Suture-based techniques versus manual compression for femoral venous haemostasis after electrophysiology procedures.

BACKGROUND AND AIMS: Methods for femoral venous haemostasis following electrophysiology (EP) procedures include manual compression (MC) and suture-based techniques such as a figure-of-eight suture secured with a hand-tied knot (Fo8HT) or a modified figure-of-eight suture secured with a 3-way stopcock (Fo8MOD). We hypothesised that short-term bleeding outcomes using the Fo8MOD approach would be superior to MC. We additionally compared outcomes between Fo8MOD and Fo8HT approaches. METHODS: We studied consecutive patients undergoing EP procedures at our institution between March and December 2023. Patients were categorised into three haemostasis groups: MC, Fo8HT and Fo8MOD. Access site complications were classified as major (requiring intervention or blood transfusion, delaying discharge or resulting in death) or minor (bleeding/haematoma requiring additional compression). RESULTS: 1089 patients were included: MC 718 (65.9%); Fo8HT 105 (9.6%); Fo8MOD 266 (24.4%). Procedures were most commonly for atrial fibrillation (52.4%), atrial flutter (10.9%), and atrioventricular nodal re-entrant tachycardia (10.1%). In patients receiving periprocedural anticoagulation (865, 79.4%), Fo8MOD associated with fewer complications than MC or Fo8HT (major: MC 2.2%, Fo8HT 6.0%, Fo8MOD 0.8%, p = .01; minor: MC 16.5%, Fo8HT 12.0%, Fo8MOD 7.4%, p = .002). In patients not receiving periprocedural anticoagulation, complications did not differ between haemostasis methods (total major and minor complications 5.8%, p = .729 for between groups rates). On multivariable logistic regression, Fo8MOD was associated with a significantly lower risk of access site complications (OR 0.29 [95% CI 0.17-0.48], p < .001), whilst intraprocedural heparinisation (OR 5.25 [2.88-9.69], p < .001) and larger maximal sheath size (OR 1.06 [1.00-1.11], p = .04) were associated with a higher risk of complications. CONCLUSION: Femoral haemostasis with Fo8MOD associates with fewer access site complications than MC and Fo8HT following EP procedures that need periprocedural anticoagulation.

Predictors of the need for atrioventricular nodal ablation following redo ablation for atrial fibrillation.

Background: Patients who have recurrent atrial fibrillation (AF) following redo catheter ablation may eventually be managed with a pace-and-ablate approach, involving pacemaker implant followed by atrioventricular nodal ablation (AVNA). We sought to determine which factors would predict subsequent AVNA in patients undergoing redo AF ablation. Methods: We analyzed patients undergoing redo AF ablations between 2013 and 2019 at our institution. Follow-up was censored on December 31, 2021. Patients with no available follow-up data were excluded. Time-to-event analysis with Cox proportional hazard regression was used to compare those who underwent AVNA to those who did not. Results: A total of 467 patients were included, of whom 39 (8.4%) underwent AVNA. After multivariable adjustment, female sex (aHR 4.68 [95% CI 2.30-9.50]; p < 0.001), ischemic heart disease (aHR 2.99 [95% CI 1.25-7.16]; p = 0.014), presence of a preexisting pacemaker (aHR 3.25 [95% CI 1.10-9.60]; p = 0.033), and persistent AF (aHR 2.22 [95% CI 1.07-4.59]; p = 0.032) were associated with increased risk of subsequent AVNA requirement. Conclusion: Female sex, ischemic heart disease, and persistent AF may be useful clinical predictors of the requirement for subsequent AVNA and may be considered as part of shared clinical decision making.

Cost, efficiency, and outcomes of pulsed field ablation vs thermal ablation for atrial fibrillation: A real-world study.

