Prevention of esophageal lesions during atrial fibrillation catheter ablation using esophageal temperature monitoring: A systematic review and meta-analysis.

INTRODUCTION: The use of esophageal temperature monitoring (ETM) for the prevention of esophageal injury during atrial fibrillation (AF) ablation is often advocated. However, evidence supporting its use is scarce and controversial. We therefore aimed to review the evidence assessing the efficacy of ETM for the prevention of esophageal injury. METHODS: We performed a meta-analysis and systematic review of the available literature from inception to December 31, 2022. All studies comparing the use of ETM, versus no ETM, during radiofrequency (RF) AF ablation and which reported the incidence of endoscopically detected esophageal lesions (EDELs) were included. RESULTS: Eleven studies with a total of 1112 patients undergoing RF AF ablation were identified. Of those patients, 627 were assigned to ETM (56%). The overall incidence of EDELs was 9.8%. The use of ETM during AF ablation was associated with a non significant increase in the incidence of EDELs (12.3% with ETM, vs. 6.6 % without ETM, odds ratio, 1.44, 95%CI, 0.49, 4.22, p = .51, I2 = 72%). The use of ETM was associated with a significant increase in the energy delivered specifically on the posterior wall compared to patients without ETM (mean power difference: 5.13 Watts, 95% CI, 1.52, 8.74, p = .005). CONCLUSIONS: The use of ETM does not reduce the incidence of EDELs during RF AF ablation. The higher energy delivered on the posterior wall is likely attributable to a false sense of safety that may explain the lack of benefit of ETM. Further randomized controlled trials are needed to provide conclusive results.

[Cardiology: what's new in 2023]. / Cardiologie: ce qui a changé en 2023.

The year 2023 has been extremely rich in new publications in the various subfields of cardiology. Furthermore, the European Society of Cardiology (ESC) has issued revised guidelines focused on the management of acute coronary syndrome (ACS) and endocarditis, as well as an update on the recommendations for the management of heart failure and cardiovascular prevention. The most significant updates according to the Cardiology Department of CHUV are summarized in this review article.

L'année 2023 a été extrêmement riche en nouvelles publications dans les différents sous-domaines de la cardiologie. De plus, la Société européenne de cardiologie (ESC) a formulé des directives révisées axées sur le management du syndrome coronarien aigu (SCA) et de l'endocardite ainsi qu'une mise à jour des recommandations sur la prise en charge de l'insuffisance cardiaque et la prévention cardiovasculaire. Les nouveautés les plus importantes selon l'équipe du Service de cardiologie du CHUV sont résumées dans cet article de synthèse.

The influence of cardiac arrhythmias on the detection of heartbeats in the photoplethysmogram: benchmarking open-source algorithms.

Objective.Cardiac arrhythmias are a leading cause of mortality worldwide. Wearable devices based on photoplethysmography give the opportunity to screen large populations, hence allowing for an earlier detection of pathological rhythms that might reduce the risks of complications and medical costs. While most of beat detection algorithms have been evaluated on normal sinus rhythm or atrial fibrillation recordings, the performance of these algorithms in patients with other cardiac arrhythmias, such as ventricular tachycardia or bigeminy, remain unknown to date.Approach. ThePPG-beatsopen-source framework, developed by Charlton and colleagues, evaluates the performance of the beat detectors namedQPPG,MSPTDandABDamong others. We applied thePPG-beatsframework on two newly acquired datasets, one containing seven different types of cardiac arrhythmia in hospital settings, and another dataset including two cardiac arrhythmias in ambulatory settings.Main Results. In a clinical setting, theQPPGbeat detector performed best on atrial fibrillation (with a medianF1score of 94.4%), atrial flutter (95.2%), atrial tachycardia (87.0%), sinus rhythm (97.7%), ventricular tachycardia (83.9%) and was ranked 2nd for bigeminy (75.7%) behindABDdetector (76.1%). In an ambulatory setting, theMSPTDbeat detector performed best on normal sinus rhythm (94.6%), and theQPPGdetector on atrial fibrillation (91.6%) and bigeminy (80.0%).Significance. Overall, the PPG beat detectorsQPPG,MSPTDandABDconsistently achieved higher performances than other detectors. However, the detection of beats from wrist-PPG signals is compromised in presence of bigeminy or ventricular tachycardia.

