Pre-emptive treatment of heart failure exacerbations in patients managed with the HeartLogic™ algorithm.

AIMS: Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs. HeartLogic™ is an algorithm programmed into implanted devices incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing pre-emptive treatment of congestion to prevent acute decompensation. We aim to assess the impact and security of pre-emptive HF management, guided by the HeartLogic™ index. METHODS AND RESULTS: The HeartLogic™ France Cohort Study is an investigator-initiated, prospective, multi-centre, non-randomized study. Three hundred ten patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450 ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic™ index calculation will be included across 10 French centres. The HeartLogic™ index will be monitored remotely for 12 months and in the event of a HeartLogic™ index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, unscheduled hospitalizations for ventricular or atrial arrhythmia and HeartLogic™ index evolution over time. Blood samples will be collected for biobanking, and quality of life will be assessed. Finally, the safety of a HeartLogic™-triggered strategy for initiating or increasing diuretic therapy will be assessed. A blind and independent committee will adjudicate the events. CONCLUSIONS: The HeartLogic™ France Cohort Study will provide robust real-world data in a cohort of HF patients managed with the HeartLogic™ algorithm allowing pre-emptive treatment of heart failure exacerbations.

Asymptomatic left circumflex artery stenosis is associated with higher arrhythmia recurrence after persistent atrial fibrillation ablation.

Background: The pathophysiology of persistent atrial fibrillation (AF) remains unclear. While several studies have demonstrated an association between myocardial infarction and atrial fibrillation, the role of stable coronary artery disease (CAD) is still unknown. As a result, we aimed to assess the association between CAD obstruction and AF recurrence after persistent AF ablation in patients with no history of CAD. Materials and methods: This observational retrospective study included consecutive patients who underwent routine preprocedural cardiac computed tomography (CCT) before persistent AF ablation between September 2015 and June 2018 in 5 European University Hospitals. Exclusion criteria were CAD or coronary revascularization previously known or during follow-up. Obstructive CAD was defined as luminal stenosis ≥ 50%. Results: All in all, 496 patients (mean age 61.8 ± 10.0 years, 76.2% males) were included. CHA2DS2-VASc score was 0 or 1 in 225 (36.3%) patients. Obstructive CAD was present in 86 (17.4%) patients. During the follow-up (24 ± 19 months), 207 (41.7%) patients had AF recurrence. The recurrence rate was not different between patients with and without obstructive CAD (43.0% vs. 41.5%, respectively; P = 0.79). When considering the location of the stenosis, the recurrence rate was higher in the case of left circumflex obstruction: 56% vs. 32% at 2 years (log-rank P ≤ 0.01). After Cox multivariate analysis, circumflex artery obstruction (HR 2.32; 95% CI 1.36-3.98; P < 0.01) was independently associated with AF recurrence. Conclusion: Circumflex artery obstruction detected with CCT was independently associated with 2-fold increase in the risk of AF recurrence after persistent AF ablation. Further research is necessary to evaluate this pathophysiological relationship.

Independent factors of low radiation dose during atrial fibrillation ablation with cryoballoon or radiofrequency: Results from the "Go for zero fluoroscopy" registry.

AIMS: Atrial fibrillation (AF) catheter ablation is a common procedure requiring in most cases the use of fluoroscopy. We aimed to evaluate the factors associated with a lower dose of fluoroscopy used during AF ablation with cryoballoon or radiofrequency. METHODS: In this prospective European registry, centers were requested to provide procedural characteristics of consecutive AF ablation cases. Lower doses of fluoroscopy were defined as those with dose-area-product (DAP) under the median dose used in the radiofrequency and the cryoballoon ablation groups. RESULTS: A total of 638 AF ablation procedures were collected (n = 492 for radiofrequency and n = 146 for cryoballoon ablation groups) in 25 centers. The median [IQR] DAP were 926 [349;2092] and 1516 [418;3408] cGy*cm2 in the radiofrequency and cryoballoon groups, respectively. Main factors associated with lower DAP in cryoballoon ablation group were electrophysiology dedicated laboratory (OR 6.04, 95%CI 1.16-31.54; P = .03) and frequent dosimetry report (OR 21.39, 95%CI 5.43-98.54; P = .03). Main factors associated with lower DAP in the radiofrequency ablation group were the use of a chest dosimeter (OR 12.57, 95% CI 2.88-54.90; P = .01), biplane X-ray equipment (OR 3.12, 95%CI 1.89-5.16; P < .01), university hospital (OR 2.10, 95%CI 1.35-3.25; P = .01), electrophysiology dedicated laboratory (OR 2.45, 95%CI 1.48-4.05; P < .01) and use of contact force enabled catheter (OR 22.60, 95%CI 6.82-74.88; P < .01). CONCLUSION: This real-life study of fluoroscopy use during AF ablation provides new data about current practices across European countries. Technological advances and quality of the fluoroscopic environment were the main factors associated with lower radiation dose during AF ablation.