BACKGROUND: With the exponential growth of catheter ablation for atrial fibrillation (AF), there is increasing interest in associated health care costs. Pulsed field ablation (PFA) using a single-shot pentaspline multielectrode catheter has been shown to be safe and effective for AF ablation, but its cost efficiency compared to conventional thermal ablation modalities (cryoballoon [CB] or radiofrequency [RF]) has not been evaluated. OBJECTIVE: The purpose of this study was to compare cost, efficiency, effectiveness, and safety between PFA, CB, and RF for AF ablation. METHODS: We studied 707 consecutive patients (PFA: 208 [46.0%]; CB: 325 [29.4%]; RF: 174 [24.6%]) undergoing first-time AF ablation. Individual procedural costs were calculated, including equipment, laboratory use, and hospital stay, and compared between ablation modalities, as were effectiveness and safety. RESULTS: Skin-to-skin times and catheter laboratory times were significantly shorter with PFA (68 and 102 minutes, respectively) than with CB (91 and 122 minutes) and RF (89 and 123 minutes) (P < .001). General anesthesia use differed across modalities (PFA 100%; CB 10.2%; RF 61.5%) (P < .001). Major complications occurred in 1% of cases, with no significant differences between modalities. Shorter procedural times resulted in lower staffing and laboratory costs with PFA, but these savings were offset by substantially higher equipment costs, resulting in higher overall median costs with PFA (£10,010) than with CB (£8106) and RF (£8949) (P < .001). CONCLUSION: In this contemporary real-world study of the 3 major AF ablation modalities used concurrently, PFA had shorter skin-to-skin and catheter laboratory times than did CB and RF, with similarly low rates of complications. However, PFA procedures were considerably more expensive, largely because of higher equipment cost.

Delineating postinfarct ventricular tachycardia substrate with dynamic voltage mapping in areas of omnipolar vector disarray.

Background: Defining postinfarct ventricular arrhythmic substrate is challenging with voltage mapping alone, though it may be improved in combination with an activation map. Omnipolar technology on the EnSite X system displays activation as vectors that can be superimposed onto a voltage map. Objective: The study sought to optimize voltage map settings during ventricular tachycardia (VT) ablation, adjusting them dynamically using omnipolar vectors. Methods: Consecutive patients undergoing substrate mapping were retrospectively studied. We categorized omnipolar vectors as uniform when pointing in one direction, or in disarray when pointing in multiple directions. We superimposed vectors onto voltage maps colored purple in tissue >1.5 mV, and the voltage settings were adjusted so that uniform vectors appeared within purple voltages, a process termed dynamic voltage mapping (DVM). Vectors in disarray appeared within red-blue lower voltages. Results: A total of 17 substrate maps were studied in 14 patients (mean age 63 ± 13 years; mean left ventricular ejection fraction 35 ± 6%, median 4 [interquartile range 2-8.5] recent VT episodes). The DVM mean voltage threshold that differentiated tissue supporting uniform vectors from disarray was 0.27 mV, ranging between patients from 0.18 to 0.50 mV, with good interobserver agreement (median difference: 0.00 mV). We found that VT isthmus components, as well as sites of latest activation, isochronal crowding, and excellent pace maps colocated with tissue along the DVM border zone surrounding areas of disarray. Conclusion: DVM, guided by areas of omnipolar vector disarray, allows for individualized postinfarct ventricular substrate characterization. Tissue bordering areas of disarray may harbor greater arrhythmogenic potential.

Cryoballoon pulmonary vein isolation as first-line treatment of typical atrial flutter: long-term outcomes of the CRAFT trial.

BACKGROUND: CRAFT was an international, multicentre, randomised controlled trial across 11 sites in the United UK and Switzerland. Given the evidence that pulmonary vein triggers may be responsible for atrial flutter (AFL) as well as atrial fibrillation (AF), we hypothesised that cryoballoon pulmonary vein isolation (PVI) would provide greater symptomatic arrhythmia reduction than cavotricuspid isthmus (CTI) ablation, whilst also reducing the subsequent burden of AF. Twelve-month outcomes were previously reported. In this study, we report the extended outcomes of the CRAFT study to 36 months. METHODS: Patients with typical AFL and no evidence of AF were randomised 1:1 to cryoballoon PVI or radiofrequency CTI. All patients received an implantable loop recorder (ILR) for continuous cardiac rhythm monitoring. The primary outcome was time-to-symptomatic arrhythmia recurrence > 30 s. Secondary outcomes included time-to-first-AF episode ≥ 2 min. The composite safety outcome included death, stroke and procedural complications. RESULTS: A total of 113 patients were randomised to cryoballoon PVI (n = 54) or radiofrequency CTI ablation (n = 59). Ninety-one patients reconsented for extended follow-up beyond 12 months. There was no difference in the primary outcome between arms, with the primary outcome occurring in 12 PVI vs 11 CTI patients (HR 0.97; 95% CI 0.43-2.20; p = 0.994). AF ≥ 2 min was significantly less frequent in the PVI arm, affecting 26 PVI vs 36 CTI patients (HR 0.48; 95% CI 0.29-0.79; p = 0.004). The composite safety outcome occurred in 5 PVI and 6 CTI patients (p = 0.755). CONCLUSION: Cryoballoon PVI shows similar efficacy to radiofrequency CTI ablation in reducing symptomatic arrhythmia recurrence in patients presenting with isolated typical AFL but significantly reduces the occurrence of subsequent AF.