Case report: First-in-human combined low-dose whole-heart irradiation and high-dose stereotactic arrhythmia radioablation for immunosuppressive refractory cardiac sarcoidosis and ventricular tachycardia.

Background: Cardiac sarcoidosis is associated with heart failure, conduction abnormalities, and life-threatening arrhythmias including ventricular tachycardia (VT). Radiotherapy has been suggested as a treatment for extra-cardiac sarcoidosis in patients refractory to immunomodulatory treatment. Methods: The effectiveness and safety of low-dose whole-heart radiotherapy for therapy refractory cardiac sarcoidosis were evaluated in a pre- and post-intervention case report comparing the 54 months before and after treatment. Immunomodulatory low-dose whole-heart irradiation as sarcoidosis treatment consisted of a 2 × 2 Gy scheme. Additionally, high-dose single-fraction stereotactic arrhythmia radioablation of 1 × 20 Gy was applied to the pro-arrhythmic region to manage the ventricular tachycardia episodes. Cardiac sarcoidosis disease activity was measured by hypermetabolic areas on repeated fluorodeoxyglucose ([18F]FDG)-PET/computed tomography (CT) scans and by evaluating changes in ventricular tachycardia episodes before and after treatment. Results: One patient with therapy refractory progressive cardiac sarcoidosis and recurrent ventricular tachycardia was treated. The cardiac sarcoidosis disease activity showed a durable regression of inflammatory disease activity from 3 months onwards. The [18F]FDG-PET/CT scan at 54 months did not show any signs of active cardiac sarcoidosis, and a state of remission was achieved. The number of sustained VT episodes was reduced by 95%. We observed that the development of moderate aortic valve regurgitation was likely irradiation-related. No other irradiation-related adverse events occurred, and the left ventricular ejection fraction remained stable. Conclusion: We report here for the first time on the beneficial and lasting effects of combined immunomodulatory low-dose whole-heart radiotherapy and high-dose stereotactic arrhythmia radioablation in a patient with therapy refractory cardiac sarcoidosis and recurrent VT.

Personalized pulmonary vein antrum isolation guided by left atrial wall thickness for persistent atrial fibrillation.

AIMS: Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF. METHODS AND RESULTS: Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50-67), fluoroscopy time was 43 s (IQR 20-71), and radiofrequency (RF) time was 16.5 min (IQR 14.3-18.4). The median AI tailored to the local LAWT was 387 (IQR 360-410) for the anterior wall and 335 (IQR 300-375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up. CONCLUSION: In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).

Reproducibility analysis of the computerized tomography angiography-derived left atrial wall thickness maps.

BACKGROUND: Adapting the ablation index (AI) to the left atrial wall thickness (LAWT) derived from computed tomography angiography (CTA) allows for a personalized approach that showed to improve PVI safety and outcomes. METHODS: Three observers with different degrees of experience performed complete LAWT analysis of CTA for 30 patients and repeated the analysis for 10 of these patients. Intra- and inter-observer reproducibility of these segmentations was assessed. RESULTS: Geometric congruence of repeated reconstruction of LA endocardial surface showed that 99.4% of points in the 3D reconstructed mesh were within < 1 mm distance for the intra-observer variability and 95.1% for the inter-observer. For the LA epicardial surface, an 82.4% of points were within < 1 mm for intra-observer and a 77.7% for inter-observer. A 1.99% of points were further than 2 mm for the intra-observer and a 4.1% for the inter-observer. Colour agreement between LAWT maps showed that a 95.5% and a 92.9% intra- and inter-observer respectively presented the same colour or a change to the colour immediately above or below. The ablation index (AI), which was adapted to this LAWT colour maps to perform a personalized pulmonary vein isolation (PVI), showed an average difference in the derived AI lower than 25 units in all cases. For all analyses, the concordance increased with user-experience. CONCLUSION: Geometric congruence of LA shape was high, for both endocardial and epicardial segmentations. LAWT measurements were reproducible, increasing with user experience. This translated into a negligible impact in the target AI.

