Pulmonary vein isolation alone or in combination with substrate modulation after electrical cardioversion failure in patients with persistent atrial fibrillation: The PACIFIC trial: Study design.

INTRODUCTION: Pulmonary vein isolation (PVI) is effective at treating 50% of unselected patients with persistent atrial fibrillation (AF). Alternatively, PVI combined with a new ablation strategy entitled the Marshall-PLAN ensures a 78% 1-year sinus rhythm (SR) maintenance rate in the same population. However, a substantial subset of patients could undergo the Marshall-PLAN unnecessarily. It is therefore essential to identify those patients who can be treated with PVI alone versus those who may truly benefit from the Marshall-PLAN before ablation is performed. In this context, we hypothesized that electrical cardioversion (EC) could help to select the most appropriate strategy for each patient. METHODS: In this multicentre, prospective, randomized study, patients with AF recurrence within 4 weeks after EC will be randomized 1:1 to PVI alone or the Marshall-PLAN. Conversely, patients in whom SR is maintained for ≥4 weeks after EC will be treated with PVI only and included in a prospective registry. The primary endpoint will be the 1-year SR maintenance rate after a single ablation procedure. RESULTS AND CONCLUSION: The Marshall-PLAN might be necessary in patients with an advanced degree of persistent AF (i.e., where SR is not maintained for ≥4 uninterrupted weeks after EC). Conversely, in patients with mild or moderate persistent AF (i.e., where SR is maintained for ≥4 weeks after EC), PVI alone might be a sufficient ablation strategy. The PACIFIC trial is the first study designed to assess whether rhythm monitoring after EC could help to identify patients who should undergo adjunctive ablation strategies beyond PVI.

Left atrial epicardial adipose tissue radiodensity is associated with electrophysiological properties of atrial myocardium in patients with atrial fibrillation.

OBJECTIVE: To evaluate whether the epicardial adipose tissue (EAT) phenotype is associated with the electrophysiological properties of adjacent atrial myocardium in patients with atrial fibrillation (AF). METHODS: Between January and May 2017, 30 consecutive patients referred for a first AF catheter ablation were prospectively included. For each patient, a pre-procedural computed tomography scan was performed to assess total and left atrial (LA) EAT amount and radiodensity. A detailed point-by-point voltage mapping using an electroanatomic mapping system was realized to assess the presence of LA low-voltage zone (LVZ). RESULTS: Ten patients (33.3%) presented at least one LVZ. Older age (65 ± 7 vs. 58 ± 10 years, p = 0.05) was the only clinical parameter associated with LVZ. Despite no greater LA-EAT thickness by CT scan (3.0 [2.6-3.5] mm vs. 2.8 [2.2-3.1] mm, p = 0.354), patients with LA-LVZ presented significantly lower LA-EAT radiodensity than patients with no LA-LVZ (- 101.8 ± 12.5 HU vs. - 90.4 ± 6.3 HU, p = 0.004). No difference between total-EAT volume (131 ± 61 cm3 vs.107 ± 58 cm3, p = 0.361) and total-EAT radiodensity (- 106.8 ± 4.3 HU vs. - 102.4 ± 6.9 HU, p = 0.119) was found. CONCLUSION: Low LA-EAT radiodensity is associated with the presence of LVZ in patients with medical history of AF. KEY POINTS: • Cardiovascular risk factors are associated with low adipose tissue computed tomography attenuation. • Epicardial adipose tissue (EAT) has emerged as an important factor in the pathogenesis of metabolic-related cardiac diseases such as atrial fibrillation. • We showed that low left atrial EAT attenuation is associated with the presence of low-voltage zone, a surrogate for atrial fibrosis, within the adjacent myocardium.

No impact of sports practice before or after atrial fibrillation ablation on procedure efficacy in athletes: a case-control study.

