Repositioning and extraction of stylet-driven pacing leads with extendable helix used for left bundle branch area pacing.

Conventional stylet-driven leads with extendable helix can be implanted successfully for left bundle branch area pacing (LBBAP) with a low acute complication rate. We report two cases in which lead repositioning after a first unsuccessful attempt to LBBAP was associated with fracture of the helix rotating mechanism and failure to fully extract the pacing lead.

Single freeze per vein strategy with the second-generation cryoballoon for atrial fibrillation: a propensity score-matched study between 180- and 240-s application time in a large cohort of patients.

Aims: The single-freeze strategy using the second-generation cryoballoon (CB-A, Arctic Front Advance, Medtronic, Minneapolis, MN, USA) has been reported to be as effective as the recommended double-freeze approach in several single-centre studies. In this retrospective, international, multicentre study, we compare the 3-min single-freeze strategy with the 4-min single-freeze strategy. Methods and results: Four hundred and thirty-two patients having undergone pulmonary vein isolation (PVI) by means of CB-A using a single-freeze strategy were considered for this analysis. A cohort of patients who were treated with a 3-min strategy (Group 1) was compared with a propensity score-matched cohort of patients who underwent a 4-min strategy (Group 2). Pulmonary vein isolation was successfully achieved in all the veins using the 28-mm CB-A. The procedural and fluoroscopy times were lower in Group 1 (67.8 ± 17 vs. 73.8 ± 26.3, P < 0.05; 14.9 ± 7.8 vs. 24.2 ± 10.6 min, P < 0.05). The most frequent complication was PNP, with no difference between the two groups (P = 0.67). After a mean follow-up of 13 ± 8 months, taking into consideration a blanking period of 3 months, 85.6% of patients in Group 1 and 87% of patients in Group 2 were free from arrhythmia recurrence at final follow-up (P = 0.67). Conclusion: There is no difference in acute success, rate of complications, and freedom from atrial fibrillation recurrences during the follow-up between 3-min and 4-min per vein freeze strategies. The procedural and fluoroscopy times were significantly shorter in 3-min per vein strategy.

New electrocardiographic criteria to differentiate the Type-2 Brugada pattern from electrocardiogram of healthy athletes with r'-wave in leads V1/V2.

AIMS: Diagnosis of Type-2 Brugada pattern remains challenging and it could be confused with other electrocardiogram (ECG) patterns presenting an r'-wave in leads V1-V2 like in healthy athletes. This could impact their ability to perform competitive sports. The aim of the study was to evaluate, as a proof of concept, the new ECG criteria to differentiate the Type-2 Brugada pattern from the ECG pattern of healthy athletes depicting an r'-wave in leads V1-V2. METHODS AND RESULTS: Surface ECGs from 50 patients with Brugada syndrome and type-2 Brugada pattern and 58 healthy athletes with an r'-wave in leads V1-V2 were analysed. Different criteria based on the characteristics of the triangle formed by the ascendant and descendant arms of the r'-wave in leads V1-V2 were compared. The duration of the base of the triangle at 0.5 mV (5 mm) from high take-off ≥160 ms (4 mm) has a specificity (SP) of 95.6%, sensitivity (SE) 85%, positive predictive value (PPV) 94.4%, and negative predictive value (NPV) 87.9%. The duration of the base of the triangle at the isoelectric line ≥60 ms (1.5 mm) in leads V1-V2 has an SP of 78%, SE 94.8%, PPV 79.3%, and NPV 93.5%. The ratio of the base at isoelectric line/height from the baseline to peak of r'-wave in leads V1-V2 has an SP of 92.1%, SE 82%, PPV 90.1%, and NPV 83.3%. CONCLUSIONS: The three new ECG criteria were accurate to distinguish the Type-2 Brugada pattern from the ECG pattern with an r'-wave in healthy athletes. The duration of the base of the triangle at 0.5 mV from the high take-off is the easiest to measure and may be used in clinical practice.

The importance of class-I antiarrhythmic drug test in the evaluation of patients with syncope: unmasking Brugada syndrome.