[Cardiology: what's new in 2022]. / Cardiologie : ce qui a changé en 2022.

The year of 2022 was marked by many novelties in the fields of interventional cardiology, heart failure, electrophysiology, cardiac imaging, and congenital heart disease. These advances will certainly change our daily practice, on top of improving the diagnosis and treatment of many heart conditions. In addition, the European Society of Cardiology has updated its guidelines on pulmonary hypertension, ventricular arrhythmias and sudden death, cardiovascular assessment of patients undergoing non-cardiac surgery. The members of the Cardiology division of Lausanne University Hospital (CHUV) here present the publications which they considered to be the most important of the past year.

L'année 2022 a été marquée par de nombreuses nouveautés dans les domaines de la cardiologie interventionnelle, de l'insuffisance cardiaque, de l'électrophysiologie, de l'imagerie cardiaque et des cardiopathies congénitales. Ces progrès vont certainement faire évoluer notre pratique quotidienne, en plus d'améliorer le diagnostic et le traitement de nombreuses cardiopathies. Par ailleurs, la Société européenne de cardiologie a mis à jour ses recommandations portant sur l'hypertension pulmonaire, les arythmies ventriculaires et la mort subite ainsi que le bilan cardiologique avant une chirurgie non cardiaque. Les membres du Service de cardiologie du CHUV vous présentent ici les travaux qui leur ont semblé être les plus importants de l'année écoulée.

Preventive substrate ablation in chronic post-myocardial infarction patients with high-risk scar characteristics for ventricular arrhythmias: rationale and design of PREVENT-VT study.

BACKGROUND: Recent studies showed that an early strategy for ventricular tachycardia (VT) ablation resulted in reduction of VT episodes or mortality. Cardiac magnetic resonance (CMR)-derived border zone channel (BZC) mass has proved to be a strong non-invasive predictor of VT in post-myocardial infarction (MI). CMR-guided VT substrate ablation proved to be safe and effective for reducing sudden cardiac death (SCD) and VA occurrence. METHODS: PREVENT-VT is a prospective, randomized, multicenter, and controlled trial designed to evaluate the safety and efficacy of prophylactic CMR-guided VT substrate ablation in chronic post-MI patients with CMR-derived arrhythmogenic scar characteristics. Chronic post-MI patients with late gadolinium enhancement (LGE) CMR will be evaluated. CMR images will be post-processed and the BZC mass measured: patients with a BZC mass > 5.15 g will be eligible. Consecutive patients will be enrolled at 3 centers and randomized on a 1:1 basis to undergo a VT substrate ablation (ABLATE arm) or optimal medical treatment (OMT arm). Primary prevention ICD will be implanted following guideline recommendations, while non-ICD candidates will be implanted with an implantable cardiac monitor (ICM). The primary endpoint is a composite outcome of sudden cardiac death (SCD) or sustained monomorphic VT, either treated by an ICD or documented with ICM. Secondary endpoints are procedural safety and efficiency outcomes of CMR-guided ablation. DISCUSSION: In some patients, the first VA episode causes SCD or severe neurological damage. The aim of the PREVENT-VT is to evaluate whether primary preventive substrate ablation may be a safe and effective prophylactic therapy for reducing SCD and VA occurrence in patients with previous MI and high-risk scar characteristics based on CMR. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04675073, registered on January 1, 2021.

