Four typical pulmonary venous pressure curves displaying the level of occlusion during atrial fibrillation ablation by cryoballoon.

Background: Cryoballoon ablation is safe and effective for pulmonary vein isolation in patients with symptomatic drug-refractory paroxysmal atrial fibrillation. To monitor adhesion between the balloon and the pulmonary vein, an alternative technique to pulmonary venography is to analyze changes in the pressure curve. Methods: We have described the adhesion level characterized by four types of pressure waveforms. Results: These correlated with the extent of contrast agent leakage (Cohen's kappa of 0.81 [IC 95%: 0.63-0.99]). Conclusion: Monitoring the venous pressure curve is easy to perform and has the advantage of being able to detect balloon movement during the first few seconds of treatment.

Recurrences of Atrial Fibrillation Despite Durable Pulmonary Vein Isolation: The PARTY-PVI Study.

BACKGROUND: Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are mainly due to pulmonary vein reconnection. However, a growing number of patients have AF recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown. We analyzed the impact of current ablation strategies in a large multicenter study. METHODS: Patients undergoing a redo ablation for AF and presenting durable PVI were included. The freedom from atrial arrhythmia after pulmonary vein-based, linear-based, electrogram-based, and trigger-based ablation strategies were compared. RESULTS: Between 2010 and 2020, 367 patients (67% men, 63±10 years, 44% paroxysmal) underwent a redo ablation for AF recurrences despite durable PVI at 39 centers. After durable PVI was confirmed, linear-based ablation was performed in 219 (60%) patients, electrogram-based ablation in 168 (45%) patients, trigger-based ablation in 101 (27%) patients, and pulmonary vein-based ablation in 56 (15%) patients. Seven patients (2%) did not undergo any additional ablation during the redo procedure. After 22±19 months of follow-up, 122 (33%) and 159 (43%) patients had a recurrence of atrial arrhythmia at 12 and 24 months, respectively. No significant difference in arrhythmia-free survival was observed between the different ablation strategies. Left atrial dilatation was the only independent factor associated with arrhythmia-free survival (HR, 1.59 [95% CI, 1.13-2.23]; P=0.006). CONCLUSIONS: In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.

Ventricular fibrillation in acute myocardial infarction: 20-year trends in the FAST-MI study.

AIMS: Sudden cardiac arrest remains a major complication of acute myocardial infarction (AMI) and is frequently related to ventricular fibrillation (VF). Incidence and impact of VF among patients hospitalized for AMI were evaluated. METHODS AND RESULTS: Data from the FAST-MI programme consisting of 5 French nationwide prospective cohort studies between 1995 and 2015 were analysed, totally including 14 423 patients with AMI (66 ± 14 years, 72% males, 59% ST-elevation myocardial infarction). Overall, proportion of patients presenting in-hospital VF decreased from 3.9% in 1995 to 1.8% in 2015 (P < 0.001). One-year mortality decreased from 60.7% to 24.6% (P < 0.001). However, compared with patients who did not develop VF, the over-risk of 1-year mortality associated with VF was stable over time [hazard ratio (HR) 6.78, 95% confidence interval (CI) 5.03-9.14 in 1995 and HR 6.64, 95% CI 4.20-10.49 in 2015, P = 0.52]. This increased mortality in the VF group was mainly related to fatal events occurring prior to hospital discharge, representing 86.2% of 1-year mortality, despite the very low rate of implantable cardioverter defibrillator in the VF group (2.6%). CONCLUSION: This study demonstrates that in-hospital VF incidence and mortality in the setting of AMI have significantly decreased over the past 20 years. Nevertheless, VF remained steadily associated with approximately a 10-fold increased relative risk of in-hospital mortality, without an impact on post-discharge mortality. Beyond long-term cardiac defibrillation strategy, these results emphasize the need to identify in-hospital interventions to further reduce mortality in VF patients. STUDY REGISTRATION: ClinicalTrials.gov Identifier: NCT00673036, NCT01237418, NCT02566200.

Preventing atrial fibrillation by combined right isthmus ablation and cryoballoon pulmonary vein isolation in patients with typical atrial flutter: PAF-CRIOBLAF study.