INTRODUCTION: The Brugada syndrome (BrS) can first present with syncope. Class-I antiarrhythmic drug (AAD) test is used to unmask the diagnostic coved-type ECG pattern in case it is not spontaneously present. The aim of the study was to analyze patients with BrS presenting with syncope as first manifestation and compare patients with syncope and a spontaneous coved-type ECG to patients with syncope in whom a class-I AAD test unmasked the disease. METHODS AND RESULTS: Fifty-eight of 157 probands (36.9%) had syncope as first manifestation of the disease. Twenty-six patients (44.8%, group A) showed a spontaneous coved-type ECG diagnostic for BrS at first presentation. In 32 patients (55.2%, group B) without spontaneous coved-type ECG pattern at first presentation (36% normal ECGs and 19% type-II ECG pattern), a class-I AAD test unmasked the disease. Twenty-one patients of group A and 29 patients of group B underwent implantable cardioverter defibrillator (ICD) implantation. The mean follow up as 9.7 ± 55.7 month. Four patients in group A (15.4%) and 3 patients (9.3%) in group B had appropriate ICD shock delivery due to ventricular fibrillation or ventricular tachycardia (P = NS). CONCLUSION: One of 3 patients with BrS presents first with syncope. More than one-third of these patients have a normal ECG at investigation for syncope and the correct diagnosis would have been missed without a class-I AAD test. Patients presenting with syncope are at similar risk irrespective of the presence of a spontaneous coved-type ECG.

Verification of pulmonary vein isolation during single transseptal cryoballoon ablation: a comparison between the classical circular mapping catheter and the inner lumen mapping catheter.

AIMS: Cryoballoon ablation has proven very effective in achieving pulmonary vein isolation (PVI). The novel Achieve inner lumen mapping catheter designed to be used in conjunction with the cryoballoon, serves as both a guidewire and a mapping catheter. To our knowledge, this is the first study comparing the latter to verification of electrical isolation with the 'traditional' circular mapping catheter. METHODS AND RESULTS: We assigned 40 consecutive patients matched for age and left atrial diameter suffering of paroxysmal atrial fibrillation to cryoballoon PVI using either the circular mapping catheter or the Achieve as a mapping catheter. Duration of procedure as well as fluoroscopy times were significantly lower in the Achieve group than in the circular mapping catheter group (111 ± 14 min vs. 126 ± 13 min, P < 0.005 and 22 ± 5 min vs. 29 ± 4 min, P < 0.0001, respectively). There were no significant differences between both groups in terms of mean degree of occlusion, mean minimal temperatures, and PVI. Pulmonary vein isolation could be documented by real-time recordings in 55% of veins in the Achieve group with mean time to isolation of 65 ± 23 s. CONCLUSION: Cryoballoon ablation in conjunction with the novel Achieve is feasible, safe, and affords PVI in nearly all veins in similar proportions to the approach with the traditional guidewire. Furthermore, if compared to the procedure with the circular mapping catheter, cryoballoon ablation with the Achieve is significantly faster and associated to shorter fluoroscopy times.

The value of a family history of sudden death in patients with diagnostic type I Brugada ECG pattern.

AIMS: We sought to investigate the value of a family history of sudden death (SD) in Brugada syndrome (BS). METHODS AND RESULTS: Two hundred and eighty consecutive patients (mean age: 41 ± 18 years, 168 males) with diagnostic type I Brugada ECG pattern were included. Sudden death occurred in 69 (43%) of 157 families. One hundred and ten SDs were analysed. During follow-up VF (ventricular fibrillation) or SD-free survival rate was not different between patients with or without a family history of SD of a first-degree relative, between patients with or without a family history of multiple SD of a first-degree relative at any age and between patients with or without a family history of SD in first-degree relatives ≤35 years. One patient had family history of SD of two first-degree relative ≤35 years with arrhythmic event during follow-up. In univariate analysis male gender (P = 0.01), aborted SD (P < 0.001), syncope (P = 0.04), spontaneous type I ECG (P < 0.001), and inducibility during electrophysiological (EP) study (P < 0.001) were associated with worse prognosis. The absence of syncope, aborted SD, spontaneous type I ECG, and inducibility during EP study was associated with a significantly better prognosis (P < 0.001). CONCLUSION: Family history of SD is not predictive for future arrhythmic events even if considering only SD in first-degree relatives or SD in first-degree relatives at a young age. The absence of syncope, aborted SD, spontaneous type I ECG, and inducibility during EP study is associated with a good five-year prognosis.

