Early Detection and Treatment of Atrial Arrhythmias Alleviates the Arrhythmic Burden in Paced Patients: The SETAM Study.

BACKGROUND: Remote monitoring (RM) can remotely detect atrial tachyarrhythmias (ATAs). The benefit of RM compared to conventional follow-up in the detection and management of ATA was assessed in recipients of dual-chamber pacemakers. METHODS: The multicenter randomized SETAM study enrolled 595 patients in sinus rhythm with a CHA2 DS2 -VASc score ≥2, without ATA history and untreated with antiarrhythmics and antithrombotics, randomly assigned to RM (RM-ON; n = 291) versus ambulatory follow-up (RM-OFF; n = 304) during 12.8 ± 3.3 months. ATA occurrence, burden, and management were analyzed together with adverse clinical events. RESULTS: Patients were 79 ± 8 years old, 63% men, with a CHA2 DS2 -VASc score of 3.7± 1.2. ATA were detected in 83 patients (28%) in the RM-ON versus 66 (22%) in the RM-OFF group (P = 0.06). The median time between the pacemaker implantation and the first treated ATA was 114 days [44; 241] in the RM-ON versus 224 days [67; 366] in the RM-OFF group (hazard ratio [HR] = 0.56; 95% confidence interval [CI]: 0.37-0.86; P = 0.01). Therapies for ATA were initiated in 92 patients and the time to treatment of ATA was shortened by 44% in the RM-ON group (HR = 0.565; 95% CI: 0.37-0.86; P = 0.01). Over the last 4 months of follow-up, the mean ATA burden was alleviated by 4 hours/day (18%) in the RM-ON group. The rate of adverse clinical events was similar in both groups. CONCLUSION: Remotely monitored patients were diagnosed and treated earlier for ATA, and subsequently had a lower ATA burden.

[Hypnosis rhythmology practice : Results of a French survey]. / Pratiques d'hypnose en rythmologie en France : résultats d'une enquête de pratique.

This survey evaluated hypnosis practice in French centres in June 2020. The survey was sent via email to different rhythmology centres in France and responses from cardiologists and nurses were obtained. We present here the preliminary results of this survey. Hypnosis was used on a regular basis in 7.5% of the centres and 13% of the participants received education on hypnosis. 75% of the participants were interested to have an education of hypnosis. The survey points the different possibilities of improvement of management of patients while having the different procedures.

A new and simple method for distinguishing complete from incomplete block through the cavotricuspid isthmus.

BACKGROUND: A complete line of block (CLOB) in the cavotricuspid isthmus (CTI) is the endpoint of typical atrial flutter ablation. Before CTI block is obtained, a progressive CTI conduction delay due to an incomplete line of block (InLOB) can be difficult to distinguish from CLOB. The purpose of this study was to assess a new simple approach based on the changes in atrio-ventricular (AV) conduction delays during septal and lateral right atrial pacing, to distinguish a CLOB from an InLOB during typical atrial flutter (AFL) ablation. METHODS AND RESULTS: Forty patients who presented an InLOB before a CLOB, and a stable (AV) conduction delay at 600 ms cycle length pacing (when in sinus rhythm), during AFL ablation were included in this study. A 24-pole mapping catheter was positioned so that 2 adjacent dipoles bracketed the targeted CTI line of block (LOB), with proximal dipoles lateral to the LOB and distal dipoles in the coronary sinus. Two pacing sites were lateral (position L1 and L2) and one was septal (position S) to the LOB, with locations L1 and S closest to the LOB. During L1, L2 and S site pacing, the delay between the pacing artefact and the peak of the R wave in a surface ECG (lead II) was measured. We measured the following conduction delays (mean +/- SD in ms), during InLOB versus CLOB: (L1 to R) 320.5 +/- 68.0 versus 367.0 +/- 62.0, p = 0.001; (L2 to R) 333.0 +/- 59.0 versus 338.0 +/- 62.0, p = 0.663, (S to R) 259.4 +/- 51.5 versus 247.1 +/- 55.5, p = 0.987. We calculated the following data during an InLOB versus a CLOB: (L1R-L2R) -12.3 +/- 7 versus 20.2 +/- 12.7, p = 0.001; (L1R-SR) 51.1 +/- 21.5 versus 120.1 +/- 16.6, p < 0.05. The sensitivity, specificity, positive and negative predictive values for CLOB with (L1R-SR > 94 ms) and with (L1R-L2R > 0 ms) were respectively; 100%, 98%, 98% and 100%. CONCLUSIONS: This study establishes that lateral versus septal right atrial pacing sites combined with the measure of AV conduction delay on a surface ECG can be useful to distinguish a CLOB from an InLOB during AFL ablation.