Silent pulmonary veins at redo ablation for atrial fibrillation: Implications and approaches.

BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Despite promising success rates, redo ablation is sometimes required. At redo, PVs may be found to be isolated (silent) or reconnected. We studied patients with silent vs reconnected PVs at redo and analysed associations with adverse outcomes. METHODS: Patients undergoing redo AF ablations between 2013 and 2019 at our institution were included and stratified into silent PVs or reconnected PVs. The primary outcome was a composite of further redo ablation, non-AF ablation, atrioventricular nodal ablation, and death. Secondary outcomes included arrhythmia recurrence. RESULTS: A total of 467 patients were included with mean 4.6 ± 1.7 years follow-up, of whom 48 (10.3%) had silent PVs. The silent PV group had had more often undergone >1 prior ablation (45.8% vs 9.8%; p<0.001), had more persistent AF (62.5% vs 41.1%; p=0.005) and had more non-PV ablation performed both at prior ablation procedures and at the analysed redo ablation. The primary outcome occurred more frequently in those with silent PVs (25% vs 13.8%; p=0.053). Arrhythmia recurrence was also more common in the silent PV group (66.7% vs 50.6%; p=0.047). After multivariable adjustment, female sex (aHR 2.35 [95% CI 2.35-3.96]; p=0.001) and ischaemic heart disease (aHR 3.21 [95% CI 1.56-6.62]; p=0.002) were independently associated with the primary outcome, and left atrial enlargement (aHR 1.58 [95% CI 1.20-2.08]; p=0.001) and >1 prior ablation (aHR 1.88 [95% CI 1.30-2.72]; p<0.001) were independently associated with arrhythmia recurrence. Whilst a finding of silent PVs was not itself significant after multivariable adjustment, this provides an easily assessable parameter at clinically indicated redo ablation which informs the clinician of the likelihood of a worse future prognosis. CONCLUSIONS: Patients with silent PVs at redo AF ablation have worse clinical outcomes.

UltraSOUND-based characterization of ventricular tachycardia SCAR and arrhythmogenic substrate: The SOUNDSCAR study.

BACKGROUND: Intracardiac echocardiography (ICE) represents a valuable image integration technique, with the unique advantage of dynamic real-time scar characterization. OBJECTIVES: The goals of this study were to assess the correlation between ICE-defined and electroanatomic mapping (EAM)-defined scar in patients with ischemic cardiomyopathy and to define the outcomes of ICE-guided ventricular tachycardia (VT) ablation. METHODS: Thirty-eight patients with ischemic cardiomyopathy (SOUNDSCAR cohort) underwent full left ventricular (LV) ICE imaging and EAM. ICE-defined scar parameters (end-diastolic and end-systolic wall diameter [EDWD and ESWD], end-systolic wall thickening [percentage difference between EDWD and ESWD with respect to EDWD], slope [end-diastole to end-systole wall thickening], and American Heart Association wall motion scoring) were correlated with EAM-defined scar (voltage <1.5 mV). In a separate cohort (n = 21), outcomes of an ICE-guided VT ablation approach (EAM focused to ICE-defined scar regions) were compared with those of conventional ablation (full left ventricular mapping with EAM only; n = 21). RESULTS: In the 38 SOUNDSCAR patients (mean age 67 ± 11 years; 35 male [92%]; left ventricular ejection fraction 31% ± 10%; 2474 ICE segments; 524 ICE sectors), all ICE-defined parameters strongly predicted EAM-defined scar (area under the curve: American Heart Association score 0.873; ESWD 0.880; EDWD 0.827; slope 0.855; percentage difference between EDWD and ESWD with respect to EDWD, 0.851). All ICE-defined parameters had large effect sizes for predicting EAM-defined scar (logistic regression, P < .001). A detailed topographical comparison of ICE-defined (slope) and EAM-defined scar was possible in 25 patients and demonstrated 88% ± 10% overlap. Compared with conventional VT ablation, ICE-guided ablation was associated with shorter procedure times and comparable VT-free survival (ICE-guided vs conventional: procedure time 240 ± 20 minutes vs 298 ± 39 minutes; P < .001; VT recurrence 3 [14%] vs 7 [31%]; P = .19). CONCLUSION: ICE-defined scar demonstrates a strong correlation with EAM-defined scar. ICE-guided VT ablation is associated with enhanced procedural efficiency.

