptoms, but also sleep phases, stress, medication intake, etc. This helps the doctor to better classify any arrhythmias when evaluating the ECG. You can download the patient diary for a Holter ECG here.
As a patient of the RHYTHMOLOGICUM, we guarantee that we will not have your Holter ECG evaluated by an external provider, as is often the case. The evaluation is carried out by our team of doctors in person, so as not to run the risk of any contextual information being lost.

Event ECG (also known as an event recorder or loop recorder). These devices allow the recording of cardiac arrhythmias in predefined heart rate ranges over an even longer period of up to four weeks.
So-called patient-activated event recorders are a good alternative for symptomatic cardiac arrhythmias that occur in attacks.
Apple has done pioneering work with the ECG recording option in the Apple Watch since version 4. The Apple Smartwatch is now approved as a medical device in the US and Europe and is particularly useful for detecting atrial fibrillation.
Outside the iOS world, smartwatches from Withings®, Samsung® and Fitbit® are good certified alternatives. Other manufacturers are sure to follow.

Implantable event recorders (“loop” recorders)

These small, easy-to-implant devices can continuously record the heart rhythm for several years. 
They are particularly suitable for suspected very rare but dangerous arrhythmias, such as sudden fainting spells with the potential for injury from falls, or to search for atrial fibrillation in cases of unclear stroke.

Electrophysiological study (EPS)

The recording of electrical signals from the heart using special catheters has become less important in the pure diagnosis of cardiac arrhythmias. Less than 5% of the catheter-based electrophysiological procedures we perform are purely diagnostic examinations. However, the EPU is still a prerequisite and thus an integral part of a catheter ablation to trigger and characterize a cardiac arrhythmia.

The diagnostic EPU occasionally still plays a role in confirming the indication for pacemaker implantation and in characterizing the risk of sudden cardiac death.

Under local anesthesia and general sedation (conscious sedation), access ports are placed in the groin area via a blood vessel, through which one to two (rarely more) thin catheters are inserted into the heart. The catheters enable the derivation of electrical signals from different heart chambers with high precision in the range of a few milliseconds. The electrical stimulation can be used to characterize the physiological and pathophysiological conduction properties of the heart muscle and the specific conduction system, and to trigger or terminate any cardiac arrhythmias. In addition, the administration of short-acting medications can often influence the inducibility of cardiac arrhythmias.

A diagnostic EPU rarely takes longer than 20 to 45 minutes and is – even if it may appear otherwise at first glance – a procedure with very few complications. 

If the purpose of the EPU is to evaluate cardiovascular comorbidities, which play a crucial role in the assessment of cardiac arrhythmias, further examinations are possible in the RHYTHMOLOGICUM in addition to pure rhythm diagnostics:
These include, in particular, ultrasound procedures, ergometry and laboratory medical examinations.

Transthoracic echocardiography (syn. cardiac ultrasound, “echo”)

Transthoracic echocardiography (TTE) has been an established procedure for decades for assessing the anatomy and functioning of the heart. It is a non-invasive, painless examination that can be repeated at any time. In rhythmology, the ejection fraction (EF), valvular dysfunction, dimensions of the heart cavities and regional (segmental wall motion abnormalities) are required for the classification and prognosis of arrhythmias. 
An echocardiography takes just 5-15 minutes, depending on the issue at hand.

Special electrophysiological issues relate in particular to the pumping function of the ventricles, the size and function of the atria and the malfunctioning of the heart valves.

Transesophageal echocardiography 
(syn. “swallow echo”)

This examination technique has also been used successfully in cardiology for many years. In rhythmology, its main use is to rule out blood clots in the left atrium in preparation for an atrial fibrillation ablation. TEE, better known as an esophageal echo, can rule out a thrombus with 99% certainty and thus increase the safety of the atrial fibrillation ablation.
The examination is carried out under sedation and carries hardly any risk if performed by an experienced cardiologist.

Intracardiac echocardiography

A thin catheter that can be inserted into the heart via the groin provides a direct view of important cardiac structures and the electrophysiological probes. We are happy to use this rarely performed examination technique in cases of complex anatomy or difficult puncturing of the atrial septum.

