Integrating new approaches to atrial fibrillation management: the 6th AFNET/EHRA Consensus Conference.

There are major challenges ahead for clinicians treating patients with atrial fibrillation (AF). The population with AF is expected to expand considerably and yet, apart from anticoagulation, therapies used in AF have not been shown to consistently impact on mortality or reduce adverse cardiovascular events. New approaches to AF management, including the use of novel technologies and structured, integrated care, have the potential to enhance clinical phenotyping or result in better treatment selection and stratified therapy. Here, we report the outcomes of the 6th Consensus Conference of the Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA), held at the European Society of Cardiology Heart House in Sophia Antipolis, France, 17-19 January 2017. Sixty-two global specialists in AF and 13 industry partners met to develop innovative solutions based on new approaches to screening and diagnosis, enhancing integration of AF care, developing clinical pathways for treating complex patients, improving stroke prevention strategies, and better patient selection for heart rate and rhythm control. Ultimately, these approaches can lead to better outcomes for patients with AF.

Transvenous defibrillation leads: high incidence of failure during long-term follow-up.

INTRODUCTION: Patients with implantable cardioverter defibrillators (ICD) critically depend on correct functioning of their system. The aim of this study was to determine the incidence and clinical presentation of transvenous ICD lead failures during long-term follow-up. METHODS AND RESULTS: The study group consisted of 261 consecutive patients who received Medtronic right ventricular polyurethane transvenous leads (models 6884, 6966, 6936) between 1990 and 1998 as part of an abdominal (n = 70) or pectoral (n = 191) ICD system. During mean follow-up of 4.0 +/- 2.6 years, 31 patients (12%) developed a lead-related sensing failure with oversensing of artifacts. All failures except two were compatible with an insulation defect and occurred late after ICD placement (6.0 +/- 1.8 years after implant). Lead survival decreased from 98% at 4-year follow-up to only 62% at 8-year follow-up. Lead survival was not related to patient age, sex, venous lead implantation route, or device implantation site. In 26 (87%) of 31 patients, a sensing defect resulted in inappropriate detection of ventricular fibrillation and subsequent delivery of 3 +/- 3 (range 1-11) inappropriate shocks in 19 (61%) of 31 patients. Device interrogation showed artifacts classified as nonsustained ventricular tachycardia in 21 patients, 40 +/- 43 days before clinically relevant failure of the system. One patient with a subclavian crush syndrome required resuscitation because of undersensing of true ventricular fibrillation. CONCLUSION: Transvenous polyurethane ICD leads showed a high rate of lead insulation failure late after implantation with frequent inappropriate shock deliveries. Close follow-up is mandatory in patients with these leads. Automated device control features with patient alert function integrated into new devices may contribute to early detection of lead failure.

Pulmonary vein bigeminy: electrophysiological characteristics and results of catheter ablation.

UNLABELLED: Pulmonary vein bigeminy is the pair of a second, late and ectopic pulmonary vein potential following atrial far-field activation and a first passive pulmonary vein potential during sinus rhythm. The aim of this study was to determine the electrophysiological characteristics of pulmonary vein bigeminy and to evaluate its relevance as a trigger for paroxysmal atrial fibrillation. METHODS AND RESULTS: Pulmonary vein bigeminy was recorded in 8 of 45 patients (18%) who underwent mapping of pulmonary veins for ablation of focal atrial fibrillation. The premature ectopic pulmonary vein potentials were conducted to the atria in 5 patients and were not conducted (concealed bigeminy) in 3 patients. The coupling interval of the ectopic pulmonary vein potential to the preceding atrial signal during sinus rhythm was significantly longer in patients with conducted bigeminy (375 +/- 25 ms) than with concealed bigeminy (230 +/- 17 ms). The pulmonary vein bigeminy was driven by coronary sinus pacing with the pacing cycle length at lower stimulation rates and was suppressed by overdrive pacing. Coronary sinus pacing led to a separation of the first pulmonary vein potential from the atrial signal but the interval between the atrial signal and the second pulmonary vein potential remained unchanged. Focal ablation at the site of earliest ectopic pulmonary vein activity in 5 patients induced rapid repetitive firing before elimination of the pulmonary vein bigeminy. Ostial disconnection of the arrhythmogenic pulmonary vein in 3 patients was associated with elimination of the pulmonary vein bigeminy. During the follow-up of 9 +/- 5 months after ablation of the pulmonary vein bigeminy, 5 of the 8 patients (63%) were free of atrial fibrillation without antiarrhythmic medication. CONCLUSIONS: The response of pulmonary vein bigeminy to atrial pacing and ostial ablation suggests that pulmonary vein bigeminy depends on an intact electrophysiological breakthrough between the left atrium and the pulmonary vein. Ablation targeting the pulmonary vein bigeminy is a possible limited approach for this subgroup of patients with paroxysmal atrial fibrillation.