An approach to help differentiate postinfarct scar from borderzone tissue using Ripple Mapping during ventricular tachycardia ablation.

BACKGROUND: Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium <0.50 mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate postinfarct scar from conducting borderzone (BZ) during ventricular tachycardia (VT) ablation. METHODS: Fifteen consecutive patients (left ventricular ejection fraction 30 ± 7%) underwent endocardial left ventricle pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50 mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue <0.50 mV defined the RM-BZ. RESULTS: RM-scar was significantly smaller than the traditional 0.50 mV cutoff (median 4% vs. 12% shell area, p < .001). 65 ± 16% of tissue <0.50 mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from BZ tissue was 0.22 ± 0.07 mV, though this ranged widely (from 0.12 to 0.35 mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs. 347 ms, p = .001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs. 1.2, p = .013) with faster RM-BZ conduction speed (0.72 vs. 0.34 m/s, p = .001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367 ± 38 ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs. 3.2, p = .059), and slower RM-BZ conduction speed (0.36 vs. 0.63 m/s, p = .036). RM guided ablation collocated within 66 ± 20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes preablation vs. 0 post, p < .001) at 11 ± 6 months follow-up. CONCLUSION: Postinfarct scars appear significantly smaller than traditional 0.50 mV cut-offs suggest, with voltage thresholds unique to each patient.

Incidence of vascular complications for electrophysiology procedures in the ultrasound era: a single-centre experience over 10,000 procedures in the long term.

BACKGROUND: Ultrasound (US) is being increasingly used to guide vascular access for electrophysiology (EP) procedures in many centres. Nonetheless, the incidence and predictors of vascular complications in the US era are limited. In this study, we describe our experience of vascular access-related complications associated with EP procedures which were performed with the routine use of US-guided vascular access. METHODS: A total of 10,158 consecutive EP procedures in 8361 patients performed from April 2014 (when our centre moved to a policy of routine US-guided vascular access for EP procedures) to March 2022 were included. The outcome of interest was any vascular access-related complication that occurred within 7 days of the procedure; these were classified as severe if surgical intervention and/or blood transfusion was required, major if non-surgical intervention or delayed hospital discharge was required, or minor if it did not fulfil the criteria for severe or major. RESULTS: During the study period, 2 (0.02%) severe vascular complications occurred, including 1 pseudo-aneurysm requiring surgery and 1 retroperitoneal haemorrhage requiring blood transfusion. Nine (0.09%) major complications occurred, including 6 hematomas managed by compression devices, 1 type B aortic dissection, 1 AV fistula managed conservatively and 1 haematoma managed conservatively but delayed hospital discharge. Eighteen (0.18%) minor haematomas were seen that did not require any intervention or delayed hospital discharge. On multivariable analysis, female sex [OR (95% CI): 2.5 (1.2, 5.4)] and use of an arterial access [OR (95% CI): 19.3 (7.1, 52.3)] were seen to be independent predictors of the 29 vascular complications. CONCLUSION: With the use of US-guided vascular access in EP procedures, major vascular complications are exceedingly rare, particularly those needing surgical intervention. Our results provide additional evidence for scientific guidelines to support US use.

Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter.