Ergometry

The stress ECG examination is an indispensable part of cardiological diagnostics. In rhythmological diagnostics, ergometry enables a very reliable assessment of heart rate behavior at rest, but also during and after physical exertion.
Furthermore, the stress often has an influence on the triggering of cardiac arrhythmias, such as in the diagnosis of extra beats, which increase under stress, but can also occasionally disappear again.

Classifications 
cardiac arrhythmia

Classifications

Bradycardiac cardiac arrhythmia

An incredible feat. Normally, we are not consciously aware of our heartbeat. It is only when we experience arrhythmias such as extra beats or skipped beats that we feel our heart.
Eine unglaubliche Leistung. Normalerweise nimmt man den Herzschlag nicht bewusst wahr. Erst bei Herzrhythmusstörungen wie Extraschlägen oder Aussetzern spürt man sein Herz.

Bradycardia: physiologically slowed heartbeat

At rest, the heart rate usually fluctuates between 60 and 100 beats per minute, depending on the size of the heart and the individual level of fitness. In particularly well-trained people, heart rates below 50/min are more the norm.
If the resting heart rate is below 60 bpm even without endurance sports, this is called a bradycardia. This is not yet a cause for concern, but it should be investigated and treated, especially if it is accompanied by symptoms such as unusual tiredness, dizziness, fainting spells or shortness of breath during everyday activities. A clinical examination, ECG, long-term ECG, stress test, cardiac ultrasound and laboratory tests help to confirm the diagnosis of bradycardia and identify possible causes. Occasionally, sleep studies or tilt table tests are indicated for certain forms of bradycardic arrhythmias.

There are many ways to classify bradycardic arrhythmias. We prefer a pragmatic and practical approach:

Reversible causes
These include

  • Side effects of medications (sleeping pills, opioids, antidepressants and antipsychotics, antihypertensives and antiarrhythmics)
  • Hypothyroidism
  • electrolyte imbalances (blood salts)
  • inflammatory diseases (rheumatoid arthritis, lupus)
  • sleep-related breathing disorders (sleep apnea syndrome)

Irreversible causes

  • degenerative diseases of the heart muscle and the conduction system
  • genetic diseases of the cardiac ion channels
  • storage diseases of the heart
  • Diseases of the heart muscle and circulatory disorders of the heart
  • Rare complication after heart surgery or percutaneous interventional treatments (heart valve therapy, catheter ablation).

While in the case of reversible causes, treatment of the underlying disease can eliminate the bradycardia and its symptoms, in the case of irreversible causes, the implantation of a pacemaker is often necessary.

In the case of bradycardic cardiac arrhythmias, a distinction is made between functional disorders of impulse formation and functional disorders of cardiac conduction. A brief digression into the electroanatomy of the heart:
The heart consists of four chambers. The impulse (origin of the electrical activity) is normally generated in the so-called sinus node, which is located in the upper rear part of the right atrium. The left atrium is excited via the atrial musculature in a very short time (approx. 0.1 s). At the same time, the electrical stimulus also reaches the second important stimulus conduction structure, the AV node (atrioventricular node). The AV node filters the electrical stimulus conduction like a capacitor and normally only conducts electrical impulses up to the maximum heart rate. This delay is vital and protects the main chambers from high heart rates – as in atrial fibrillation or atrial flutter – and thus from life-threatening ventricular rates >250/min.
The third level of the conduction system includes specific pathways that conduct the electrical impulses from the AV node to the working musculature of the main chambers (His bundle, Tawara’s legs, Purkinje system).

Sinus node disease

In addition to reversible causes, sinus node disease is often due to a degenerative disease. As a result of aging processes, the highly sensitive network of impulse-generating cells is irreversibly damaged by connective tissue deposits (“fibrosis”).
This leads to pronounced sinus bradycardia at rest, an inadequate increase in heart rate under stress (“chronotropic incompetence”) and promotes the occurrence of atrial arrhythmias such as atrial fibrillation and atrial flutter (brady-tachycardia syndrome).
In the case of corresponding symptoms, often the only long-term solution is the implantation of a pacemaker.

