Four typical pulmonary venous pressure curves displaying the level of occlusion during atrial fibrillation ablation by cryoballoon.

Background: Cryoballoon ablation is safe and effective for pulmonary vein isolation in patients with symptomatic drug-refractory paroxysmal atrial fibrillation. To monitor adhesion between the balloon and the pulmonary vein, an alternative technique to pulmonary venography is to analyze changes in the pressure curve. Methods: We have described the adhesion level characterized by four types of pressure waveforms. Results: These correlated with the extent of contrast agent leakage (Cohen's kappa of 0.81 [IC 95%: 0.63-0.99]). Conclusion: Monitoring the venous pressure curve is easy to perform and has the advantage of being able to detect balloon movement during the first few seconds of treatment.

ATE Score Diagnostic Accuracy for Predicting the Absence of Intra-Atrial Thrombi Before AF Ablation.

BACKGROUND: In a preliminary study in patients hospitalized for catheter ablation of atrial fibrillation (AF), the atrial thrombus exclusion (ATE) score (stroke, hypertension, heart failure, and D-dimers >270 ng/mL) was developed to rule out the diagnosis of intra-atrial thrombus, with a negative predictive value (NPV) of 100%, and to avoid performing transesophageal echocardiography (TEE). OBJECTIVES: The present study was designed to prospectively confirm the NPV of the ATE score in an independent population. METHODS: Consecutive patients hospitalized for catheter ablation of AF or left atrial tachycardia (LAT) were prospectively enrolled in a multicenter study. D-dimer levels were measured within 48 hours before ablation. An ATE score of 0 was considered predictive of no thrombus. TEE was routinely performed at the beginning or just before the ablation procedure. The primary endpoint was the presence of atrial thrombus diagnosed by TEE. RESULTS: The analysis included 3,072 patients (53.3% paroxysmal AF, 36.7% persistent AF, and 10% LAT). A thrombus was detected in 29 patients (0.94%; 95% CI: 0.63%-1.35%), all on appropriate anticoagulant therapy. An ATE score of 0 was observed in 818 patients (26.6%), and the sensitivity, specificity, positive predictive value, and NPV were 93.1%, 26.8%, 1.2%, and 99.8%, respectively. Follow-up of the 2 false negative patients revealed the persistence of chronic organized thrombi. CONCLUSIONS: In patients hospitalized for catheter ablation of AF or LAT, the ATE score identifies a population at very low risk for atrial thrombus. In consultation with the patient, the cardiologist may consider not performing a preoperative TEE in case of an ATE score of 0.

Impact of peri-procedural management of direct oral anticoagulants on pocket haematoma after cardiac electronic device implantation: the StimAOD multicentre prospective study.

AIMS: The study aims to investigate the impact of direct oral anticoagulant (DOAC) management on the incidence of pocket haematoma in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation. METHODS AND RESULTS: All consecutive patients receiving DOAC and undergoing cardiac electronic device implantation were included in a large multicentre prospective observational study (NCT03879473). The primary endpoint was clinically relevant haematoma within 30 days after implantation. Overall, 789 patients were enrolled [median age 80 (IQR 72-85) years old, 36.4% women, median CHA2DS2-VASc score 4 (IQR 0-8)], of which 632 (80.1%) received a pacemaker implantation. Antiplatelet therapy was combined with DOAC in 146 patients (18.5%). Direct oral anticoagulants (DOACs) were interrupted 52 (IQR 37-62) h before the procedure and resumed 31 (IQR 21-47) h later. Ninety-six percent of the patients had at least 12 h DOAC interruption before the procedure, and 78% had at least 12 h DOAC interruption after the procedure. Overall, anticoagulation was interrupted for 72 (IQR 48-96) h. Pre- or post-procedural heparin bridging was used in 8.2% and 3.9%, respectively. Timing of DOAC interruption of resumption was not associated with clinically relevant haematoma. Clinically relevant haematoma occurred in 26 patients (3.3%), and thromboembolic events occurred in 5 patients (0.6%). CONCLUSION: In this large real-life registry where most patients had DOAC interruption, clinically relevant haematoma was rare. Despite DOAC interruption and high CHA2DS2-VASc score, thromboembolic events occurred seldomly, highlighting that bleeding exceeds thromboembolic risk in this peri-procedural period. Future research is needed to identify risk factors for clinically relevant haematoma and meaningfully guide clinicians in optimizing DOAC management.