OBJECTIVE: We aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL). METHODS: Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter was an international, multicentre, open with blinded assessment trial. Patients with CTI-dependent AFL and no documented atrial fibrillation (AF) were randomised to either cryoballoon PVI alone or radiofrequency CTI ablation. Primary efficacy outcome was time to first recurrence of sustained (>30 s) symptomatic atrial arrhythmia (AF/AFL/atrial tachycardia) at 12 months as assessed by continuous monitoring with an implantable loop recorder. Primary safety outcome was a composite of death, stroke, tamponade requiring drainage, atrio-oesophageal fistula, pacemaker implantation, serious vascular complications or persistent phrenic nerve palsy. RESULTS: Trial recruitment was halted at 113 of the target 130 patients because of the SARS-CoV-2 pandemic (PVI, n=59; CTI ablation, n=54). Median age was 66 (IQR 61-71) years, with 98 (86.7%) men. At 12 months, the primary outcome occurred in 11 (18.6%) patients in the PVI group and 9 (16.7%) patients in the CTI group. There was no significant difference in the primary efficacy outcome between the groups (HR 1.11, 95% CI 0.46 to 2.67). AFL recurred in six (10.2%) patients in the PVI arm and one (1.9%) patient in the CTI arm (p=0.116). Time to occurrence of AF of ≥2 min was significantly reduced with cryoballoon PVI (HR 0.46, 95% CI 0.25 to 0.85). The composite safety outcome occurred in four patients in the PVI arm and three patients in the CTI arm (p=1.000). CONCLUSION: Cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF. TRIAL REGISTRATION NUMBER: NCT03401099.

Prevalence and risk factors of cardiac thrombus prior to ventricular tachycardia catheter ablation in structural heart disease.

AIMS: Assess prevalence, risk factors, and management of patients with intra-cardiac thrombus referred for scar-related ventricular tachycardia (VT) ablation. METHODS AND RESULTS: Consecutive VT ablation referrals between January 2015 and December 2019 were reviewed (n = 618). Patients referred for de novo, scar-related VT ablation who underwent pre-procedure cardiac computed tomography (cCT) were included. We included 401 patients [61 ± 14 years; 364 male; left ventricular ejection fraction (LVEF) 40 ± 13%]; 45 patients (11%) had cardiac thrombi on cCT at 49 sites [29 LV; eight left atrial appendage (LAA); eight right ventricle (RV); four right atrial appendage]. Nine patients had pulmonary emboli. Overall predictors of cardiac thrombus included LV aneurysm [odds ratio (OR): 6.6, 95%, confidence interval (CI): 3.1-14.3], LVEF < 40% (OR: 3.3, CI: 1.5-7.3), altered RV ejection fraction (OR: 2.3, CI: 1.1-4.6), and electrical storm (OR: 2.9, CI: 1.4-6.1). Thrombus location-specific analysis identified LV aneurysm (OR: 10.9, CI: 4.3-27.7) and LVEF < 40% (OR: 9.6, CI: 2.6-35.8) as predictors of LV thrombus and arrhythmogenic right ventricular cardiomyopathy (OR: 10.6, CI: 1.2-98.4) as a predictor for RV thrombus. Left atrial appendage thrombi exclusively occurred in patients with atrial fibrillation. Ventricular tachycardia ablation was finally performed in 363 including 7 (16%) patients with thrombus but refractory electrical storm. These seven patients had tailored ablation with no embolic complications. Only one (0.3%) ablation-related embolic event occurred in the entire cohort. CONCLUSION: Cardiac thrombus can be identified in 11% of patients referred for scar-related VT ablation. These findings underscore the importance of systematic thrombus screening to minimize embolic risk.

Performance and safety of temperature- and flow-controlled radiofrequency ablation for ventricular arrhythmia.