Conduction disorders

These bradycardic dysrhythmias also often have a degenerative cause. The symptoms are similar to those of sinus node disease: dizziness, fainting spells (syncope), shortness of breath during physical exertion. Once the diagnosis has been confirmed, the implantation of a pacemaker can also enable a symptom-free life here.
The classification of conduction disorders into AV block I-III degrees, bifascicular (two pathways affected) or trifascicular (three pathways disturbed), supra- or infrahisarian (above or below the His bundle) is medically and prognostically important. In particular, a pragmatic symptom- and cause-oriented approach is helpful for older patients.

Tachycardic arrhythmia

If the heart rate is above 100/min, either intermittently or continuously, regardless of physical exertion, this is referred to as a tachycardic arrhythmia.

Sinus tachycardia

The sinus rhythm is able to adapt quickly and as needed to the activity level of the person. During physical work, the oxygen requirement of the muscles increases many times over. The heart can meet this increased demand by increasing the blood volume per heartbeat (stroke volume) and even more by increasing the heart rate (beats/min). While about 5 liters of blood are pumped through the circulation at rest, this value increases sixfold during heavy physical exertion.
If the sinus rate is above 100 beats/min at rest or if it increases disproportionately during light physical exertion, this is referred to as inadequate or non-physiological sinus tachycardia.
There are many possible causes of non-physiological sinus tachycardia:

Cardiac causes, i.e. those affecting the heart:
• Heart failure
• Heart attack
• Diseases of the heart muscle
• Diseases of the heart valves (mitral valve or aortic valve insufficiency)

Extracardiac, i.e. causes outside of the heart:
• Lack of oxygen (due to anemia or “thin air” at high altitudes)
• low blood pressure (e.g. due to dehydration)
• fever
• hormone disorders (e.g. hyperthyroidism)
• medications (e.g. adrenergic substances such as in asthma sprays or antihypertensives)
• luxury foods (caffeine, nicotine, alcohol)
• drugs (cannabis, cocaine, amphetamines)
• Disorders of the autonomic nervous system
• Psychosomatic illnesses

If cardiac problems have been ruled out and extracardiac causes have been eliminated, but the sinus tachycardia is still present, it may also be a disorder of the autonomic system or, not infrequently, a psychosomatic illness.
Symptomatic drug therapy is usually only indicated and useful after comprehensive diagnostic exclusion procedures. Catheter ablation for the treatment of sinus tachycardia is rarely necessary in our practice.

Atrial tachycardias

This form of cardiac arrhythmia is relatively rare. It may be caused by a focus of increased electrical activity, a microcirculation or a mechanism involving circulatory tachycardia. Atrial tachycardias are increasingly being observed as a result of ablation of atrial fibrillation. 
Drug therapy is often difficult and often fails due to the side effects of the medications administered. Catheter ablation is clearly the most effective treatment, but it is not always successful at the first attempt.

AV nodal reentry tachycardia (AVNRT)

AVNRT is the most common tachycardic arrhythmia in young people. It is almost always congenital, and occasionally there is a familial predisposition. The mechanism of tachycardia is based on the different conduction properties of the tissue supplying the AV node (slow and fast conduction of excitation). It is triggered by extra beats or volleys of extra beats.

In younger patients, the heart rate is typically around 150/min. It is described as starting and stopping suddenly, “like flipping a switch”.

In general, AVNRT is a benign arrhythmia. However, in up to 5% of patients, there is a possibility of sudden loss of consciousness triggered by the body’s own reflex.

Due to the possibility of a complete cure in over 95% of cases, we recommend catheter ablation as the treatment of choice for this arrhythmia.

AV reentry tachycardia (AVRT)

This arrhythmia is very similar to the AVNRT described above in terms of frequency and symptoms. The heart rate is usually somewhat higher (often >200/min). However, the mechanism of the tachycardia is different. It is caused by a muscle bridge between the atrium and the ventricle that remains from the embryonic formation of the heart. Here, too, additional beats can trigger the tachycardia. 95% of these reentry tachycardias in AVRT have an activation from the atrium via the AV node to the ventricle and back via the additional conduction pathway (orthodromic AVRT). Only 5% of tachycardias have a reverse mechanism (antidromic AVRT).
AVRT is found in Wolf-Parkinson-White (WPW) syndrome. It is very rare, but of great medical significance, that rapid atrial arrhythmias such as atrial fibrillation can pass unhindered to the ventricles via the muscle bridge between the atrium and ventricle, which lacks the braking and protective properties of the AV node, and can lead to syncope or even sudden cardiac death. Therefore, we recommend catheter ablation as the method of first choice for patients with this arrhythmia.