Relationship between the posterior atrial wall and the esophagus: esophageal position and temperature measurement during atrial fibrillation ablation (AWESOME-AF). A randomized controlled trial.

BACKGROUND: Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation. METHODS: Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol. RESULTS: Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise (> 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p < 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4). CONCLUSION: The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).

Relationship between the posterior atrial wall and the esophagus: Esophageal position during atrial fibrillation ablation.

Background: Atrial fibrillation ablation implies a risk of esophageal thermal injury. Esophageal position can be analyzed with imaging techniques, but evidence for esophageal mobility is inconsistent. Objectives: The purpose of this study was to analyze esophageal position stability from one procedure to another and during a single procedure. Methods: Esophageal position was compared in 2 patient groups. First, preprocedural multidetector computerized tomography (MDCT) of first pulmonary vein isolation and redo intervention (redo group) was segmented with ADAS 3D™ to compare the stability of the atrioesophageal isodistance prints. Second, 3 imaging modalities were compared for the same procedure (multimodality group): (1) preprocedural MDCT; (2) intraprocedural fluoroscopy obtained with the transesophageal echocardiographic probe in place with CARTOUNIVU™; and (3) esophageal fast anatomic map (FAM) at the end of the procedure. Esophageal position correlation between different imaging techniques was computed in MATLAB using semiautomatic segmentation analysis. Results: Thirty-five redo patients were analyzed and showed a mean atrioesophageal distance of 1.2 ± 0.6 mm and a correlation between first and redo procedure esophageal fingerprint of 91% ± 5%. Only 3 patients (8%) had a clearly different position. The multi-imaging group was composed of 100 patients. Esophageal position correlation between MDCT and CARTOUNIVU was 82% ± 10%; between MDCT and esophageal FAM was 80% ± 12%; and between esophageal FAM and CARTOUNIVU was 83% ± 15%. Conclusion: There is high stability of esophageal position between procedures and from the beginning to the end of a procedure. Further research is undergoing to test the clinical utility of the esophageal fingerprinted isodistance map to the posterior atrial wall.

[Epicardial adipose tissue and atrial fibrillation]. / Tissu adipeux épicardique et fibrillation auriculaire.

Atrial fibrillation (AF) is the most common arrhythmia encountered in adults; it is associated with a significant morbidity and mortality. Obesity is a risk factor contributing to AF occurrence. Recently, interest has focused on epicardial adipose tissue (EAT), defined as a fatty deposit located between the epicardium and the visceral pericardium. Its characteristics are distinct from classic adipose deposits: it infiltrates the epicardial myocardium and secretes cytokines, which modulate cardiomyocyte electrophysiology and cardiac remodeling. Different studies show that EAT can be an independent risk factor for AF and that EAT thickness, as measured by CT or MRI, could predict the presence, severity and recurrence of AF.

La fibrillation auriculaire (FA) est l'arythmie la plus fréquemment rencontrée chez l'adulte ; elle est associée à une morbi-mortalité importante. L'obésité est un facteur de risque contribuant à sa survenue. Récemment, l'intérêt s'est porté sur le tissu adipeux épicardique (TAE), défini comme un dépôt adipeux situé entre l'épicarde et le péricarde viscéral. Ses caractéristiques sont distinctes des dépôts adipeux classiques : il infiltre le myocarde épicardique et sécrète des cytokines modulant l'électrophysiologie des cardiomyocytes et provoquant un remodelage fibro-adipeux cardiaque. Différentes études montrent que le TAE peut être un facteur de risque indépendant de survenue de FA. L'épaisseur du TAE mesurée par CT-scan ou par IRM pourrait être utilisée comme facteur prédictif de la présence, de la gravité et de la récidive de FA.

New Insights in Central Venous Disorders. The Role of Transvenous Lead Extractions.