Virtual Reality for Sedation During Atrial Fibrillation Ablation in Clinical Practice: Observational Study.

BACKGROUND: Connected devices are dramatically changing many aspects in health care. One such device, the virtual reality (VR) headset, has recently been shown to improve analgesia in a small sample of patients undergoing transcatheter aortic valve implantation. OBJECTIVE: We aimed to investigate the feasibility and effectiveness of VR in patients undergoing atrial fibrillation (AF) ablation under conscious sedation. METHODS: All patients who underwent an AF ablation with VR from March to May 2020 were included. Patients were compared to a consecutive cohort of patients who underwent AF ablation in the 3 months prior to the study. Primary efficacy was assessed by using a visual analog scale, summarizing the overall pain experienced during the ablation. RESULTS: The AF cryoablation procedure with VR was performed for 48 patients (mean age 63.0, SD 10.9 years; n=16, 33.3% females). No patient refused to use the device, although 14.6% (n=7) terminated the VR session prematurely. Preparation of the VR headset took on average 78 (SD 13) seconds. Compared to the control group, the mean perceived pain, assessed with the visual analog scale, was lower in the VR group (3.5 [SD 1.5] vs 4.3 [SD 1.6]; P=.004), and comfort was higher in the VR group (7.5 [SD 1.6] vs 6.8 [SD 1.7]; P=.03). On the other hand, morphine consumption was not different between the groups. Lastly, complications, as well as procedure and fluoroscopy duration, were not different between the two groups. CONCLUSIONS: We found that VR was associated with a reduction in the perception of pain in patients undergoing AF ablation under conscious sedation. Our findings demonstrate that VR can be easily incorporated into the standard ablation workflow.

Impact of the atrial lead pacing site regarding atrial fibrillation onset in patients with sinus node dysfunction.

Symptomatic sinus node disease (SND) most frequently requires the implantation of a dual chamber pacemaker of which the right atrial lead is generally implanted in the right atrial appendage (RAA) or the lateral wall (LW).The aim of this retrospective study was to evaluate the impact of the right atrial lead pacing site regarding the onset of AF in patients with SND. RESULTS: 126 patients were included (53% males; 76 yo). 64 (51%) patients were implanted in the RAA and 62 (49%) in the LW. The two groups were not different in terms of CHA2DS2-VASc score and indexed left atrial volume. Forty-eight months after implantation, AF occurred in 17 (26.6%) of the RAA group and 6 (9.7%) in the lateral group. In the multivariate models, RAA site was the only factor associated with AF onset, with an Hazard Ratio of 2.5 (95%CI 1.1; 5.7; P=0.03). CONCLUSION: In our study, RAA pacing was associated with 2.5 higher risk of AF onset in patients with SND. Further larger randomized studies are needed to confirm these findings.

Mortality and cardiac resynchronization therapy with or without defibrillation in primary prevention.

AIMS: Cardiac resynchronization therapy with (CRTD) or without (CRTP) defibrillator is recommended in selected patient with systolic chronic heart failure and wide QRS. There is no guideline firmly indicating choice between CRTP and CRTD in primary prevention, particularly in older patients. METHODS AND RESULTS: Based on the French administrative hospital-discharge database, information was collected from 2010 to 2017 for all patients implanted with CRTP or CRTD in primary prevention. Outcome analyses were undertaken in the total study population and in propensity-matched samples. During follow-up (913 days, SD 841, median 701, IQR 151-1493), 45 697 patients were analysed (CRTP 19 266 and CRTD 26 431). Incidence rate (%patient/year) of all-cause mortality was higher in CRTP patients (11.6%) than in CRTD patients (6.8%) [hazard ratio (HR) 1.70, 95% confidence interval (CI) 1.63-1.76, P < 0.001]. After propensity-matched analyses, mortality of patients over 75 years old with non-ischaemic cardiomyopathy (NICM) was not different with CRTP and CRTD (HR 0.93, 95% CI 0.80-1.09, P = 0.39). The CRTP patients under 75 years old with NICM had a higher mortality than CRTD patients (HR 1.22, 95% CI 1.03-1.45, P = 0.02). Mortality rate was also higher with CRTP than with CRTD irrespectively of age in patients with ischaemic cardiomyopathy (ICM) (<75 years old: HR 1.22, 95% CI 1.08-1.37, P = 0.01; ≥75 years old: HR 1.13, 95% CI 1.04-1.22, P = 0.003). CONCLUSION: In this real-life study, CRTD was associated with a significantly lower all-cause mortality than CRTP in patients with ICM and in patients with NICM under 75 years old. Patients over 75 years old with NICM did not have lower mortality with primary prevention CRTD implantation.