Atrial flutter

Atrial flutter is the most common sustained cardiac arrhythmia after atrial fibrillation. Similar to atrial fibrillation there is a significantly increased risk of stroke due to the formation of blood clots in the left atrium.
In typical atrial flutter, the excitation front circles around the tricuspid valve (three-leaved valve) between the right atrium and right ventricle. Less common forms occur after heart surgery or catheter interventions. In these cases, the excitation usually circles around scar tissue.
The aim of medical treatment is to lower the heart rate and to protect against stroke.
There are currently no medications available that can safely and effectively restore the heart rhythm or prevent atrial flutter. Ablation therapy is therefore also used to treat this condition, and it can be performed with a high degree of safety and effectiveness (90%).

Atrial fibrillation

Atrial fibrillation has only been in the public eye since the beginning of the 1980s. The link between stroke and this cardiac arrhythmia has therefore only been known for a short time.

Thanks to the consistent inhibition of blood clotting, the stroke rate and thus mortality from this by far the most common cardiac arrhythmia has been dramatically reduced. Drug treatment and, in particular, interventional treatment with catheter ablation can effectively prevent the arrhythmia.

Nevertheless, atrial fibrillation with its epidemiological dimension (1-2% of the population suffer from this arrhythmia) remains a major challenge of our time – for the affected patients and their relatives, but also for the health care systems.

Atrial fibrillation is not harmless. Recent studies show that atrial fibrillation not only reduces quality of life, but can also lead to heart failure, dementia and, statistically, an earlier death.

Therefore, treatment of atrial fibrillation is indicated at an early stage, even in apparently asymptomatic or low-symptom forms.

Our brochure “Living with Atrial Fibrillation” provides more information on the development, symptoms, progression and basic treatment of this heart rhythm disorder.

Depending on the individual risk of stroke, anticoagulation is the basic treatment for atrial fibrillation and serves to prevent blood clots from forming in the left atrium. These clots can form in a pouch-like bulge in the left atrium, known as the atrial appendage, when the pumping function is severely restricted by atrial fibrillation.
The high frequency of electrical activity (up to 450/min and more) of the atria during atrial fibrillation practically brings the mechanical contraction to a standstill.
Drug treatment can be supplemented with conduction-delaying medications such as beta blockers, especially at an increased baseline frequency above 100/min. The actual antiarrhythmic drugs used to prevent atrial fibrillation are only partially effective or have a high side effect profile in most forms of atrial fibrillation.

Therefore, catheter ablation has become established as the most effective and least complicated treatment method in recent years.
Depending on the stage of atrial fibrillation, but also on its cause, pulmonary vein isolation (syn. pulmonary vein isolation, PVI) is also effective in the long term (at least one year) between 60 and 80%.

At our center, we favor pulmonary vein isolation using cooling technology (also known as cryoablation or cryo-PVI) as the primary procedure. In our view, cryoablation is the gentlest and most physiological therapeutic procedure, which specifically destroys the cells that trigger atrial fibrillation without affecting the connective tissue framework of the heart. In addition, the body’s own inflammatory reactions, which occur after ablation and can themselves trigger atrial fibrillation, are less pronounced with this form of energy.

For more information on ablation therapy, see pulmonary vein isolation.

Extrasystoles

Extrasystoles are additional heartbeats. They can originate from the atria (atrial extrasystoles, supraventricular extrasystoles) or from the ventricles (ventricular extrasystoles, ventricular extrasystoles).

Both atrial and ventricular extrasystoles lead to a so-called compensatory pause, which many patients describe as the main symp

Atrial extrasystoles

Atrial extrasystoles are usually harmless and rarely cause any symptoms. However, if they occur very frequently (e.g. more than 10,000/24h) or in volleys (several extra beats in succession), they can cause significant symptoms. Patients then usually complain of feelings of restlessness or anxiety, dizziness and reduced physical performance. Atrial extrasystoles can occasionally trigger cardiac arrhythmias such as supraventricular tachycardias.