New oral anticoagulants in patients undergoing atrial flutter radiofrequency catheter ablation: an observational study.

AIM: Atrial flutter (AFL) ablation requires optimal periprocedural anticoagulation in order to minimize thromboembolic events/bleeding risk. This study describes the characteristics of patients receiving new oral anticoagulants before AFL ablation and assesses complications. METHODS: This multicenter, retrospective study reports ischemic and hemorrhagic predischarge, postprocedural complications. RESULTS: We evaluated 60 patients (62.3% male; mean age: 69.2 ± 9.7 years; CHA2DS2-VASc score: 2.44 ± 1.46, HAS-BLED score: 1.14 ± 0.7). Twenty-one (35.0%) and 23 patients (38.3%) received twice-daily dabigatran 110 or 150 mg; 16 patients (26.6%) received once-daily rivaroxaban (15 mg [n = 5] or 20 mg [n = 11]). Four cases of postprocedural minor bleeding were reported. CONCLUSION: This is the first study assessing new oral anticoagulants for periprocedural anticoagulation, specifically in patients undergoing AFL ablation. No major bleeding was reported. Further prospective investigation is warranted.

Prospective comparison between conventional transseptal puncture and transseptal needle puncture with radiofrequency energy.

PURPOSE: Patients undergoing left atrial ablation require transseptal puncture, which can be challenging, even for experienced physicians. This study compared the efficacy and safety of radiofrequency (RF) energy transseptal punctures to conventional approach. METHODS: Patients requiring transseptal puncture for left atrial access were included using either conventional approach or the NRG™ RF transseptal needle as first attempt. Procedure time for transseptal access, fluoroscopy time, crossover, and safety of both techniques were compared. RESULTS: A total of 241 transseptal punctures were performed in 148 consecutive patients (114 men, 54 ± 10 years, left atrial volume 32 ± 10 ml/m(2)) who underwent 157 procedures with left atrial access, mainly for atrial fibrillation. It was a repeat transseptal procedure in 49 patients. Procedures were guided by transesophageal echocardiography. RF transseptal puncture was planned in 119 procedures. RF was delivered in 98 procedures (82%) for 139/187 punctures: 48 punctures did not require RF, including 25 punctures performed by exposing the needle tip, 22 through patent foramen ovale, and 1 RF delivery failure by the generator. Average time for RF transseptal was 4.8 ± 2.8 min compared to 7.5 ± 8.5 min for conventional approach (p = 0.045). Fluoroscopy time was 1.8 ± 1.3 min for RF transseptal and 2.9 ± 2.8 min for standard approach (p = 0.043). Four patients required crossover to RF transseptal needle in the conventional group (p = 0.003). One tamponade occurred at the end of procedure in a patient using the RF needle, and one interatrial septum dissection with aortic root hematoma occurred in the conventional group. CONCLUSIONS: Transseptal needle puncture using RF energy can be performed safely and quickly under imaging guidance.

A randomized clinical trial of continuous flow nitrous oxide and nalbuphine infusion for sedation of patients during radiofrequency atrial flutter ablation.