AIMS: High-power ablation is effective for ventricular arrhythmia ablation; however, it increases the risk of steam pops. The aim of this study was to define the safety and efficacy of QMODE ablation in the ventricle and the risk of steam pop. METHODS AND RESULTS: Consecutive patients undergoing ventricular ablation using QDOT were included in a prospective single-centre registry. Procedural data, complications, and follow-up were systematically analysed and compared with a historical ventricular tachycardia (VT) and premature ventricular complexes (PVC) cohort ablated using STSF. QMODE (≤50 W) ablation was performed in 107 patients [age 62 ± 13 years; 76% male; VT (n = 41); PVC (n = 66)]. A total of 2456 applications were analysed [power: 45.9 ± 5.0 W with minimal power titration (90% > 95% max power); duration 26 ± 8 s; impedance drop 9.4 ± 4.7 Ω; ablation index: 569 ± 163; mean-max temperature 44.3 ± 2.6°C]. Ventricular tachycardia ablation was associated with shorter radiofrequency (RF) time and a trend towards shorter procedure times using QDOT (QDOT vs. STSF: 20.1 ± 14.7 vs. 31 ± 17 min; P = 0.002, 151 ± 59 vs. 172 ± 48 min; P = 0.06). Complications, VT recurrence, and mortality rates were comparable (QDOT vs. STSF: 2% vs. 2%; P = 0.9, 24% vs. 27%; P = 0.82, and 2% vs. 4%; P = 0.67). Five audible steam pops (0.02%) occurred. Premature ventricular complex ablation was associated with comparable RF and procedure times (QDOT vs. STSF: 4.8 ± 4.6 vs. 3.9 ± 3.1 min; P = 0.25 and 96.1 ± 31.9 vs. 94.6 ± 24.7 min; P = 0.75). Complication and PVC recurrence were also comparable (QDOT vs. STSF: 0% vs. 3%; P = 0.17 and 19% vs. 22%; P = 0.71). CONCLUSION: Ventricular ablation using QMODE ≤ 50 W is safe and effective for both VT and PVC ablation and is associated with a low risk for steam pop.

Current practices and expectations to reduce environmental impact of electrophysiology catheters: results from an EHRA/LIRYC European physician survey.

The healthcare sector accounts for nearly 5% of global greenhouse gas emissions (GHG) and is a significant contributor to complex waste. Reducing the environmental impact of technology-heavy medical fields such as cardiac electrophysiology (EP) is a priority. The aim of this survey was to investigate the practice and expectations in European centres on EP catheters environmental sustainability. A 24-item online questionnaire on EP catheters sustainability was disseminated by the EHRA Scientific Initiatives Committee in collaboration with the Lyric Institute. A total of 278 physicians from 42 centres were polled; 62% were motivated to reduce the environmental impact of EP procedures. It was reported that 50% of mapping catheters and 53% of ablation catheters are usually discarded to medical waste, and only 20% and 14% of mapping and ablation catheters re-used. Yet, re-use of catheters was the most commonly cited potential sustainability solution (60% and 57% of physicians for mapping and ablation catheters, respectively). The majority of 69% currently discarded packaging. Reduced (42%) and reusable (39%) packaging also featured prominently as potential sustainable solutions. Lack of engagement from host institutions was the most commonly cited barrier to sustainable practices (59%). Complexity of the process and challenges to behavioral change were other commonly cited barriers (48% and 47%, respectively). The most commonly cited solutions towards more sustainable practices were regulatory changes (31%), education (19%), and product after-use recommendations (19%). In conclusion, EP physicians demonstrate high motivation towards sustainable practices. However, significant engagement and behavioural change, at local institution, regulatory and industry level is required before sustainable practices can be embedded into routine care.

Resuming Training in High-Level Athletes After Mild COVID-19 Infection: A Multicenter Prospective Study (ASCCOVID-19).

BACKGROUND: There is a paucity of data on cardiovascular sequelae of asymptomatic/mildly symptomatic SARS-Cov-2 infections (COVID). OBJECTIVES: The aim of this prospective study was to characterize the cardiovascular sequelae of asymptomatic/mildly symptomatic COVID-19 among high/elite-level athletes. METHODS: 950 athletes (779 professional French National Rugby League (F-NRL) players; 171 student athletes) were included. SARS-Cov-2 testing was performed at inclusion, and F-NRL athletes were intensely followed-up for incident COVID-19. Athletes underwent ECG and biomarker profiling (D-Dimer, troponin, C-reactive protein). COVID(+) athletes underwent additional exercise testing, echocardiography and cardiac magnetic resonance imaging (CMR). RESULTS: 285/950 athletes (30.0%) had mild/asymptomatic COVID-19 [79 (8.3%) at inclusion (COVID(+)prevalent); 206 (28.3%) during follow-up (COVID(+)incident)]. 2.6% COVID(+) athletes had abnormal ECGs, while 0.4% had an abnormal echocardiogram. During stress testing (following 7-day rest), COVID(+) athletes had a functional capacity of 12.8 ± 2.7 METS with only stress-induced premature ventricular ectopy in 10 (4.3%). Prevalence of CMR scar was comparable between COVID(+) athletes and controls [COVID(+) vs. COVID(-); 1/102 (1.0%) vs 1/28 (3.6%)]. During 289 ± 56 days follow-up, one athlete had ventricular tachycardia, with no obvious link with a SARS-CoV-2 infection. The proportion with troponin I and CRP values above the upper-limit threshold was comparable between pre- and post-infection (5.9% vs 5.9%, and 5.6% vs 8.7%, respectively). The proportion with D-Dimer values above the upper-limit threshold increased when comparing pre- and post-infection (7.9% vs 17.3%, P = 0.01). CONCLUSION: The absence of cardiac sequelae in pauci/asymptomatic COVID(+) athletes is reassuring and argues against the need for systematic cardiac assessment prior to resumption of training (clinicaltrials.gov; NCT04936503).