As a rule, atrial extrasystoles are harmless and rarely cause any symptoms. However, if they occur very frequently (e.g. more than 10,000 per 24 hours) or in volleys (several extra beats in succession), they can cause significant symptoms. Patients then usually complain of feelings of restlessness or anxiety, dizziness and reduced physical performance. Atrial extrasystoles can occasionally trigger cardiac arrhythmias such as supraventricular tachycardias.

Ventricular extrasystoles

Most ventricular extrasystoles are also harmless. However, they can become problematic if the extra beats become very frequent, weakening the function of the left ventricle over the medium to long term, regardless of any symptoms. Therefore, according to current knowledge, patients with more than 10,000 extra beats per day or more than 10% of the total number of heartbeats should at least have regular heart ultrasound examinations to detect any functional impairment early on and to be able to initiate therapeutic measures if necessary.
The diagnostic method of choice for quantifying the extra beats is the long-term ECG (Holter ECG). With the normal 12-channel ECG, conclusions can be drawn with some certainty about the point of origin of the ventricular extrasystoles.
Some types of ventricular extrasystoles are also a symptom of an underlying heart disease and can be prognostically relevant.
For example, frequent or coupled ventricular extrasystoles in patients who have had extensive myocardial infarction with severe impairment of left ventricular function may be a harbinger of life-threatening ventricular tachycardia and should be investigated further as a matter of urgency. The same applies to certain genetic heart diseases.

Symptomatic ventricular extra beats can be treated safely and effectively by catheter ablation in most locations.

Ventricular tachycardias

Here, too, the spectrum ranges from harmless to life-threatening situations. For no other cardiac arrhythmia is precise knowledge of possible causative heart diseases so important.
Ventricular tachycardia can originate in both the right and left ventricles.
Some special forms occur at a young age and are prognostically benign. However, they can lead to pronounced symptoms and require treatment. If a genetic, inflammatory or muscular heart disease can be ruled out, a beta blocker or a calcium antagonist is usually used. If these medications are ineffective or have side effects, ablation can also be a very effective treatment for these tachycardias. The majority of these so-called idiopathic tachycardias originate in the outflow tract of the right ventricle, more rarely in the left ventricle, in the aortic root or in the specific conduction system (fascicular or Purkinje system).
Ventricular tachycardia in patients with underlying heart disease (after myocardial infarction, after myocarditis, hypertrophic and dilated cardiomyopathy) has a poor prognosis in the medium to long term if left untreated, especially in patients with impaired left ventricular function. Drug therapy is only possible to a limited extent, as many antiarrhythmic drugs can favor ventricular tachycardia or are not suitable as long-term therapy due to numerous possible complications.
An implantable cardioverter defibrillator (ICD) is usually used to treat symptomatic ventricular tachycardia in patients with a left ventricular ejection function of ≤35%, but also for prevention. Ablation treatment may also be necessary if the ICD has to intervene frequently.

Ventricular fibrillation

Ventricular fibrillation is the most fatal of all cardiac arrhythmias. Ventricular tachycardia often progresses to life-threatening ventricular fibrillation. Therefore, both cardiac arrhythmias are often considered together in terms of their significance. Primary ventricular fibrillation (without preceding ventricular tachycardia) is probably rare and is occasionally triggered by a very specific form of ventricular extrasystole from the specific conduction system.
Most patients in whom ventricular fibrillation is observed are already fitted with an ICD and can literally be saved by timely intervention of the device.

A problem is posed by repeated ICD discharges due to repeated episodes of ventricular fibrillation. For this group of patients, a very effective ablation therapy has been developed in recent years, which is based on modulation of the Purkinje system.

Treatment

Treatment of cardiac arrhythmias

Cardiac pacemaker

Cardiac pacemakers are small devices that are usually implanted in the shoulder region below the collarbone and are connected to the heart via one, two or three probes (syn. electrode cable) and control the

Types
Depending on the underlying disease, the following pacemaker types are used.