AIMS: Limited data exist on the efficacy of catheter ablation (CA) for sport-related atrial fibrillation (AF). Impact of sports practice resumption post-CA remains unknown. We aimed to determine AF CA efficacy in athletes vs. non-athletes, and to assess the impact of sport practice resumption. METHODS AND RESULTS: From 1153 first-time AF CA performed between 2009 and 2017, 73 athletes were matched with 73 sedentary patients based on age, sex, and closest CA procedure date. Athletes were defined as performing ≥6 h/week of vigorous sports to achieve ≥2000 h accumulated lifetime sports activity. They were mostly males (93.2%) with a mean age of 55 ± 9.8 years. Before CA, athletes practiced 10.2 ± 3.9 h/week of vigorous exercise vs. 4.6 ± 3.4 after CA. Within first year after CA, physical activity was stopped in 12 (16.4%) athletes, lowered in 45 (61.9%), and resumed at same intensity in 16 (21.9%). Athletes and non-athletes suffered from same AF recurrence rates during 5-year follow-up after CA: 38 (52.0%) vs. 35 (47.9%), respectively [adjusted hazard ratio (HR) on age, body mass index (BMI), obstructive sleep apnoea (OSA), and reduced left ventricular ejection fraction (LVEF), 1.17 (0.70-1.97, P = 0.54)]. No significant impact of physical activity resumption status was found regarding AF recurrence rates at 1-year and beyond (P = 0.60). Procedure effectiveness was significantly lower in athletes with non-paroxysmal AF [adjusted on age, BMI, reduced LVEF, and OSA HR 2.36 (confidence interval 1.19-4.70), P = 0.01]. CONCLUSION: Sports practice before and after CA has no significant impact on AF recurrence rates in athletes within 5-year after AF CA.

A report on the impact of remote monitoring in patients with S-ICD: Insights from a prospective registry.

INTRODUCTION: Several clinical studies have demonstrated that remote monitoring (RM) offers potential benefits in transvenous implantable cardioverter defibrillator (ICD). The potential interest of RM in subcutaneous-ICD (S-ICD) recipients has never been evaluated. The aim of this study was to evaluate the alert burden and its clinical relevance in a prospective cohort of S-ICD recipients. METHODS: We prospectively and consecutively enrolled all patients undergoing S-ICD implantation at Lille University Hospital from September 2015 to January 2017 and gave them a LATITUDE™ NXT RM system. The relevance of transmissions was assessed by the following ratio: number of transmissions leading to reaction or intervention per patient/number of transmissions per patient. RESULTS: From September 2015 to January 2017, 69 patients were enrolled with a mean follow-up of 415 ± 96.3 days. The mean age was 44.6 ± 15.6 years old, and 25% (n = 17) had ischemic cardiomyopathy. At the end of follow-up, 12% of the patients had events recorded by RM. These events were related to nine ICD shocks and eight untreated events. A total of 1,423 transmissions were collected. Most of these transmissions were patient-initiated without any event (77%, n = 1,096) or scheduled without any event (19%, n = 272). Only 3.2% ± 1.1 of the transmissions per patient led to reactions or interventions. CONCLUSION: On the basis of the current method of transmitting, S-ICD RM allowed detection of relevant events in 12% of patients but generated a high unactionable transmission burden. As a result of these findings, efforts should be made to optimize transmissions considering automatic transmissions and to focus on patient education.

Catheter ablation reduces ventricular tachycardia burden in patients with arrhythmogenic right ventricular cardiomyopathy: insights from a north-western French multicentre registry.