BACKGROUND: Although less common, typical atrial flutter shares similar pathophysiological roots with atrial fibrillation. Following successful cavo-tricuspid isthmus ablation using radiofrequency, many patients, however, develop atrial fibrillation in the mid-to-long-term. This study sought to assess whether pulmonary vein isolation conducted at the same time as cavo-tricuspid isthmus ablation would significantly modify the atrial fibrillation burden upon follow-up in patients suffering from typical atrial flutter. METHODS: This was a multicenter randomized controlled study involving typical atrial flutter patients with history of non-predominant atrial fibrillation (1 atrial fibrillation episode only, in 67% of population) who were scheduled for cavo-tricuspid isthmus radiofrequency ablation. Patients were randomly assigned to either undergo cavo-tricuspid isthmus ablation alone or cavo-tricuspid isthmus plus pulmonary vein isolation (CTI+). Pulmonary vein isolation was performed using cryoballoon technology. An outpatient consultation with ECG and 1-week Holter monitoring was performed at 3, 6 months, 1 year, and 2 years postprocedure. The primary endpoint was atrial fibrillation recurrences lasting more than 30 s at 2 years postablation. RESULTS: Of the patients enrolled, 36 were included in each group. At 2-year follow-up, the atrial fibrillation recurrence rate was significantly higher in the CTI vs CTI+group (25/36, 69% vs. 12/36, 33% respectively; P < .001), with similar typical atrial flutter recurrence rates. There were no differences in undesirable events, except for transient phrenic nerve palsy reported from three CTI+patients (8.3%). CONCLUSION: Pulmonary vein isolation using cryoballoon technology was proven to significantly reduce the atrial fibrillation incidence at 2 years postcavo-tricuspid isthmus ablation.

Exclusion of Intra-Atrial Thrombus Diagnosis Using D-Dimer Assay Before Catheter Ablation of Atrial Fibrillation.

OBJECTIVES: This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus. BACKGROUND: Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi. METHODS: Patients admitted for catheter ablation of AF (n = 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS2 score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE). RESULTS: The incidence of atrial thrombus was 1.92%. CHADS2 score and D-dimer level were significantly associated with atrial thrombus (p < 0.0001 and p < 0.0001, respectively). A zero CHADS2 score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS2 score (p < 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus. CONCLUSIONS: An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.

The second generation cryoballoon has improved durable isolation of left but not right pulmonary veins: new insights from a multicentre study.

Aims: Pulmonary vein isolation (PVI) using second-generation cryoballoon (CB2) is associated with improved outcomes compared with first generation (CB1). We aimed at investigating the characteristics of left and right PV reconnections after CB1 and CB2 ablations in patients with clinical recurrences requiring redo ablation. Methods and results: From 2010 to 2016, 776 patients underwent 28-mm cryoballoon PVI for symptomatic paroxysmal atrial fibrillation (AF) in 3 centres, 279 with CB1 and 497 with CB2. Among them, 94 patients (12.1%) had symptomatic AF recurrences requiring a redo ablation [43 (15.4%) CB1 and 51 (10.3%) CB2]. The benefit of CB2 over CB1 was compared for each PV. Durable PVI was confirmed in 7 CB1 (16.3%) and 14 CB2 (27.4%) patients, and 2.7 ± 2.1 and 1.4 ± 1.4 gaps per patient were found, respectively (P = 0.002). Significantly more left superior and left inferior PVs were found to be isolated in CB2 compared with CB1 group (78.4% vs. 48.8%, P = 0.005 and 78.4% vs. 46.5%, P = 0.003, respectively) while the rate of durable right superior and right inferior PVs isolation were similar (68.6% vs. 60.5%, P = 0.542 and 66.7% vs. 55.8%, P = 0.387, respectively). Significantly fewer gaps were found in left PVs in CB2 patients, while there was no significant difference for right PVs. Gaps localization was similar in both groups. Conclusion: Fewer reconnection gaps are observed during redo ablations of paroxysmal AF in patients primarily ablated with CB2. This difference is driven by less reconnection gaps observed in both left PVs, while no difference was observed for right PVs.

Causes-of-death analysis of patients with cardiac resynchronization therapy: an analysis of the CeRtiTuDe cohort study.

AIMS: The choice of resynchronization therapy between with (CRT-D) and without (CRT-P) a defibrillator remains a contentious issue. Cause-of-death analysis among CRT-P, compared with CRT-D, patients could help evaluate the extent to which CRT-P patients would have additionally benefited from a defibrillator in a daily clinical practice. METHODS AND RESULTS: A total of 1705 consecutive patients implanted with a CRT (CRT-P: 535 and CRT-D: 1170) between 2008 and 2010 were enrolled in CeRtiTuDe, a multicentric prospective follow-up cohort study, with specific adjudication for causes of death at 2 years. Patients with CRT-P compared with CRT-D were older (P < 0.0001), less often male (P < 0.0001), more symptomatic (P = 0.0005), with less coronary artery disease (P = 0.003), wider QRS (P = 0.002), more atrial fibrillation (P < 0.0001), and more co-morbidities (P = 0.04). At 2-year follow-up, the annual overall mortality rate was 83.80 [95% confidence interval (CI) 73.41-94.19] per 1000 person-years. The crude mortality rate among CRT-P patients was double compared with CRT-D (relative risk 2.01, 95% CI 1.56-2.58). In a Cox proportional hazards regression analysis, CRT-P remained associated with increased mortality (hazard ratio 1.54, 95% CI 1.07-2.21, P = 0.0209), although other potential confounders may persist. By cause-of-death analysis, 95% of the excess mortality among CRT-P subjects was related to an increase in non-sudden death. CONCLUSION: When compared with CRT-D patients, excess mortality in CRT-P recipients was mainly due to non-sudden death. Our findings suggest that CRT-P patients, as currently selected in routine clinical practice, would not potentially benefit with the addition of a defibrillator.