BACKGROUND: In patients with common atrial flutter (CAF), radiofrequency ablation (RFA) causes discomfort. Patients undergoing RFA often feel pain which is difficult to control as the mechanisms are unclear. HYPOTHESIS: Inhaled nitrous oxide (N2O) is a potent sedative-analgesic-anxiolytic agent that may relieve anxiety and discomfort during CAF ablation. METHODS AND RESULTS: In a prospective randomized study, the effect of Inhaled N2O was compared with that of intravenous sedation with Nalbuphine during CAF ablation in 76 patients (64 +/- 13 years, 56 men). We used a 24 pole mapping catheter around the tricuspid annulus and a 8-mm tip ablation catheter for each patient. Forty-two patients (group 1) underwent radiofrequency (RF) application to the cavotricuspid isthmus 5 minutes after the beginning of inhalation of a (50% N2O/50% O2) mixture. Thirty-four patients (group 2), underwent the first RF application 15 minutes after the end of an infusion of Nalbuphine (20 mg delivered over 15 minutes). Ablation-related anxiety and discomfort were assessed using a visual analog scale (VAS) ranging from 0 to 100 mm, with 0 correlating to the statement "no pain at all" and 100 with "the worst possible pain." The VAS score was determined at the end of each application. The number of RF applications (group 1; 10 +/- 8 vs group 2; 11 +/- 6, P = NS) and procedure duration (group 1; 75 +/- 53 minutes vs group 2; 72 +/- 45 minutes, P = NS), were similar for the two groups. N(2)O sedation compared with nalbuphine infusion reduced VAS for anxiety (10 mm +/- 8 vs 58 mm +/- 22, P < 0.05) and for discomfort (18 mm +/- 9 vs 45 mm +/- 34, P < 0.01), respectively. Although there was more frequent vomiting in group 1; 7 of 42 (17%) than in group 2; 3 of 34 (9%), P < 0.05, patients were less likely to have hypotension during the procedure 1 of 42 (2.5%) versus 4 of 34 (12%), P < 0.05, respectively. CONCLUSION: Inhalation of a (50% N2O/50% O2) mixture during RF ablation for atrial flutter is a safe and efficient way to reduce anxiety and discomfort caused by RF applications.

Simple and efficient identification of conduction gaps in post-ablation recurring atrial flutters.

AIMS: Cavo-tricuspid isthmus (CTI) radiofrequency (RF) ablation is a curative therapy for common atrial flutter (AFl), but is associated with a recurrence rate of 5-26%. Although complete bidirectional conduction block is usually achieved, the recurrence of AF is due to recovered conducting isthmus tissue through which activation wavefronts pass. We evaluated a simple and efficient electrophysiological strategy, which pinpoints the ablation target. METHODS AND RESULTS: Twenty-five patients (19 men), mean age 61 +/- 6, with recurrent AFl required a repeat ablation, 250 +/- 160 days after a successful RF CTI procedure. Transverse CTI conduction was monitored during AFl or coronary sinus (CS) pacing by a 24-pole mapping catheter positioned in the right atrium (RA), with the distal poles in the CS, proximal poles on the lateral RA, and intermediate poles on the CTI. A slow conduction area traversing the CTI (velocity, 37 +/- 22 vs. 98 +/- 26 cm/s on either side, P < 0.05) and a lower potential amplitude than at both sides (0.2 +/- 0.15 vs. 0.5 +/- 0.5 mV, P < 0.05), defined by a bayonet-shaped depolarization sequence, were considered to represent the incomplete line of block (InLOB). An ablation catheter was progressively dragged up to this InLOB, from the tricuspid annulus to the inferior vena cava, analysing the widely separated double potentials (DPs) until these coalesced. In nine patients (35%), the target conduction gap was a coalesced fractionated atrial potential within the InLOB (duration, 77 +/- 12 ms), and in 16 patients (65%), a narrow DP toward the healthy margins of this InLOB (duration, 28 +/- 15 ms). Adopting this strategy yields 100% successful re-ablation of recurring AFl leading to bidirectional block, with a mean 2.7 +/- 1.4 RF applications. CONCLUSION: Transverse CTI mapping precisely locates the InLOB and helps find conduction gaps along the CTI in re-ablation procedures for common AFl.