Single-chamber pacemaker

In this case, electrical impulses are delivered via an electrode to a heart chamber – usually the right ventricle, more rarely to the right atrium. The main indication for the implantation of a single-chamber pacemaker is bradycardia (a heart rhythm disorder with a slow heart rate) with permanent atrial fibrillation or infrequent pauses in the formation or co of impulses.

Dual-chamber pacemaker

Today, of all types, dual-chamber pacemakers are most frequently implanted. The pulse generator is connected to the right atrium and the right ventricle via two pacemaker electrodes. Dual-chamber pacemakers can perfectly mimic the natural electrical activity and the contraction dynamics of the heart. They are therefore also referred to as physiological pacemakers.

Three-chamber pacemaker
(also known as a biventricular pacemaker or cardiac resynchronization therapy)

In certain forms of heart failure, the electrical activation of the two main chambers is disrupted, which leads to an increased loss of effective stroke work. A synchronized, well-timed stimulation with a three-chamber pacemaker can enable the ventricles to work more efficiently again, leading to a significant improvement in the performance of these patients.

Modern pacemaker systems consist of two components:

• the pulse generator, comprising a battery and electronic control element, which is protected by a capsule to make it waterproof and resistant to mechanical irritation/p>

• the pacemaker electrodes, flexible insulated cables that are connected to the inside of the heart via small screw mechanisms or anchors. Some single-chamber pacemakers no longer require these cables (so-called “leadless pacemakers”); their use is currently limited to patients at increased risk of pacemaker infections or to very old patients.

Pacemakers have an average lifespan of at least 5 to 12 years. When a device is replaced due to battery exhaustion, only the pulse generator is replaced; ideally, the electrodes will last a lifetime.

Implantation of a pacemaker is a relatively common routine procedure that is highly effective and low-risk. The minor surgical procedure usually takes between 20 minutes (single-chamber systems, change of device) and 2 hours (triple-chamber devices).
Light sedation and careful local anesthesia are usually sufficient. Many pacemaker implantations can be performed on an outpatient basis without increased risk.
After a pacemaker implantation, the system has usually healed well after about four weeks. Physical activities, including those involving the arms, are again possible without restriction.

Complications during the implantation of a pacemaker are rare, but should be taken seriously. These include

• Probe dislocation: The “slipping” of the implanted electrodes is the most common risk in the first hours and days after implantation. In about 3-4% of pacemaker implantations, a reoperation with renewed fixation of the dislocated probe is necessary.
• Pericardial effusion:can be significantly reduced by avoiding probe placement at vulnerable sites (right ventricular apex, right atrial side wall).
• Pneumothorax: puncture of the vein leading to the heart (subclavian vein, collarbone vein) can occasionally lead to injury of the lung with air accumulation in the chest and difficult breathing.
• Hematoma (blood clot) at the site of implantation, especially under certain blood-thinning substances.
• Infection of the pacemaker system (up to 1%): In addition to careful asepsis in a sterile operating environment, the duration of the pacemaker implantation plays a major role (the shorter the implantation time, the lower the risk of a pacemaker infection).

Can a pacemaker improve quality of life?

A pacemaker implantation should quickly alleviate the symptoms caused by an excessively slow heartbeat, such as dizziness, syncope and reduced performance.

Modern pacemaker systems allow an active life with unrestricted physical activity. Apart from combat and extreme sports with a high risk of mechanical damage to the pacemaker, almost anything is possible. However, you should ask your cardiologist if you have unusual hobbies.

The pacemaker system should be checked once or twice a year. The intervals depend, among other things, on the individual technical parameters, additional illnesses or possible cardiac arrhythmias.

The controls include a physical examination, in particular of the pacemaker pocket, a query of the pacemaker’s event memory, the patient’s own rhythm, the battery status and various technical parameters for connecting the unit to the heart tissue.