Comparison between the novel diamond temp and the classical 8-mm tip ablation catheters in the setting of typical atrial flutter.

PURPOSE: Radiofrequency (RF) catheter ablation is widely accepted as a first-line therapy for cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). The novel DiamondTemp (DT) catheter with temperature feedback during RF ablation has been released recently on the market. The purpose of this study was to evaluate the impact of DiamondTemp (DT) technology on ablation efficiency during AFL. METHODS: In this single-center study, 30 consecutive patients with typical AFL indicated to ablation of CTI were included. The first 15 patients underwent CTI ablation using 8-mm tip catheter, and the following 15 patients underwent temperature-controlled RF ablation using DT catheter. The endpoints were number and mean total duration of RF applications, mean temperature reached in the setting of CTI, procedural times, and fluoroscopy times. RESULTS: There were no significant differences between the two groups concerning baseline characteristics. Mean duration of the each application (71.5 s ± 30.6 vs 12.4 s ± 13.2, p value < 0.001), mean total duration of RF applications (517,73 s ± 377,96 vs 112,8 s ± 43,58; p value < 0.001), procedural times (51.6 min ± 24.2 vs 38.6 ± 8.2; p = 0.03), and fluoroscopy times (16.2 min ± 10.2 vs 8 min ± 4.24; p = 0.005) were longer in the 8-mm ablation catheter group. Mean temperature measurements (51.9 °C ± 3.59 vs 56.7 °C ± 3.34, p value < 0.003) were as well lower in the 8-mm ablation catheter group. CONCLUSIONS: Catheter ablation of CTI-dependent AFL by means of DT resulted in a significant reduction of total and single application RF delivery time, procedure, and fluoroscopy times.

Complications of atrial fibrillation ablation: when prevention is better than cure.

As atrial fibrillation ablation is becoming increasingly popular in many cardiac electrophysiological laboratories around the world, preventing, avoiding, or treating procedure-related complications is of utmost importance. In our review of the literature regarding this issue, we addressed in detail all the potential collateral and undesired effects associated to this intervention.

Pulmonary vein ostium shape and orientation as possible predictors of occlusion in patients with drug-refractory paroxysmal atrial fibrillation undergoing cryoballoon ablation.

AIMS: No specific data are available on the influence of pulmonary vein (PV) anatomy and shape on cryoballoon ablation (CA) catheter efficacy in delivering cryothermal energy and, consequently, in obtaining PV isolation. METHODS AND RESULTS: Among a larger series of patients (68) with drug-refractory paroxysmal atrial fibrillation who underwent CA in our department, 52 patients were included in our study. All of them had a multislice cardiac computed tomography (MSCT) before the procedure. We retrospectively evaluated their MSCT scans focusing our attention on PV ovality and orientation in the frontal plane. A fair inverse association was documented between the ovality index of the left PVs and the degree of occlusion (r=-0.486 and P<0.003 for the LSPV and r=-0.360 and P=0.033 for the LIPV), whereas no association was found between the ovality index of the right PVs and the degree of occlusion (r=-0.283 and P=0.083 for the RSPV and r=0.235 and P=0.093 for RIPV). Nevertheless, a strong inverse association was found between the orientation of the PV ostia and the degree of occlusion in each vein (r=-0.804 and P<0.001 for the LSPV, r=-0.415 and P=0.013 for LIPV, r=-0.798 and P<0.001 for the RSPV, and r=-0.867 and P<0.001 for RIPV). CONCLUSION: Pulmonary vein ostium shape and orientation evaluated by MSCT proved to be useful in predicting the degree of occlusion obtained during CA.

Dissociation between anterograde and retrograde conduction during transvenous cryoablation of parahissian accessory pathways.

Ablation of parahissian accessory pathways (APs) is a challenging procedure because of the high risk to provoke "iatrogenic" atrioventricular (AV) nodal block. The feasibility and safety of cryoablation (CA) have been already demonstrated both in patients with AV nodal reentry tachycardia and in those with anteroseptal APs. However, dissociation between anterograde and retrograde conduction after CA has not yet been described. We report two cases of CA of parahissian AP associated with transient dissociation between anterograde and retrograde conduction.

