Recently, the clinical entity embolic stroke of undetermined source (ESUS) has been defined for patients with ischemic strokes, where neither a cardioembolic nor a non-cardiac source can be detected. These patients may suffer from asymptomatic atrial fibrillation (AF), terminating spontaneously and thus eluding detection. Implantable loop recorders (ILR) with automatic AF detection algorithms can detect short-lasting, subclinical AF. The aim of this study was to prospectively assess and predict AF detection in patients with ESUS using ILR with daily remote interrogation. Patients with acute ESUS received an ILR, were seen every 6 months and additionally interrogated their ILR daily using remote monitoring. The incidence of AF detection was assessed and parameters which might predict AF detection (clinical and from magnetic resonance tomography) were analysed. ILR implantation was performed in 123 patients on average 20 days after stroke. During a mean follow-up of 12.7±5.5 months, AF was documented and manually confirmed in 29 of 123 patients (23.6 %). First AF detection occurred on average after 3.6±3.4 months of monitoring. Patients with AF were on average older, had a higher CHADS-VASc score and more often cerebral microangiopathy. In conclusion, AF can be documented in approximately 25 % of patients with the diagnosis of ESUS after careful work-up within a year of monitoring by an ILR and daily remote interrogation. This had important therapeutic consequences (initiation of anticoagulation for secondary stroke prevention) in these patients.

Background: Undocumented atrial fibrillation (AF) is suspected as a main stroke cause in patients with ESUS, but its prevalence is largely unknown. This prospective study therefore aimed at delineating the prevalence of AF in patients with ESUS using continuous cardiac monitoring by implantable loop recorder (ILR) with daily remote interrogation over a period of 3 years and its clinical consequences, including recurrent stroke. Methods: In consecutive patients with an ESUS diagnosis after complete work-up, an ILR was implanted and followed by daily remote monitoring until AF was detected or a follow-up of at least 3 years was completed. Additionally the ILR was interrogated in-hospital in 6-month intervals. Results: A total of 123 patients (74 male, mean age 65±9 years) were enrolledand completed the 3 years study period. AF was detected in 51 patients (41.4%). In 42 of the 51 AF positive patients (82%) oral anticoagulation was established. Recurrent strokes occurred in 28 patients (23%) of this ESUS population, 11 of these patients (21%) being AF positive, 17 (23%) AF negative. Patients with AF were slightly older than patients without AF (63.1±8.8 versus 67.5±9.6 years, p=0.12). Other parameters such as CHA2DS2-VASc score, infarct localization, micro- and macroangiopathy, carotid- or aortic plaques or stroke recurrence were not significantly different between groups. Conclusions: In ESUS patients, early implantation of an ILR with cardiac monitoring and remote transmission over a 3-year period detects AF in 41.4 % and results in oral anticoagulation in 82% of these patients

The aim of the present study was to evaluate Allium ursinum leaves and flowers extract anti-inflammatory effect. Plant extract 1:1 (w:v) was prepared from A. ursinum leaves by a modified Squibb repercolation method. The in vivo anti-inflammatory effects were evaluated on a rat turpentine oil-induced inflammation (i.m. 6 mL/kg BW). The animals were randomly assigned to nine groups (n=8): negative control, inflammation, A. ursinum flower extract (AUF), A. ursinum leaves extract (AUL), indomethacin (INDO) (20 mg/kg BW), aminoguanidine (AG) (50 mg/kg b.w./d i.p.) as a selective NOS2 inhibitor, NG-nitro L-arginine methyl ester (NAME) (5 mg/kg b.w./d i.p.) as a nonselective NOS inhibitor, L-arginine (ARG) (100 mg/kg b.w./d i.p.), NO synthesis substrate, and Trolox (20 mg/kg b.w./d i.p) as an antioxidant. At 24h from inflammation induction total oxidative status (TOS), oxidative stress index (OSI), nitric oxide (NOx) and in vitro phagocytosis test were reduced and the total antioxidative reactivity (TAR) was increased by the testes plant extracts. AUF had a better inhibitory effect than AUL. In conclusion, we provided evidence for the hypothesis that A. ursinum leaves and flowers extract exerts anti-inflammatory activity by inhibiting the phagocytosis through the reduction of the nitro-oxidative stress.

Background His bundle pacing (HBP) promises physiological cardiac stimulation using the conduction system for a synchronous ventricular excitation, excluding the risk of pacing-induced cardiomyopathy. In daily practice, HBP is rather rarely used in Germany, in part because it has been recommended to use an electrophysiological unit (EPU) for registration of the His bundle potential and the HV interval. We attempted HBP replacing the EPU by a normal pacing system analyzer (PSA) with high resolution of the electrogram (EGM) which is used during daily clinical routine (Figs. 1 & 2). Methods Consecutive patients (pts) with attempted HBP in our department were included in this prospective study. We used a 4,1F and a 7F lead together with specific sheaths to reach the His bundle. Mapping was performed using a conventional PSA (atrial channel, unipolar mode, 20 mm/mV). We recorded the success of the implantation for HBP, selective versus non-selective His bundle capture, parameters of sensing and pacing performance, operation and fluoroscopy times, the number of lead implantation attempts and QRS duration before and after HBP. Results Implantation of a system for HBP was attempted in 265 pts (mean age 78±12 years, 102 female, mean left ventricular ejection fraction 55±8%) and was successful in 244 (92%), selective His bundle capture was achieved in 55%, non-selective in 37%. Implantation success rates increased from 86% (earliest quartile) to 98% (latest quartile). Mean operation time was 95±46 min, mean fluoroscopy time 11±10 min; a mean of 6±7 attempts (median: 3) were necessary. Mean R wave amplitude was 5±4 mV, mean threshold 0,7±0,5 V at 1,0 ms. QRS duration before implantation was 111±29 ms, post implantation 88±20 ms. Conclusions HBP in daily clinical routine can be successful in >90% of cases without an EPU. Mean operation and fluoroscopy times were similar to those needed for biventricular pacing. An extremely narrow paced QRS could be achieved that indicates extremely good synchronization with HBP. Funding Acknowledgement Type of funding sources: None.

Arrhythmogenic syncopes can clinically resemble epileptic seizures ("convulsive syncope"). During basic work-up of syncope, the 12 lead ECG may provide valuable clues indicating an arrhythmogenic cause of syncope, showing excitation as well as repolarisation abnormalities. If an arrhythmogenic cause of syncope is suspected but ECG documentation as a proof of diagnosis is missing, implantation of an ILR can be useful. In LQTS, multiple gene mutations are known but cover only a fraction of clinical LQTS.