Over the last decades, the implementation of new technology in cardiac pacemakers and defibrillators as well as the increasing life expectancy have been associated with a higher incidence of transvenous lead complications over time. Variable degrees of venous stenosis at the level of the subclavian vein, the innominate trunk and the superior vena cava are reported in up to 50% of implanted patients. Importantly, the number of implanted leads seems to be the main risk factor for such complications. Extraction of abandoned or dysfunctional leads is a potential solution to overcome venous stenosis in case of device upgrades requiring additional leads, but also, in addition to venous angioplasty and stenting, to reduce symptoms related to the venous stenosis itself, i.e., the superior vena cava syndrome. This review explores the role of transvenous lead extraction procedures as therapeutical option in case of central venous disorders related to transvenous cardiac leads. We also describe the different extraction techniques available and other clinical indications for lead extractions such as lead infections. Finally, we discuss the alternative therapeutic options for cardiac stimulation or defibrillation in case of chronic venous occlusions that preclude the implant of conventional transvenous cardiac devices.

Personalized paroxysmal atrial fibrillation ablation by tailoring ablation index to the left atrial wall thickness: the 'Ablate by-LAW' single-centre study-a pilot study.

AIMS: To determine if adapting the ablation index (AI) to the left atrial wall thickness (LAWT), which is a determinant of lesion transmurality, is feasible, effective, and safe during paroxysmal atrial fibrillation (PAF) ablation. METHODS AND RESULTS: Consecutive patients referred for PAF first ablation. Left atrial wall thickness three-dimensional maps were obtained from multidetector computed tomography and integrated into the CARTO navigation system. Left atrial wall thickness was categorized into 1 mm layers and AI was titrated to the LAWT. The ablation line was personalized to avoid thicker regions. Primary endpoints were acute efficacy and safety, and freedom from atrial fibrillation (AF) recurrences. Follow-up (FU) was scheduled at 1, 3, 6, and every 6 months thereafter. Ninety patients [60 (67%) male, age 58 ± 13 years] were included. Mean LAWT was 1.25 ± 0.62 mm. Mean AI was 366 ± 26 on the right pulmonary veins with a first-pass isolation in 84 (93%) patients and 380 ± 42 on the left pulmonary veins with first-pass in 87 (97%). Procedure time was 59 min (49-66); radiofrequency (RF) time 14 min (12.5-16); and fluoroscopy time 0.7 min (0.5-1.4). No major complication occurred. Eighty-four out of 90 (93.3%) patients were free of recurrence after a mean FU of 16 ± 4 months. CONCLUSION: Personalized AF ablation, adapting the AI to LAWT allowed pulmonary vein isolation with low RF delivery, fluoroscopy, and procedure time while obtaining a high rate of first-pass isolation, in this patient population. Freedom from AF recurrences was as high as in more demanding ablation protocols. A multicentre trial is ongoing to evaluate reproducibility of these results.

Cardiovascular magnetic resonance determinants of ventricular arrhythmic events after myocardial infarction.

AIMS: To non-invasively characterize, by means of late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), scar differences, and potential variables associated with ventricular tachycardia (VT) occurrence in chronic post-myocardial infarction (MI) patients. METHODS AND RESULTS: A case-control study was designed through retrospective LGE-CMR data analysis of chronic post-MI patients (i) consecutively referred for VT substrate ablation after a first VT episode (n = 66) and (ii) from a control group (n = 84) with no arrhythmia evidence. The myocardium was characterized differentiating core, border zone (BZ), and BZ channels (BZCs) using the ADAS 3D post-processing imaging platform. Clinical and scar characteristics, including a novel parameter, the BZC mass, were compared between both groups. One hundred and fifty post-MI patients were included. Four multivariable Cox proportional hazards regression models were created for total scar mass, BZ mass, core mass, and BZC mass, adjusting them by age, sex, and left ventricular ejection fraction (LVEF). A cut-off of 5.15 g of BZC mass identified the cases with 92.4% sensitivity and 86.9% specificity [area under the ROC curve (AUC) 0.93 (0.89-0.97); P < 0.001], with a significant increase in the AUC compared to other scar parameters (P < 0.001 for all pairwise comparisons). Adding BZC mass to LVEF allowed to reclassify 33.3% of the cases and 39.3% of the controls [net reclassification improvement = 0.73 (0.71-0.74)]. CONCLUSIONS: The mass of BZC is the strongest independent variable associated with the occurrence of sustained monomorphic ventricular tachycardia in post-MI patients after adjustment for age, sex, and LVEF. Border zone channel mass measurement could permit a more accurate VT risk stratification than LVEF in chronic post-MI patients.