Ajmaline challenge in young individuals with suspected Brugada syndrome.

BACKGROUND: The clinical characteristics and the results of ajmaline challenge in young individuals with suspected Brugada syndrome (BS) have not been systematically investigated. METHODS: Among a larger series of patients included in the BS database of our Department, 179 patients undergoing ajmaline challenge were included in the study and categorized in two groups according to age: group 1 (<18 years old) and group 2 (≥18 years old). Clinical features and results of the ajmaline challenge of each group were compared. RESULTS: Young individuals were more often asymptomatic compared to adult patients (P = 0.002). They showed a higher number of normal ECGs (P = 0.023), a lower percentage of Brugada type II electrocardiographic pattern compared to the adult population (P = 0.011), and a comparable amount of spontaneous Brugada type III electrocardiographic pattern (P = 0.695). Ajmaline provoked a higher degree of intraventricular conduction delay (P = 0.002) and higher degree of prolongation of the ventricular repolarization phase (P = 0.013) in young individuals but its pro-arrhythmic risk was comparable in the two groups (P = 0.684). Furthermore, inducibility of ventricular arrhythmias in young patients with a positive ajmaline test was comparable to that of the adults with a positive ajmaline test (P = 0.694). CONCLUSIONS: The present study demonstrates the low-risk profile of the ajmaline test in young patients when performed by experienced physicians and nurses in an appropriate environment.

Real world data on non-complex catheter ablations performed on zero fluoroscopy in a secondary centre in the south of Belgium.

OBJECTIVE: We have designed a study, whose aim was to confirm the feasibility and safety of the zero fluoroscopy approach in the treatment of supraventricular tachycardias (SVT) and premature ventricular contractions (PVCs) originating in the right ventricle in a secondary centre located in the south of Belgium. METHODS: We included in our retrospective analysis patients with a clinical history and/or electrocardiographic documentation of SVT or frequent symptomatic monomorphic PVCs referred to our centre from November 2019 to March 2020 for catheter ablation. RESULTS: A total of 49 patients were considered eligible for potential enrolment in the study, 3 were excluded because of presence of a manifest left sided atrio-ventricular accessory pathway, 5 because of left ventricular PVCs and 4 because of left atrial tachycardia. 4 patients were instead excluded because of need of utilisation of fluoroscopy during the procedure. A total of 33 patients were therefore included in the analysis. Right atrial flutters and typical AVNRT were the most common arrhythmia treated, corresponding together to the 81% of the total. Right femoral access was obtained in 86% of cases with left femoral access used in the remaining when right femoral access was not successful after the third attempt. Coronary sinus cannulation was efficacious within 10 min in 76% of cases. There were four minor complications overall. CONCLUSION: The main finding of our study is that non-complex ablations can be performed on zero-fluoroscopy safely and with a good clinical outcome also in a secondary centre.

Mortality Rate and Predictors Among Patients with COVID-19 Related Acute Respiratory Failure Requiring Mechanical Ventilation: a Retrospective Single Centre Study.

AIM: The objective of the study was to assess mortality rates in COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) who also requiring mechanical ventilation. The predictors of mortality in this cohort were analysed, and the clinical characteristics recorded. MATERIAL AND METHOD: A single centre retrospective study was conducted on all COVID-19 patients admitted to the intensive care unit of the Epicura Hospital Center, Province of Hainaut, Belgium, between March 1st and April 30th 2020. RESULTS: Forty-nine patients were included in the study of which thirty-four were male, and fifteen were female. The mean (SD) age was 68.8 (10.6) and 69.5 (12.6) for males and females, respectively. The median time to death after the onset of symptoms was eighteen days. The median time to death, after hospital admission was nine days. By the end of the thirty days follow-up, twenty-seven patients (55%) had died, and twenty-two (45%) had survived. Non-survivors, as compared to those who survived, were similar in gender, prescribed medications, COVID-19 symptoms, with similar laboratory test results. They were significantly older (p = 0.007), with a higher co-morbidity burden (p = 0.026) and underwent significantly less tra-cheostomy (p < 0.001). In multivariable logistic regression analysis, no parameter significantly predicted mortality. CONCLUSIONS: This study reported a mortality rate of 55% in critically ill COVID-19 patients with ARDS who also required mechanical ventilation. The results corroborate previous findings that older and more comorbid patients represent the population at most risk of a poor outcome in this setting.