[Cardiac rhythm management of patients with atrial fibrillation]. / Prise en charge rythmologique des patients ayant une fibrillation atriale.

Cardiac rhythm management of patients with atrial fibrillation. Cardiac rhythm management of atrial fibrillation (AF) is essential to improve symptoms as well as outcomes in patients with AF; this can be achieved either by rhythm or rate control strategies. Many studies published between 2000 and 2010 have supported the point that these two strategies were both acceptable therapeutic options (without clear superiority of one to the other), even in heart failure patients, pinpointing the side effects and the lack of efficacy of many antiarrhythmic pharmacological drugs. Nevertheless, many patients remain symptomatic despite adequate ventricular rate control and eventually require sinus rhythm restoration and maintenance. Then, rhythm control options have evolved and now include catheter ablation either by radiofrequency or cryotherapy, which allow maintaining sinus rhythm and reduce AF-associated symptoms more reliably than antiarrhythmic drugs, particularly in younger patients. Furthermore, interest in rhythm control by catheter ablation has been reinvigorated by the results of recently published trials, especially in patients with heart failure. However, the impact of catheter ablation on morbidity and mortality have still to be proven before considering it in asymptomatic patients.

Prise en charge rythmologique des patients présentant une fibrillation atriale. Une prise en charge rythmologique des patients ayant une fibrillation atriale est indispensable afin d'améliorer leurs symptômes et leur pronostic. Cette prise en charge rythmologique consiste soit à contrôler le rythme sinusal, soit à contrôler la fréquence ventriculaire. Des études cliniques menées entre 2000 et 2010 n'avaient pas permis de démontrer la supériorité d'une des deux approches, notamment en termes de mortalité totale, y compris chez les patients insuffisants cardiaques. L'explication venait en partie du manque d'efficacité et de l'iatrogénie des traitements anti arythmiques (pharmacologiques) jusque-là utilisés. Cependant, nombre de patients en FA restent symptomatiques, et la restauration du rythme sinusal doit être privilégiée. L'avènement des techniques ablatives, qui ont montré leur supériorité sur les traitements anti arythmiques, a soulevé un regain d'intérêt pour la stratégie de contrôle du rythme, particulièrement chez les patients jeunes symptomatiques ainsi que chez les insuffisants cardiaques. Des études de morbi-mortalité sont cependant nécessaires avant d'envisager une ablation chez des patients asymptomatiques.

Exclusion of Intra-Atrial Thrombus Diagnosis Using D-Dimer Assay Before Catheter Ablation of Atrial Fibrillation.

OBJECTIVES: This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus. BACKGROUND: Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi. METHODS: Patients admitted for catheter ablation of AF (n = 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS2 score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE). RESULTS: The incidence of atrial thrombus was 1.92%. CHADS2 score and D-dimer level were significantly associated with atrial thrombus (p < 0.0001 and p < 0.0001, respectively). A zero CHADS2 score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS2 score (p < 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus. CONCLUSIONS: An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.

Implantable cardioverter-defibrillator therapy among patients with non-ischaemic vs. ischaemic cardiomyopathy for primary prevention of sudden cardiac death.

Aim: The magnitude of benefit related to implantable cardioverter defibrillator (ICD) therapy for primary prevention of sudden cardiac death (SCD) in non-ischaemic cardiomyopathy (NICM) and ischaemic cardiomyopathy (ICM) has not been evaluated extensively in clinical practice. Methods and results: Of the 5539 consecutive patients enrolled in the multicentre Défibrillateur Automatique Implantable-Prévention Primaire (DAI-PP) study (2002-12), 5485 patients (with information on underlying heart disease) were included in the present analysis: 2181 (39.8%) had NICM and 3304 (60.2%) had ICM. ICM patients were older (63.7 ±10.3 vs. 60.6 ± 12.2 years, P < 0.0001), with a higher ejection fraction [27% (25-30) vs. 25% (20-30), P < 0.0001], narrower QRS (37.3% vs. 21.4% with QRS <120, P < 0.0001), and higher prevalence of sinus rhythm (77.3% vs. 74.0%, P = 0.009). During a mean follow-up of 3.1 ± 2.2 years, 814 patients died, giving a mortality incidence of 48.6 per 1000 person-years [95% confidence interval (CI) 45.2-51.9], higher among ICM patients (52.3, 95% CI 47.8-56.7) than in NICM patients (42.4, 95% CI 37.3-47.6; P = 0.008) (adjusted hazard ratio 1.31, 95% CI 1.06-1.61, P = 0.01). The increase in mortality among ICM patients was mainly due to non-cardiovascular mortality (P = 0.0002), whereas incidences of cardiovascular mortality (including ICD-unresponsive SCD) were similar in the two groups. Incidences of appropriate ICD interventions (anti-tachycardia pacing, shocks) were similar, but inappropriate therapies were more frequent in NICM (7.94 vs. 5.96%; P = 0.005). Conclusion: NICM and ICM patients had a same rate of ICD therapy for primary prevention of SCD in everyday practice. But, ICM patients more often died of a non- cardiovascular cause of death. Clinical Trial Registration: NCT 01992458.