Aims: Studies assessing radiofrequency ablation (RFA) of ventricular tachycardia (VT) in arrhythmogenic right ventricular cardiomyopathy (ARVC) report VT recurrences, but have not evaluated the impact of RFA on relevant clinical events during follow-up. We aimed to investigate relevant RFA outcomes in a multicentric registry. Methods and results: This study included 49 patients with ARVC (46 with definite diagnosis, 3 with borderline diagnosis according to revised Task Force Criteria) who underwent 92 RFA procedures (83 endocardial, 9 combined endo-epicardial) between 1999-2015. Ventricular tachycardia recurrences and VT burden were assessed after each procedure or after the last RFA. Over a mean follow-up of 64 ± 51 months, VT-free survival was 37% at 1 year, 19% at 5 years, and 14% at 10 years. Ventricular tachycardia burden was significantly reduced after one procedure (23 vs. 11 VT episodes/year, P < 0.01) and after the last RFA (14 vs. 2 VT episodes/year, P < 0.01). Over a mean follow-up of 49 ± 52 months, clinical response after the last RFA (freedom from sudden cardiac death, VT requiring hospitalization, or heart transplantation) was 86% at 1 year, 69% at 5 years, and 60% at 10 years. Clinical response was associated with right ventricular dysfunction (RVD) and low numbers of mappable VT before the first RFA. Conclusion: RFA was predominantly targeted at the endocardial surface. Ventricular tachycardia recurrences were common, but few ARVC patients experienced major clinical events during follow-up. Further studies should investigate the benefit of extensive substrate ablation combined with endo-epicardial strategies.

Potential role of antitachycardia pacing alerts for the reduction of emergency presentations following shocks in patients with implantable cardioverter-defibrillators: implications for the implementation of remote monitoring.

AIMS: Despite increased use of remote monitoring (RM) to follow up implantable cardioverter-defibrillator (ICD) recipients, many patients still receive ICD shocks in the community and present to the emergency department. Our aim was to identify the best predictors of impending shock delivery that can be measured with an ICD and to identify the most appropriate activities to alert physicians to during RM follow-up. METHODS AND RESULTS: All patients presenting to our institution for ICD shock, from November 2011 to November 2014, were enrolled in this prospective study. Patient characteristics, investigation results, and details of electrical activities from ICD interrogation were recorded at presentation. Presentations were classified as potentially avoidable if activities from a list of set criteria were apparent more than 48 h before index shock. Univariate and multivariate analyses were then used to identify predictors of potentially avoidable shocks. In total, 109 emergency presentations were recorded in 90 patients (male: 85%; 57 ± 16 years; ischaemic cardiomyopathy: 49%; LVEF: 34 ± 13%; electrical storm: 40%), of which 26 (24%) were potentially avoidable. Antitachycardia pacing (ATP) episodes were the most important predictor of impending shock. Potentially avoidable shocks were preceded by more episodes of ATP than unavoidable shocks (13 [3-67] vs. 3 [0-10]; P < 0.001). Patients followed up with RM systems configured to generate alerts following ATP delivery experienced significantly less ICD shocks (24 vs. 16%, P < 0.01). CONCLUSION: Remote monitoring systems that generate alerts following ATP delivery could reduce emergency presentations for ICD shock by 24%, as ATP is a key predictor of impending shock delivery.

Impact of remote monitoring on reducing the burden of inappropriate shocks related to implantable cardioverter-defibrillator lead fractures: insights from a French single-centre registry.

AIMS: Lead fractures in implantable cardioverter-defibrillator (ICD) patients may cause inappropriate shocks (ISs). An early diagnosis is essential to prevent adverse clinical events. Implantable cardioverter-defibrillator remote monitoring (RM) permits prompt detection of lead fracture. Limited data define the impact of RM on ISs specifically related to lead fracture. We sought to compare the number of ISs related to lead fracture in patients with vs. without RM follow-up. METHODS AND RESULTS: We checked the registry of our institution and collected, between July 2007 and June 2014, 115 cases of right ventricular lead fractures. All relevant data were documented from patients' files, device-interrogation printouts and electronic records, and remote transmissions databases when applicable. We assessed the ISs that were related to lead fracture. The first study endpoint was the number of ISs per shocked patient. Among the 82 patients with conventional follow-up (CFU) and the 33 patients with RM, a first IS occurred to 32.9% (n = 27) and 30.3% (n = 10, P = 0.83) of the patients, respectively. Shocked patients in the RM group underwent significantly fewer ISs with a mean of 6 ± 2 shocks per patient [median of 3.5 shocks (2-8)] than those in the CFU group with a mean of 18 ± 5 shocks per patient [median of 10 shocks (5-22), P = 0.03]. CONCLUSION: Remote monitoring helps to reduce the burden of ISs related to ICD lead fractures.

Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%.

AIMS: Patients with well-tolerated sustained monomorphic ventricular tachycardia (SMVT) and left ventricular ejection fraction (LVEF) over 30% may benefit from a primary strategy of VT ablation without immediate need for a 'back-up' implantable cardioverter-defibrillator (ICD). METHODS AND RESULTS: One hundred and sixty-six patients with structural heart disease (SHD), LVEF over 30%, and well-tolerated SMVT (no syncope) underwent primary radiofrequency ablation without ICD implantation at eight European centres. There were 139 men (84%) with mean age 62 ± 15 years and mean LVEF of 50 ± 10%. Fifty-five percent had ischaemic heart disease, 19% non-ischaemic cardiomyopathy, and 12% arrhythmogenic right ventricular cardiomyopathy. Three hundred seventy-eight similar patients were implanted with an ICD during the same period and serve as a control group. All-cause mortality was 12% (20 patients) over a mean follow-up of 32 ± 27 months. Eight patients (40%) died from non-cardiovascular causes, 8 (40%) died from non-arrhythmic cardiovascular causes, and 4 (20%) died suddenly (SD) (2.4% of the population). All-cause mortality in the control group was 12%. Twenty-seven patients (16%) had a non-fatal recurrence at a median time of 5 months, while 20 patients (12%) required an ICD, of whom 4 died (20%). CONCLUSION: Patients with well-tolerated SMVT, SHD, and LVEF > 30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death and recurrences were generally non-fatal. These data would support a randomized clinical trial comparing this approach with others incorporating implantation of an ICD as a primary strategy.

Decreased delivery of inappropriate shocks achieved by remote monitoring of ICD: a substudy of the ECOST trial.

INTRODUCTION: Inappropriate shocks remain a highly challenging complication of implantable cardioverter defibrillators (ICD). We examined whether automatic wireless remote monitoring (RM) of ICD, by providing early notifications of triggering events, lowers the incidence of inappropriate shocks. METHODS AND RESULTS: We studied 433 patients randomly assigned to RM (n = 221; active group) versus ambulatory follow-up (n = 212; control group). Patients in the active group were seen in the ambulatory department once a year, unless RM reported an event requiring an earlier ambulatory visit. Patients in the control group were seen in the ambulatory department every 6 months. The occurrence of first and further inappropriate shocks, and their causes in each group were compared. The characteristics of the study groups, including pharmaceutical regimens, were similar. Over a follow-up of 27 months, 5.0% of patients in the active group received ≥1 inappropriate shocks versus 10.4% in the control group (P = 0.03). A total of 28 inappropriate shocks were delivered in the active versus 283 in the control group. Shocks were triggered by supraventricular tachyarrhythmias (SVTA) in 48.5%, noise oversensing in 21.2%, T wave oversensing in 15.2%, and lead dysfunction in 15.2% of patients. The numbers of inappropriate shocks delivered per patient, triggered by SVTA and by lead dysfunction, were 74% and 98% lower, respectively, in the active than in the control group. CONCLUSION: RM was highly effective in the long-term prevention of inappropriate ICD shocks.

Pregnancy in women with an implantable cardioverter-defibrillator: is it safe?

