Multicentre evaluation of non-invasive biatrial mapping for persistent atrial fibrillation ablation: the AFACART study.

AIMS: Non-invasive electrocardiogram (ECG) mapping allows the activation of the entire atrial epicardium to be recorded simultaneously, potentially identifying mechanisms critical for atrial fibrillation (AF) persistence. We sought to evaluate the utility of ECG mapping as a practical tool prior to ablation of persistent AF (PsAF) in centres with no practical experience of the system. METHODS AND RESULTS: A total of 118 patients with continuous AF duration <1 year were prospectively studied at 8 European centres. Patients were on a median of 1 antiarrhythmic drug (AAD) that had failed to restore sinus rhythm. Electrocardiogram mapping (ECVUE™, CardioInsight, USA) was performed prior to ablation to map AF drivers (local re-entrant circuits or focal breakthroughs). Ablation targeted drivers depicted by the system, followed by pulmonary vein (PV) isolation, and finally left atrial linear ablation if AF persisted. The primary endpoint was AF termination. Totally, 4.9 ± 1.0 driver sites were mapped per patient with a cumulative mapping time of 16 ± 2 s. Of these, 53% of drivers were located in the left atrium, 27% in the right atrium, and 20% in the anterior interatrial groove. Driver-only ablation resulted in AF termination in 75 of the 118 patients (64%) with a mean radiofrequency (RF) duration of 46 ± 28 min. Acute termination rates were not significantly different amongst all 8 centres (P = 0.672). Ten additional patients terminated with PV isolation and lines resulting in a total AF termination rate of 72%. Total RF duration was 75 ± 27 min. At 1-year follow-up, 78% of the patients were off AADs and 77% of the patients were free from AF recurrence. Of the patients with no AF recurrence, 49% experienced at least one episode of atrial tachycardia (AT) which required either continued AAD therapy, cardioversion, or repeat ablation. CONCLUSION: Non-invasive mapping identifies biatrial drivers that are critical in PsAF. This is validated by successful AF termination in the majority of patients treated in centres with no experience of the system. Ablation targeting these drivers results in favourable AF-free survival at 1 year, albeit with a significant rate of AT recurrence requiring further management.

Long-Term Follow-Up of Idiopathic Ventricular Fibrillation in a Pediatric Population: Clinical Characteristics, Management, and Complications.

Background The natural history and long-term outcome in pediatric patients with idiopathic ventricular fibrillation ( IVF ) are poorly characterized. We sought to define the clinical characteristics and long-term outcomes of a pediatric cohort with an initial diagnosis of IVF . Methods and Results Patients were included from an International Registry of IVF (consisting of 496 patients). Inclusion criteria were: (1) VF with no identifiable cause following comprehensive analysis for ischemic, electrical or structural heart disease and (2) age ≤16 years. These included 54 pediatric IVF cases (age 12.7±3.7 years, 59% male) among whom 28 (52%) had a previous history of syncope (median 2 syncopal episodes [interquartile range 1]). Thirty-six (67%) had VF in situations associated with high adrenergic tone. During a median 109±12 months of follow-up, 31 patients (57%) had recurrence of ventricular arrhythmias, mainly VF . Two patients developed phenotypic expression of an inherited arrhythmia syndrome during follow-up (hypertrophic cardiomyopathy and long QT syndrome, respectively). A total of 15 patients had positive genetic testing for inherited arrhythmia syndromes. Ten patients (18%) experienced device-related complications. Three patients (6%) died, 2 due to VF storm. Conclusions In pediatric patients with IVF , a minority develop a definite clinical phenotype during long-term follow-up. Recurrent VF is common in this patient group.

Characteristics associated with low treatment satisfaction in patients with implanted cardioverter defibrillators: results from the LICAD study.

The evaluation of low treatment satisfaction (LTS) with an implanted cardioverter defibrillator (ICD) remains a neglected area of clinical research. However, a trustful attitude toward an ICD is crucial. Within the scope of ICD health technology assessment, we searched for predictors of LTS. Of 195 ICD patients enrolled (mean 59.8 years, standard deviation 12.6), 163 (83.6%) were men and 26 (16.4%) were women. We measured anxiety, helplessness, and depression with standardized instruments and LTS with 11 dichotomous items concerning a mistrustful attitude, a negative body image, and low appraisal. A total of 47 (24.1%) patients were considered as LTS patients. Multivariate logistic regression was used for assessment of LTS. Adjusted for age and survey, LTS was significantly more prevalent in depressed, anxious, and phobic patients. Multivariate logistic regression including medical and psychological covariates revealed the experience of > or =5 shocks with an odds ratio (OR) of 10.17 (95% CI 3.57-29.00, P < or = 0.001), being employed with an OR of 8.07 (95% CI 2.39-27.19, P < or = 0.001), and feelings of helplessness (OR 4.61, 95% CI 1.79-11.90, P < or = 0.002) as the most important predictors for LTS. Women had a slightly not significant effect on LTS. Age, educational status, and depression were not significant. LTS patients required more support for living with the ICD (P < or = 0.001). Thus, LTS serves as surrogate measure for deteriorated psychic health. Clinicians should be advised to identify LTS patients and to consider psychotherapeutic counseling for them.