Therapy with defibrillator (ICD, implantable cardioverter defibrillator)

In addition to reversible causes, the diseased sinus node is often due to a degenerative disease. As a result of aging processes, the highly sensitive network of impulse-forming cells is irreversibly damaged by connective tissue deposits (“fibrosis”).
In addition to reversible causes, the underlying cause of a diseased sinus node is often a degenerative disease. As a result of the aging process, the highly sensitive network of impulse-forming cells is irreversibly damaged by the deposition of connective tissue (“fibrosis”). 
This leads to pronounced sinus bradycardia at rest, an inadequate increase in heart rate under stress (chronotropic incompetence) and promotes the occurrence of atrial arrhythmias such as atrial fibrillation and atrial flutter (brady-tachycardia syndrome).
In the long term, the only effective treatment for the associated symptoms is often the implantation of a pacemaker.
Bei entsprechender Symptomatik hilft langfristig oft nur die Implantation eines Herzschrittmachers.
An implantable cardioverter defibrillator (ICD) is slightly larger than a pacemaker, but is implanted in a similar way, in the shoulder area below the collarbone. The device detects and treats life-threatening arrhythmias. An ICD continuously monitors the heart rhythm and delivers rapid electrical impulses or an electrical shock to restore the normal rhythm.
An ICD is implanted when a life-threatening arrhythmia has either already occurred (secondary prevention) or is highly likely to occur due to heart disease (primary prevention).

Single-chamber ICD

The focus here is on detecting and treating life-threatening cardiac arrhythmias. An ICD electrode is implanted in the right ventricle.

Dual-chamber ICD

An additional pacemaker electrode is placed in the right atrium. In addition to preventing rapid arrhythmias, physiological stimulation is also possible with a dual-chamber pacemaker.

Three-chamber ICD (biventricular ICD, cardiac resynchronization therapy with ICD)

This system is used in patients with desynchronized contraction of the right and left ventricles and an increased risk of malignant arrhythmias./p>

A subcutaneous ICD (S-ICD)

is a system that does not have any leads in the heart. These devices are used primarily for the prophylaxis of life-threatening cardiac arrhythmias. Chronic pacemaker stimulation is not possible with this type of device.
The most common indications for ICD implantation are

  • Sudden cardiac death
  • Severe heart failure due to coronary heart disease, especially after a heart attack
  • Heart muscle diseases with heart failure (dilated and hypertrophic cardiomyopathy
  • Genetic heart diseases with an increased risk of sudden cardiac death (Brugada syndrome, long or short QT syndrome)

Preparation, implantation and aftercare are similar to those for pacemaker implantation. The risks associated with the minor operation are also comparable.

Catheter ablation

Ablation treatment is a minimally invasive procedure used by physicians to destroy abnormal tissue. In catheter ablation, energy is transferred to the tissue via a catheter, resulting in a loss of function (excitation formation or conduction) in the cells in the area of effect.
Catheter ablation of cardiac arrhythmias is still a relatively new medical treatment procedure.
In modern electrophysiology, various forms of energy are used:>

  • Radiofrequency current (aka radiofrequency current, HF or RF current)
  • Cold (aka cryoablation)
  • Electrical vaporization (Pulsed Field Ablation, PFA)
  • Laser

Under local anesthesia and general sedation (“sleep anesthesia”), access ports are placed in the groin area via a blood vessel, through which one to three (rarely more) thin catheters are advanced into the heart.

Once the cardiac arrhythmia has been characterized and localized, one or more energy pulses are delivered. Depending on the localization of the arrhythmia and the type of the electroanatomic substrate, either the focus of abnormal tissue is switched off (direct ablation) or the propagation of excitation within a defined excitation circuit is blocked by “linear scar roads” (indirect ablation).

Depending on the underlying arrhythmia, an ablation treatment can achieve an effectiveness of almost 100%. For cardiac arrhythmias with a defined and less variable electroanatomy (AVNRT (atrial flutter), atrial flutter, AV node), this effectiveness remains consistently high even after years.

In contrast, cardiac arrhythmias with a changing substrate, such as atrial fibrillation and ventricular tachycardia, are often not as effectively treatable and often require several procedures.

Catheter ablation is not infrequently a complex procedure and can take several hours in extreme cases. With experience and good periprocedural organization, the treatment time for most procedures should be between 45 and 90 minutes.

Complications

As with any medical procedure, complications can occur. A safe and proven prevention and treatment management is an important part of the electrophysiologist’s responsible work.

Our own treatment documentation shows an overall complication rate of well under 1%, even for highly complex procedures. Each of our patients is informed about possible risks and complications as well as the organizational and technical aspects of the procedure in a detailed pre-procedure interview.