Understanding the fundamentals of acid-induced ionic liquid-based aqueous biphasic system.

Ionic-liquid-based aqueous biphasic systems (IL-based ABS) have demonstrated exceptional performance in bioseparation processes. However, IL-based ABS are of limited interest for metal extraction as most metals are not stable in their neutral or alkaline pH conditions. In the quest for better extraction systems for metals, the development of IL-based ABS with highly acidic solutions (AcABS), induced by the mixture of a hydrophilic IL ([P44414]Cl), a mineral acid (HCl, HNO3 or H2SO4) and water, opens new possibilities. A comprehensive investigation of fundamental aspects of IL-based AcABS was performed, including the temperature dependence of the phase diagrams, tie-lines and ion exchange behavior, evidencing the unique characteristics of these new systems. In particular, the favorable biphasic formation with an increase in temperature showcases the lower critical solution temperature (LCST) behavior of the phosphonium-based IL and opens many possibilities for AcABS application by creating stimuli responsive systems. The anion exchange identified highlights the IL-based AcABS complexity that renders the analytical characterization of the phases mandatory, instead of the traditional method coupling an empirical fit of the binodal with the lever-arm rule. Through judicious selection of the inorganic acid, different extraction systems can be obtained by tuning the degree of anion-exchange, underlining the versatility of the proposed AcABS system.

Mechanism of ionic-liquid-based acidic aqueous biphasic system formation.

Ionic-liquid-based acidic aqueous biphasic systems (IL-based AcABS) represent a promising alternative to the solvent extraction process for the recovery of critical metals, in which the substitution of the inorganic salt by an acid allows for a 'one-pot' approach to the leaching and separation of metals. However, a more fundamental understanding of AcABS formation remains wanting. In this work, the formation mechanisms of AcABS are elucidated through a comparison with traditional aqueous biphasic systems (ABS). A large screening of AcABS formation with a wide range of IL identifies the charge shielding of the cation as the primary structural driver for the applicability of an IL in AcABS. Through a systematic study of tributyltetradecylphosphonium chloride ([P44414]Cl) with various chloride salts and acids, we observed the first significant deviation to the cationic Hofmeister series reported for IL-based ABS. Furthermore, the weaker than expected salting-out ability of H3O+ compared to Na+ is attributed to the greater interaction of H3O+ with the [P44414]+ micelle surface. Finally, the remarkable thermomorphic properties of [P44414]Cl based systems are investigated with a significant increase in the biphasic region induced by the increase in the temperature from 298 K to 323 K. These finding allows for the extension of ABS to new acidic systems and highlights their versatility and tunability.

Ionic-Liquid-Based Acidic Aqueous Biphasic Systems for Simultaneous Leaching and Extraction of Metallic Ions.

The first instance of an acidic aqueous biphasic system (AcABS) based on tributyltetradecyl phosphonium chloride ([P44414 ][Cl]) and an acid is here reported. This AcABS exhibits pronounced thermomorphic behavior and is shown to be applicable to the extraction of metal ions from concentrated acidic solutions. Metal ions such as cobalt(II), iron(III), platinum(IV) and nickel(II) are found to partition preferentially to one of the phases of the acidic aqueous biphasic system and it is here shown that it successfully allows the difficult separation of CoII from NiII , here studied at 24 and 50 °C.

Effect of mixed anions on the physicochemical properties of a sodium containing alkoxyammonium ionic liquid electrolyte.

The physicochemical properties of the ionic liquid N-ethyl-2-(2-methoxyethoxy)-N,N-bis(2-(2-methoxyethoxy)ethyl)ethan-1-ammonium bis(trifluoromethylsulfonyl)imide (N2(2O2O1)3TFSI) as well as its solutions with sodium bis(trifluoromethylsulfonyl)imide (NaTFSI) and sodium bis(fluorosulfonyl)imide (NaFSI) are compared in order to study the effects of the anion. The NaFSI solutions show weaker interactions as suggested by lower glass transition temperatures, lower densities, lower viscosities and higher conductivities as compared to their more strongly coordinating NaTFSI analogues. The transport properties follow Vogel-Tamman-Fulcher behaviour suggesting that the mixtures are fragile glass formers. The addition of a higher concentration of Na salts results in decoupling of the translational motion from the viscosity, as observed from Walden plots, and 23Na NMR data suggests that the sodium speciation is independent of the nature of the Na salt or the temperature but is affected by the salt concentration.