Impact of COVID-19 on patients awaiting ablation for atrial fibrillation.

OBJECTIVE: Atrial fibrillation (AF) ablation services were significantly affected by the COVID-19 pandemic. We aimed to evaluate a symptom-based clinician prioritisation scheme for waiting list management compared with patient-completed quality of life (QoL) scores. We also sought to understand factors influencing QoL, particularly the impact of COVID-19, on patients awaiting AF ablation, via a bespoke questionnaire. METHODS: Patients awaiting AF ablation were sent two QoL questionnaires (Atrial Fibrillation Effect on QualiTy of Life (AFEQT) and EuroQol 5D (EQ5D-5L)) and the bespoke questionnaire. At a separate time point, patients were categorised as C1-urgent, C2-priority or C3-routine by their cardiologist based on review of clinic letters. RESULTS: There were 118 patients included with priority categorisation available for 86 patients. Median AFEQT scores were lower in C2 (30.4; 17.2-51.9) vs C3 patients (56.5; 32.1-74.1; p<0.01). Unplanned admission occurred in 3 patients in C3 with AFEQT scores of <40. Although 65 patients had AF symptoms during the pandemic, 43.1% did not seek help where they ordinarily would have. An exercise frequency of ≥3-4 times a week was associated with higher AFEQT (56.5; 41.2-74.1; p<0.001) and EQ5D (0.84; 0.74-0.88; p<0.0001) scores. CONCLUSION: The QoL of patients awaiting AF ablation is impaired and AFEQT helps to identify patients at risk of admission, over and above physician assessment. COVID-19 influenced patients seeking medical attention with symptomatic AF when they normally would. Regular exercise is associated with better QoL in patients awaiting AF ablation.

Optimal ablation strategy for arrhythmia recurrence following persistent atrial fibrillation ablation; anatomy or electrophysiology?

The optimal strategy for ablation of persistent atrial fibrillation (PsAF) remains to be defined. Established substrate-based ablation techniques, particularly techniques targeting complex electrograms, with complementary linear ablation for organized atrial tachycardias, have been associated with modest success rates. Recently, the development of VoM ethanol ablation (Et-VoM) has facilitated ablation of previously inaccessible arrhythmogenic substrate. This has allowed comparison of a standardized anatomically-guided protocol with Et-VOM to a traditional electrophysiology-guided approach for PsAF ablation.

High-resolution parahisian mapping and ablation using microelectrode embedded ablation catheters.

BACKGROUND: Accurate mapping of the compact atrioventricular (AV) node is critical during ablation of a range of arrhythmias. OBJECTIVE: The purpose of this multicenter prospective study was to test the hypothesis that microelectrode (ME)-embedded catheters more accurately define the near-field compact AV node compared to conventional catheters. METHODS: For the mapping phase, detailed AV junction maps were created in 47 patients using an ME-embedded catheter. His electrograms (EGMs) detected by conventional electrodes (Hisc) and by ME (Hisµ) were annotated. For the ablation phase, AV nodal ablation (Qmode 50 W) was performed in 10 patients after pacemaker implantation, with initial Hisc-only ablation in group 1 (n = 6) and initial Hisµ ablation in group 2 (n = 4). For the clinical phase, a prospective registry of parahisian tachycardia using QDOT was obtained. RESULTS: In the mapping phase, 7.0 ± 5.4 Hisc and 8.0 ± 5.6 Hisµ points were acquired per map (n = 47). Hisµ cloud was smaller and more proximally located than Hisc cloud: (99.4 ± 74.7 mm2 vs 197.6 ± 110.6 mm2; P = .0008). Hisµ EGMs had larger amplitudes than Hisc EGMs (0.40 ± 0.38 mV vs 0.16 ± 0.1 mV; P = .0002). In the ablation phase, for group 1: Hisc-only ablation never resulted in AV block, whereas Hisµ ablation resulted in AV block after limited ablation in all patients (after 13.3 ± 9.2 s); and for group 2: Hisµ ablation always resulted in AV block after 1 application (after 14.3 ± 10.3 s). In the clinical phase, a Hisµ-avoidance strategy could avoid AV block in a prospective registry of 11 patients. CONCLUSION: ME more accurately defines the region of the compact node, and ablation in this region is associated with a high risk for AV block. ME-based mapping has the potential to significantly enhance ablation safety and efficacy.