Pulmonary vein isolation

The treatment of atrial fibrillation by isolating the pulmonary veins has existed since the late ’90s.

The discovery that ectopic beats from remote heart muscle cells in the pulmonary veins near the heart can trigger atrial fibrillation played a decisive role in the development of this catheter-based therapy. The obliteration or isolation of these cells is significantly more effective at preventing the recurrence of atrial fibrillation episodes than antiarrhythmic drugs.

The procedure can now be performed safely and effectively, but requires an experienced team of investigators, perfect periprocedural organization and good complication management.

We use the cryoballoon technique and increasingly also pulse field ablation as ablation procedures for all initial catheter ablation procedures for atrial fibrillation.

The advantages of these ablation forms are:

  • A gentle, physiological procedure in which only the cells relevant for triggering atrial fibrillation (water-rich muscle fibers) are destroyed and the supporting and connective tissue is preserved.
  • Lower probability of the body’s own inflammatory reactions in the ablation zone, which in turn can trigger atrial fibrillation
  • Safe procedure with a low complication rate and high efficacy
  • Short procedure time (90% of procedures <60 min)
  • Good reproducibility
  • Low X-ray exposure for patient and examination team

In Germany, PVI requires an overnight stay in the hospital. Complications in the area of the access in the groin (almost always on the right) have become very rare thanks to modern wound closure techniques.

Patients can get up just a few hours after the procedure. Physical exertion such as sports, heavy lifting, long walks or hikes are not recommended for about 7-10 days.

Atrial fibrillation recurrences immediately after pulmonary vein isolation are not uncommon and can be triggered by the body’s own inflammatory reactions, which can be observed for up to 12 weeks after the procedure. A repeat invasive treatment (re-PVI) is only indicated for recurrences after 3 months and should then be performed as a matter of urgency. The most common cause of recurrent atrial fibrillation is restored electrical conduction from the pulmonary veins. The initial effectiveness of an average of 70% (60-85%) can be increased to up to 90% by this means.

The effectiveness of PVI depends on several factors:

  • Size of the left atrium
  • Extent of fibrosis of the left atrium
  • Duration of atrial fibrillation
  • Age
  • Number and severity of concomitant diseases

Glossary

Ablation: Verödung von Körpergewebe mit dem Ziel Fehlfunktionen zu behandeln

Adrenerge Substanzen: Stresshormone wie Adrenalin oder Noradrenalin

AV-Knoten: Atrioventrikulär-Knoten – kompaktes ca. 5x3x1 mm großes Gebilde aus spezialisierten Herzmuskelzellen

Bradycardia: Slow heart rhythm, formally <60/min/p>

Brugada syndrome: Genetic heart disease named after the first people to describe it, Pedro and Josep Brugada, with an increased incidence of sudden cardiac death

CRT: Cardiac resynchronization therapy

DCM: Dilated cardiomyopathy, a disease of the heart muscle characterized by an increase in the volume of the left ventricle and a reduction in its pumping function

Fascicle, fascicular: part of the ventricular conduction system, a pathway of specialized heart muscle cells that are only responsible for electrical conduction

ICD: Implantable cardioverter defibrillator 
Long QT and short QT syndrome: genetic heart disease with increased risk of potentially dangerous ventricular arrhythmias; bradycardic arrhythmias are also possible in certain forms/p>

PM: Pacemaker, heart stimulator

PVI: Pulmonary vein isolation

Purkinje system: Network of specialized impulse-conducting cells in the ventricular myocardium

Storage disease Often genetically caused disease of the heart with storage of cross-linked carbohydrates, fats, proteins, iron and others. Leads to thickening of the heart wall and to a reduction in the pumping power or filling function of the heart

Syncope: Loss of consciousness, rhythmogenic syncope: loss of consciousness due to failure or interruption of impulse formation or conduction

Tachycardia: Rapid heart rhythm, formally >100/min

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Aus Gründen der besseren Lesbarkeit verzichten wir auf dieser Website auf eine geschlechtergerechte Sprachform. Wir verwenden das generische Maskulinum und verstehen sämtliche von uns geschriebenen Personen­bezeich­nungen geltend für alle Geschlechter.

Copyright @ 2025 Rhythmologicum. All rights reserved.