Real-time contact force sensing for pulmonary vein isolation in the setting of paroxysmal atrial fibrillation: procedural and 1-year results.

INTRODUCTION: The additional benefit of contact force (CF) technology during pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) to improve mid-term clinical outcome is unclear. METHODS AND RESULTS: Eligible patients with symptomatic paroxysmal AF were enrolled in this prospective trial, comparing circular antral catheter ablation (guided by Carto 3 System, Biosense Webster) using either a new open-irrigated CF catheter (SmartTouch Thermocool, Biosense Webster) (CF group) or a non-CF open-irrigated catheter (EZ Steer Thermocool, Biosense Webster) (control group). Overall, 30 patients were enrolled in each group, with a standardized 12-month follow-up, free of antiarrhythmic therapy. Demographic, cardiovascular and anatomic characteristics were similar in both groups. Though complete PVI was eventually achieved in all cases in both groups, success using an exclusive anatomic approach was 80.0% in CF group versus 36.7% in control group (P < 0.0001). CF use was associated with significant reductions in fluoroscopy exposure (P < 0.01) and radiofrequency time (P = 0.01). The incidence rates of AF recurrence were 10.5% (95% CI, 1.38-22.4) in the CF group, and 35.9% (95% CI, 12.4-59.4) in the control group (log rank test, P = 0.04). After adjustment on potential confounders, the use of CF catheter was found to be associated with a lower AF recurrence (OR 0.18, 95% CI 0.04-0.94, P = 0.04). CONCLUSION: Our findings suggest a potential benefit of real-time CF sensing technology, in reducing AF recurrence during the first year after PVI.

Predicting favourable outcomes in the setting of radiofrequency catheter ablation of long-standing persistent atrial fibrillation: a pilot study assessing the value of left atrial appendage peak flow velocity.

BACKGROUND: Catheter ablation is an effective and potentially curative treatment in patients with atrial fibrillation (AF). AIM: To test the hypothesis that left atrial appendage peak flow velocity (LAV) assessed by echocardiography can accurately predict successful catheter ablation as well as favourable outcome in the setting of long-standing persistent AF. METHODS: This prospective pilot study enrolled 40 patients with long-standing persistent AF (age 60 ± 11 years; persistence of AF 4.2 ± 2 years) who underwent a first catheter ablation procedure using a standardized sequential stepwise protocol. LAV was assessed before the catheter ablation procedure along with classical factors (age, sex, left atrial area, AF cycle length, AF duration and left ventricular ejection fraction), all of which were tested using logistic regression for ability to predict restoration of sinus rhythm during catheter ablation as well as absence of recurrence during a 1-year follow-up. RESULTS: Eighteen patients (45%) experienced AF termination during the procedure and 18 patients (45%) did not develop any recurrence during the first 12 months. Multivariable analysis demonstrated that high LAV (>0.3 m/s) was the only independent predictor of AF termination (odds ratio 5.91, 95% confidence interval 1.06-32.88; P=0.04) and absence of recurrence at 1 year (odds ratio 4.33, 95% confidence interval 1.05-17.81; P=0.04). CONCLUSIONS: This pilot study demonstrated the feasibility and importance of LAV measurement in the setting of long-standing persistent AF to predict successful catheter ablation and favourable mid-term outcome.

Speckle tracking imaging improves in vivo assessment of EPO-induced myocardial salvage early after ischemia-reperfusion in rats.