A standardized stepwise zero-fluoroscopy approach with transesophageal echocardiography guidance for atrial fibrillation ablation.

PURPOSE: There is growing interest in performing fluoroless radiofrequency ablation (RFA) for atrial fibrillation (AF) due to the increasing awareness of risk associated with radiation exposure of patients and professional staff. The present study aimed to evaluate the feasibility, safety, and efficacy of a stepwise transesophageal echocardiography (TEE)-guided zero-fluoroscopy approach (ZFA) for RFA. METHODS: Consecutive patients (n = 111) referred for AF-ablation were prospectively enrolled with intention to RFA with ZFA. Procedural outcomes were compared with historical controls (HCs) after 1:1 propensity score matching. ZFA success was considered when no X-ray was utilized to perform the whole procedure. RESULTS: ZFA success was achieved in 80 (72%) procedures. BMI > 35 kg/m2 resulted in the only independent predictor of ZFA failure (OR = 6.10, 95% CI 1.15-46.49, p = 0.04). In comparison to HCs, a significant reduction in radiation exposure was observed in the ZFA group: fluoroscopy time (3 vs. 63 s, p < 0.001), total emitted fluoroscopy dose (0.2 vs. 6.0 mGy, p < 0.001), dose area product (0.04 vs. 1.4 Gy*cm2, p < 0.001), and effective dose (0.8 vs. 27.2 mSv*100, p < 0.001). Complete pulmonary vein isolation was achieved in all procedures. No difference was observed between the groups in in-hospital complication rate (0.9% vs. 1.8%, p = 0.99). CONCLUSIONS: This is the largest study proving procedural feasibility, safety, and efficacy of TEE-guided AF-ablation with a complete or near-complete avoidance of radiological exposure, without using intracardiac echocardiography.

Impact of a predefined pacemapping protocol use for ablation of infrequent premature ventricular complexes: A prospective, multicenter study.

BACKGROUND: Pacemapping (PM) is a useful maneuver for aiding premature ventricular complex (PVC) ablation. Its standalone clinical value is still to be defined. OBJECTIVES: The purpose of this study was to analyze the efficacy of a predefined PM protocol for low-burden PVC ablation, regardless of their site of origin (SOO) and the presence of structural heart disease. METHODS: This was a prospective, nonrandomized, multicenter study. The PM protocol was performed when <1 PVC/min was found. The "target area" was delimited by the 3 best matching points >94% correlation, and 3 radiofreqency (RF) applications were delivered. RESULTS: Of 185 patients, 105 (57%) underwent activation mapping, 60 (32%) were PM-guided, and 20 (11%) were canceled due to absence of PVCs. Baseline QRS, PVC burden, and outflow tract origin were independent predictors of PM-guided ablation. A higher proportion of right ventricular outflow tract SOO in the PM group (52% vs 40%; P = .03) was observed. Mean target area was 0.6 ± 0.9 cm2. Mean 10-ms isochronal area in local activation time (LAT)-guided procedures was higher (1.7 ± 2.3 cm2; P <.001). Mean number of PM matching points acquired was 39 ± 21 (range 6-98). Mean mapping and RF times were similar in both groups. However, significantly shorter procedural (53 ± 24 vs 61 ± 26 minutes; P = .04) as well as RF times (111 ± 51 vs 149 ± 149 seconds; P = .05) were needed in the PM group using the proposed protocol. Global clinical success reached 87% for the PM group and 90% (P = .58) the for LAT mapping group. CONCLUSION: When LAT mapping is precluded, application of a PM-guided ablation protocol directed to >94% matching correlation target area is a more efficient alternative with comparable clinical results.