Safety and efficacy of a second-generation cryoballoon in the ablation of paroxysmal atrial fibrillation.

BACKGROUND: Compared with the first-generation Arctic Front cryoballoon (ARC-CB), the new Arctic Front Advance cryoballoon (ARC-Adv-CB) increases the efficient CB-tissue contact surface during freezing, which may increase the incidence of phrenic nerve (PN) palsy (PNP). OBJECTIVE: To evaluate the safety and efficacy of paroxysmal atrial fibrillation (AF) ablation with the ARC-Adv-CB as well as the merits of a predictor of PNP. METHODS: AF ablation was performed by using a "single 28-mm big CB" approach. The rate of pulmonary vein (PV) isolation with a first cryoapplication was measured. The distance between the CB and a PN pacing catheter in the superior vena cava was measured to predict PNP during freezing. RESULTS: In 147 patients, PV were isolated with a single cryoapplication in 205 (81.3%) of 252 PV treated with the ARC-CB and in 280 (90.3%) of 310 PV treated with the ARC-Adv-CB (P = .003). The mean time to PV isolation was 52 ± 34 seconds and 40 ± 25 seconds (P < .001) and the temperature at the time of isolation was -36.1 ± 10.3°C and -32.3 ± 10.2°C (P = .001) in the ARC-CB and ARC-Adv-CB groups, respectively. Mean procedure and fluoroscopy durations were significantly shorter in the ARC-Adv-CB group. Transient PNP was observed in 7(10.6%) and 20(24.4%) of the patients treated with the ARC-CB and ARC-Adv-CB, respectively (P = .048). The distance between the lateral edge of the CB and a vertical line through the tip of the pacing catheter accurately predicted PNP (P < .001). CONCLUSIONS: The 28-mm ARC-Adv-CB enabled more efficient ablation of paroxysmal AF and shorter procedures than did the ARC-CB. This higher performance was associated with a higher incidence of PNP, which was predicted by the distance between the CB and the PN.

[Atrial fibrillation: who should be anticoagulated?]. / Fibrillation atriale : qui anticoaguler ?

The growing incidence of Atrial Fibrillation (AF) induces an increasing morbimortality, particularly thromboembolism (TE). Vitamin K Antagonists (VKA) reduce of 62 % the stroke rate in case of AF and are more efficient with INR between 2 and 3 than aspirin or the association aspirin-VKA with INR<2. The only place for clopidogrel could be its association with aspirin if VKA are contra-indicated. But VKA increase of 1.4 to 3.36 %/year the major bleedings, whereas the risk with aspirin is less important. The TE risk factors validated in case of AF are: previous TE, heart failure, hypertension, age over 75, diabetes mellitus, rhumatismal valvulopathy or mechanical valvular prosthesis. Ischemic cardiomyopathy, age between 65 and 75 and the female gender represent intermediate risks. Guidelines suggest to anticoagulate patients with previous TE or CHADS(2) score > or = 2 and to discuss VKA for a score equal to 1. Lone AF must not be anticoagulated but the continuous follow-up of occurring risk factors remains essential. Paroxysmal and persistant/permanent AF present the same TE risk. VKA are preferable if patients are older than 75 unless a major bleeding risk is present. If AF occurs on an ischemic cardiomyopathy, VKA are often essential and reduce the total mortality even if they increase the bleeding risk due to the association with antiplatelet therapy. However no precise guidelines are available on this topic. After a successful AF ablation, guidelines recommend not to modify the antithrombotic strategy. The bleeding risk score called "HEMORR2HAGE" allows to establish an individual balance of risk/benefit of VKA. The utility of transoesophagial echocardiography could be recognized in case of intermediate TE risk to suggest VKA if thrombotic criteria are identified. At least, new antithrombotic therapy will probably modify our perception of the risk/benefit ratio.

[Managing bradycardia in adults]. / Conduite a tenir devant une bradycardie de l'adulte.

Bradycardia represents a common cause of requirement for specialist advice and it looks sometimes difficult to evaluate its pathological criteria and its medical management. The authors remind the physiological mechanisms and their aetiologies, cardiac or not. Many complementary exams can be employed but a rigorous strategy is necessary, based on the use of electrocardiogram, Holter ECG, implantable loop recorder, stress test, cardiac echography, tilt testing, electrophysiological study. Once the diagnostic established, the next fundamental step consists on a rigorous evaluation of severity in order to recognize the real urgency which require an hospitalization and to initiate rapidly the most appropriate treatment, sometimes before having the complete diagnosis, or to take in charge ambulatory the less severe cases all the more a reversible causes is identified. The situation often needs to take our time to avoid conceding too easily the definitive cardiac pacing. North American guidelines concerning cardiac pacing represent at least the references which we have to follow as often as possible particularly concerning atypical cases.