A noninvasive assessment of infarct size and transmural extension of myocardial infarction (TEMI) is fundamental in experimental models of ischemia-reperfusion. Conventional echocardiography parameters are limited in this purpose. This study was designed to examine whether speckle tracking imaging can be used in a rat model of ischemia-reperfusion to accurately detect the reduction of infarct size and TEMI induced by erythropoietin (EPO) as early as 24 h after reperfusion. Rats were randomly assigned to one of three groups: myocardial infarction (MI)-control group, 45 min ischemia followed by 24 h of reperfusion; MI-EPO group, similar surgery with a single bolus of EPO administered at the onset of reperfusion; and sham-operated group. Short-axis two-dimensional echocardiography was performed after reperfusion. Global radial (GS(r)) and circumferential (GS(cir)) strains were compared with infarct size and TEMI assessed after triphenyltetrazolium chloride staining. As a result, ejection fraction, shortening fraction, GS(r), and GS(cir) significantly correlated to infarct size, whereas only GS(r) and GS(cir) significantly correlated to TEMI. EPO significantly decreased infarct size (30.8 + or - 3.5 vs. 56.2 + or - 5.7% in MI-control, P < 0.001) and TEMI (0.37 + or - 0.05 vs. 0.77 + or - 0.05 in MI-control, P < 0.001). None of the conventional echocardiography parameters was significantly different between the MI-EPO and MI-control groups, whereas GS(r) was significantly higher in the MI-EPO group (29.1 + or - 4.7 vs. 16.4 + or - 3.3% in MI-control; P < 0.05). Furthermore, GS(cir) and GS(r) appeared to be the best parameters to identify a TEMI >0.75 24 h after reperfusion. In conclusion, these findings demonstrate the usefulness of speckle tracking imaging in the early evaluation of a cardioprotective strategy in a rat model of ischemia-reperfusion.

Myocardial reperfusion injury management: erythropoietin compared with postconditioning.

Ischemic postconditioning (IPost) and erythropoietin (EPO) have been shown to attenuate myocardial reperfusion injury using similar signaling pathways. The aim of this study was to examine whether EPO is as effective as IPost in decreasing postischemic myocardial injury in both Langendorff-isolated-heart and in vivo ischemia-reperfusion rat models. Rat hearts were subjected to 25 min ischemia, followed by 30 min or 2 h of reperfusion in the isolated-heart study. Rats underwent 45 min ischemia, followed by 24 h of reperfusion in the in vivo study. In both studies, the control group (n=12; ischemia-reperfusion only) was compared with IPost (n=16; 3 cycles of 10 s reperfusion/10 s ischemia) and EPO (n=12; 1,000 IU/kg) at the onset of reperfusion. The following resulted. First, in the isolated hearts, IPost or EPO significantly improved postischemic recovery of left ventricular developed pressure. EPO induced better left ventricular developed pressure than IPost at 30 min of reperfusion (73.18+/-10.23 vs. 48.11+/-7.92 mmHg, P<0.05). After 2 h of reperfusion, the infarct size was significantly lower in EPO-treated hearts compared with IPost and control hearts (14.36+/-0.60%, 19.11+/-0.84%, and 36.21+/-4.20% of the left ventricle, respectively; P<0.05). GSK-3beta phosphorylation, at 30 min of reperfusion, was significantly higher with EPO compared with IPost hearts. Phosphatidylinositol 3-kinase and ERK1/2 inhibitors abolished both EPO- and IPost-mediated cardioprotection. Second, in vivo, IPost and EPO induced an infarct size reduction compared with control (40.5+/-3.6% and 28.9+/-3.1%, respectively, vs. 53.7+/-4.3% of the area at risk; P<0.05). Again, EPO decreased significantly more infarct size and transmurality than IPost (P<0.05). In conclusion, with the use of our protocols, EPO showed better protective effects than IPost against reperfusion injury through higher phosphorylation of GSK-3beta.

Role of congenital long-QT syndrome in unexplained sudden infant death: proposal for an electrocardiographic screening in relatives.

INTRODUCTION: Congenital long-QT syndrome (LQTS) is a sporadic or familial inherited arrhythmia. It can lead to sudden death by ventricular fibrillation which occurs at any age but particularly during infancy. Recent studies of postmortem molecular analysis in infants who died of unexplained sudden infant death syndrome (SIDS) showed abnormal mutations to LQTS in 10% to 12%. Current methods of etiologic investigation of sudden infant death syndrome do not allow the diagnosis of LQTS. A targeted anamnesis together with systematic electrocardiograms of first- and second-degree relatives could be an efficient LQTS diagnostic tool. Therefore, we propose to include them in screening procedures for SIDS etiologies. CONCLUSION: LQTS accounts for a significant number of unexplained SIDS. We suggest adding a systematic familial electrocardiographic screening to the current etiologic investigations in order to track congenital LQTS in relatives.