MANual vs. automatIC local activation time annotation for guiding Premature Ventricular Complex ablation procedures (MANIaC-PVC study).

AIMS: To assess potential benefits of a local activation time (LAT) automatic acquisition protocol using wavefront annotation plus an ECG pattern matching algorithm [automatic (AUT)-arm] during premature ventricular complex (PVC) ablation procedures. METHODS AND RESULTS: Prospective, randomized, controlled, and international multicentre study (NCT03340922). One hundred consecutive patients with indication for PVC ablation were enrolled and randomized to AUT (n = 50) or manual (MAN, n = 50) annotation protocols using the CARTO3 navigation system. The primary endpoint was mapping success. Clinical success was defined as a PVC-burden reduction of ≥80% in the 24-h Holter within 6 months after the procedure. Mean age was 56 ± 14 years, 54% men. The mean baseline PVC burden was 25 ± 13%, and mean left ventricular ejection fraction (LVEF) 55 ± 11%. Baseline characteristics were similar between the groups. The most frequent PVC-site of origin were right ventricular outflow tract (41%), LV (25%), and left ventricular outflow tract (17%), without differences between groups. Radiofrequency (RF) time and number of RF applications were similar for both groups. Mapping and procedure times were significantly shorter in the AUT-arm (25.5 ± 14.3 vs. 32.8 ± 12.6 min, P = 0.009; and 54.8 ± 24.8 vs. 67.4 ± 25.2, P = 0.014, respectively), while more mapping points were acquired [136 (94-222) AUT vs. 79 (52-111) MAN; P < 0.001]. Mapping and clinical success were similar in both groups. There were no procedure-related complications. CONCLUSION: The use of a complete automatic protocol for LAT annotation during PVC ablation procedures allows to achieve similar clinical endpoints with higher procedural efficiency when compared with conventional, manual annotation carried out by expert operators.

Left atrial wall thickness of the pulmonary vein reconnection sites during atrial fibrillation redo procedures.

BACKGROUND: Left atrial wall thickness (LAWT) has been related to pulmonary vein (PV) reconnections after atrial fibrillation (AF) ablation. The aim was to integrate 3D-LAWT maps in the navigation system and analyze the relationship with local reconnection sites during AF-redo procedures. METHODS: Consecutive patients referred for AF-redo ablation were included. Procedure was performed using a single catheter technique. LAWT maps obtained from multidetector computerized tomography (MDCT) were imported into the navigation system. LAWT of the circumferential PV line, the reconnected segment and the reconnected point, were analyzed. RESULTS: Sixty patients [44 (73%) male, age 61 ± 10 years] were included. All reconnected veins were isolated using a single catheter technique with 55 min (IQR 47-67) procedure time and 75 s (IQR 50-120) fluoroscopy time. Mean LAWT of the circumferential PV line was 1.46 ± 0.22 mm. The reconnected segment was thicker than the rest of segments of the circumferential PV line (2.05 + 0.86 vs. 1.47 + 0.76, p < .001 for the LPVs; 1.55 + 0.57 vs. 1.27 + 0.57, p < .001 for the RPVs). Mean reconnection point wall thickness (WT) was at the 82nd percentile of the circumferential line in the LPVs and at the 82nd percentile in the RPVs. CONCLUSION: A single catheter technique is feasible and efficient for AF-redo procedures. Integrating the 3D-LAWT map into the navigation system allows a direct periprocedural estimation of the WT at any point of the LA. Reconnection points were more frequently present in thicker segments of the PV line. The use of 3D-LAWT maps can facilitate reconnection point identification during AF-redo ablation.