Procedural Safety and Efficacy for Pulmonary Vein Isolation with the Novel Polarx™ Cryoablation System: A Propensity Score Matched Comparison with the Arctic Front™ Cryoballoon in the Setting of Paroxysmal Atrial Fibrillation.

BACKGROUND: The novel Polarx™ cryoablation system is currently being studied for atrial fibrillation (AF) ablation. To the best of our knowledge, no study comparing the novel cryoablation system with the standard Arctic Front™ cryoballoon is available in today's literature. This study aims to compare Polarx™ and Arctic Front™ cryoballoon in terms of safety and efficacy. METHODS: From a total cohort of 202 patients who underwent pulmonary vein (PV) isolation for paroxysmal AF through cryoablation, a population of 30 patients who used Polarx™ were compared with 30 propensity-score matched patients who used Arctic Front™. RESULTS: Pulmonary vein occlusion and electrical isolation were achieved in all (100%) veins with a mean number of 1.09 ± 0.3 occlusion per vein using Polarx™ and 1.19 ± 0.5 occlusion per vein using Arctic Front™ (p = 0.6). Shorter procedure and fluoroscopy time were observed with Polarx™ group (60.5 ± 14.23 vs 73.43 ± 13.26 mins, p = 0.001; 12.83 ± 6.03 vs 17.23 ± 7.17 mins, p = 0.01, respectively). Lower cumulative freeze duration per vein was also observed with Polarx™ (203.38 ± 72.03 vs 224.9 ± 79.35 mins, p = 0.02). There was no significant difference in isolation time between the two groups (34.47 ± 21.23 vs 34.18 ± 26.79 secs, p = 0.9). CONCLUSIONS: The novel Polarx™ cryoablation system showed similar efficacy in vein occlusion and isolation and safety profile when compared to Arctic Front™ cryoablation system. Procedure time, fluoroscopy time, and cumulative freeze duration were significantly lower with Polarx™ cryoablation system.

Pericardial effusion in atrial fibrillation ablation: a comparison between cryoballoon and radiofrequency pulmonary vein isolation.

AIMS: Atrial fibrillation (AF) ablation is increasingly being performed in electrophysiology laboratories. Pericardial effusion (PE) is certainly one of the most frequently observed complications during AF ablation. The aim of our study was to investigate the incidence and outcome of PE following cryothermal energy balloon ablation (CBA) in comparison with conventional circumferential pulmonary vein isolation with a focal radiofrequency (RF) catheter. METHODS AND RESULTS: A total of 133 consecutive patients (105 males) with paroxysmal AF were included in this study. Forty-six patients (36 males) underwent CBA (Arctic Front, Medtronic, USA) and 87 (69 males) point-by-point RF ablation guided by electroanatomical mapping (Carto, Biosense Webster, Diamond Bar, CA, USA). Ablation was performed under general anaesthesia with both techniques. All patients underwent a 2D transthoracic echocardiogram within 24 h before and after the procedure as routinely performed in our centre. Pericardial effusion was detected in 19 (14.2%) of 133 patients. Sixteen patients presented mild effusion, one moderate effusion, and two pericardial tamponades. There was no significant difference in the incidence of PE between the cryoballoon and the RF group (11 vs. 16%). A longer procedural time, coronary artery disease, and arterial hypertension were found to be independent predictors of PE during AF ablation. CONCLUSION: Pericardial effusion occurred in a similar proportion following CBA and RF ablation for AF. Pericardial effusion was mostly mild and asymptomatic, with benign clinical outcome not requiring additional hospitalization days.

Feasibility, safety, and outcome of a challenging transseptal puncture facilitated by radiofrequency energy delivery: a prospective single-centre study.