Ante-mortem characterization of sudden deaths as first-manifestation in Italy.

PURPOSE: There is a relative paucity of data on ante-mortem clinical characteristics of young (age 1 to 35 years) sudden death (SD) victims. The aim of the study was to characterize ante-mortem characteristics of SD victims, in a selected national cohort identified by a web search. METHODS: A dataset of all SD (January 2010 and December 2015) was built from national forensic data and medical records, integrated with Google search model. Families were contacted to obtain consent for interviews. Data were obtained on ante-mortem symptoms. ECG characteristics and autopsy data were available. RESULTS: Out of 301 SD cases collected, medical and family history was available in 132 (43.9%). Twenty-eight (21.1%) had a positive family history for SD. SD occurred during sport/effort in 76 (57.6%). One hundred twelve (85%) SD cases had no prior reported symptoms. Autopsy data were available in 100/132 (75.8%) cases: an extra cardiac cause was identified in 20 (20%). Among the 61 cases with a cardiac diagnosis, 21 (34%) had hypertrophic cardiomyopathy. Among the 19 (19%) victims without structural abnormalities, molecular autopsy identified pathogenic variants for channelopathies in 9 cases. Ten (10%) victims had no identifiable cause. CONCLUSIONS: Most SD were due to cardiac causes and occurred in previously asymptomatic patients. SD events mainly occurred during strenuous activity. In a minority of cases, no cause was identified. The web-based selection criteria, and incomplete data retrieval, need to be carefully taken into account for data interpretation and reproducibility.

Complication rates following ventricular tachycardia ablation in ischaemic and non-ischaemic cardiomyopathies: a systematic review.

BACKGROUND: Catheter ablation of ventricular tachycardia (VT) is associated with potential major complications, including mortality. The risk of acute complications in patients with ischaemic cardiomyopathy (ICM) and non-ischaemic cardiomyopathy (NICM) has not been systematically evaluated. METHODS: PubMed was searched for studies of catheter ablation of VT published between September 2009 and September 2019. Pre-specified primary outcomes were (1) rate of major acute complications, including death, and (2) mortality rate. RESULTS: A total of 7395 references were evaluated for relevance. From this, 50 studies with a total of 3833 patients undergoing 4319 VT ablation procedures fulfilled the inclusion criteria (mean age 59 years; male 82%; 2363 [62%] ICM; 1470 [38%] NICM). The overall major complication rate in ICM cohorts was 9.4% (95% CI, 8.1-10.7) and NICM cohorts was 7.1% (95% CI, 6.0-8.3). Reported complication rates were highly variable between studies (ICM I2 = 90%; NICM I2 = 89%). Vascular complications (ICM 2.5% [95% CI, 1.9-3.1]; NICM 1.2% [95% CI, 0.7-1.7]) and cerebrovascular events (ICM 0.5% [95% CI, 0.2-0.7]; NICM, 0.1% [95% CI, 0-0.2]) were significantly higher in ICM cohorts. Acute mortality rates in the ICM and NICM cohorts were low (ICM 0.9% [95% CI, 0.5-1.3]; NICM 0.6% [95% CI, 0.3-1.0]) with the majority of overall deaths (ICM 75%; NICM 80%) due to either recurrent VT or cardiogenic shock. CONCLUSION: Overall acute complication rates of VT ablation are comparable between ICM and NICM patients. However, the pattern and predictors of complications vary depending on the underlying cardiomyopathy.