AIMS: Although it has been shown that a transseptal (TS) puncture in the electrophysiology laboratory is associated with a high success and a low complication rate, this procedure remains challenging particularly in difficult septum anatomies (aneurismal septum and thick septum) and during repeat TS catheterization. Radiofrequency (RF) electrocautery current delivery through the TS needle has been shown to facilitate the TS puncture. The aim of this study was to verify prospectively the feasibility, safety, and outcome of RF energy delivery associated with the standard TS technique in patients undergoing a challenging TS puncture. METHODS AND RESULTS: Over a 14-month period, 162 consecutive patients underwent left atrial (LA) arrhythmia ablation in our centre. Among them, we enrolled 18 patients who failed LA access after two TS puncture attempts. In these patients, an RF delivery through TS (RF-TS) needle approach was used to reach the LA. All 18 patients had a successful RF-TS at the first attempt. A transoesophageal echocardiography (TEE) guidance and fluoroscopy views were used in all patients. No acute complications were reported. There have been no clinical sequelae after 10 +/- 4 months of follow-up following the RF-TS approach. Challenging TS punctures were more frequent in repeat LA catheterization when compared with the first LA catheterization, respectively, in 35% (13 of 37) and 4% (5 of 125) of the patients. CONCLUSION: Radiofrequency electrocautery delivery associated with the standard TS approach is a safe and reproducible technique to reach the left atrium, using the TEE guidance. This technique is helpful during repeat TS catheterization and in the presence of anatomical atrial septum abnormalities.

Long-term effects of upgrading to biventricular pacing: differences with cardiac resynchronization therapy as primary indication.

BACKGROUND: Few studies have assessed the long-term effects of cardiac resynchronization therapy (CRT) in patients with advanced heart failure (HF) and previously right ventricular apical pacing (RVAP). AIMS: To assess the clinical and hemodynamic impact of upgrading to biventricular pacing in patients with severe HF and permanent RVAP in comparison with patients who had CRT implantation as initial therapy. METHODS AND RESULTS: Thirty-nine patients with RVAP, advanced HF (New York Heart Association [NYHA] III-IV), and severe depression of left ventricular ejection fraction (LVEF) were upgraded to biventricular pacing (group A). Mean duration of RVAP before upgrading was 41.8 +/- 13.3 months. Clinical and echocardiographic results were compared to those obtained in a group of 43 patients with left bundle branch block and similar clinical characteristics undergoing "primary" CRT (group B). Mean follow-up was 35 +/- 10 months in patients of group A and 38 +/- 12 months in group B. NYHA class significantly improved in groups A and B. LVEF increased from 0.23 +/- 0.07 to 0.36 +/- 0.09 (P < 0.001) and from 0.26 +/- 0.02 to 0.34 +/- 0.10 (P < 0.001), respectively. Hospitalizations were reduced by 81% and 77% (P < 0.001). Similar improvements in echocardiographic signs of ventricular desynchronization were also observed. CONCLUSION: Patients upgraded to CRT exhibit long-term clinical and hemodynamic benefits that are similar to those observed in patients treated with CRT as initial strategy.

Ivabradine to treat inappropriate sinus tachycardia after the fast pathway ablation in a patient with severe pectus excavatum.

We present the case of a 49-year-old woman with atrioventricular nodal re-entrant tachycardia and a severe pectus excavatum. The patient underwent an electrophysiological study and fast pathway ablation. Fast pathway ablation was not done on purpose but accidentally, likely due to the abnormal position of the heart in the chest cavity in this patient suffering from severe pectus excavatum. Some hours after the ablation, the patient developed inappropriate sinus tachycardia (IST), complaining of dyspnea and fatigue. IST has been described as a complication of fast pathway ablation in 10% of the cases. In our case it was not possible to treat IST with beta-blockers due to an important lowering of the blood pressure. Digitalis, given as second choice, was not successful. Ivabradine-the specific sinus node If current inhibitors-was used to successfully lower the heart rate with immediate relief of symptoms. A 24-hour Holter, 10 days later, showed a complete control of the heart rate without any episode of IST. The patient was completely symptom free and able to undertake her normal daily activities without any discomfort. Our case confirms the potential use of ivabradine for indications other than coronary artery disease.