AIMS: To describe obstetric/neonatal and cardiac outcomes for a cohort of women carrying implantable cardioverter-defibrillators (ICDs) during pregnancy. METHODS AND RESULTS: All women in routine follow-up at our institution for ICD implantation who became pregnant between 2006 and 2013 were included in this study. All ICDs were pre-pectoral devices with bipolar endocardial leads. Obstetric/neonatal and cardiac outcomes were assessed during pregnancy and post-partum. Twenty pregnancies were conceived by 12 women carrying ICD devices, 14 of which resulted in live births and none in maternal death. Seven of these women had structural cardiomyopathies and five had channelopathies. No device-related complications were recorded. Twelve shocks (nine transthoracic and three from ICDs) were experienced during pregnancy by two women, one of whom miscarried shortly afterwards at 4 weeks gestation. One stillbirth, three miscarriages and one termination were recorded for women with long QT syndrome, repaired tetralogy of Fallot and repaired Laubry-Pezzi syndrome, respectively. Intrauterine growth restriction, low birth weight, and neonatal hypoglycaemia were recorded in four, three, and five pregnancies, respectively. CONCLUSIONS: Pregnancy had no effect on ICD operation and no evidence was found to link ICD carriage with adverse pregnancy outcomes, although one miscarriage may have been induced by ICD shock therapy. A worsening of cardiac condition occurs in specific cardiac diseases and ß-blocker therapy should be continued for all women carrying ICDs in pregnancy as the benefits outweigh the risks of taking this medication.

Impact of Catheter Ablation of Electrical Storm on Survival: A Propensity Score-Matched Analysis.

BACKGROUND: Electrical storm (ES) is a life-threatening condition, associated with substantial early and subacute mortality. Catheter ablation (CA) is a well-established therapy for ES. However, data regarding the impact of CA on the short-term and midterm survival of patients admitted for ES remain unclear. OBJECTIVES: This multicenter study aimed to investigate the impact of CA of ES on survival outcomes, while accounting for key patient characteristics associated with treatment selection. METHODS: A propensity score-matching (PSM) analysis was performed on 780 consecutive patients admitted for ES in 4 tertiary centers. PSM (1:1) based on the main characteristics associated with the use of CA or medical therapy alone was performed, resulting in 2 groups of 288 patients. RESULTS: After PSM, patients who underwent CA (n = 288) and those treated with medical therapy alone (n = 288) did not present any significant differences in the main demographic characteristics, ES presentation, and management. Compared with medical therapy alone, CA was associated with a significantly lower rate of ES recurrence at 1 year (5% vs 26%; P < 0.001). Similarly, CA was associated with a higher 1-year (91% vs 81%; P < 0.001) and 3-year (78% vs 71%; P = 0.017) survival after discharge. In subgroup analyses, effect of ablation therapy remained consistent in patients older than 70 years of age (HR: 0.39; 95% CI: 0.24-0.66), with substantial efficacy in patients with a LVEF <35% (HR: 0.39; 95% CI: 0.27-0.59). CONCLUSIONS: In propensity-matched analyses, this large study shows that CA-based management of patients admitted for ES is associated with a reduction in mortality compared with medical treatment, particularly in patients with a low ejection fraction.

Management and outcomes of pregnant women with cardiovascular diseases in a cardio-obstetric team.

BACKGROUND: Cardiovascular diseases (CVDs) are currently the leading cause of maternal death in Western countries. Although multidisciplinary cardio-obstetric teams are recommended to improve the management of pregnant women with CVD, data supporting this approach are scarce. AIMS: To describe the characteristics and outcomes of pregnant patients with CVD managed within the cardio-obstetric programme of a tertiary centre. METHODS: We included every pregnant patient with history of CVD managed by our cardio-obstetric team between June 2017 and December 2019, and collected all major cardiovascular events (death, heart failure, acute coronary syndromes, stroke, endocarditis and aortic dissection) that occurred during pregnancy, peripartum and the following year. RESULTS: We included 209 consecutive pregnancies in 202 patients. CVDs were predominantly valvular heart diseases (37.8%), rhythm disorders (26.8%), and adult congenital heart diseases (22.5%). Altogether, 47.4% were classified modified World Health Organization (mWHO)>II, 66.5% had CARdiac disease in PREGnancy score (CARPREG II)≥2 and 80 pregnancies (38.3%) were delivered by caesarean section. Major cardiovascular events occurred in 16 pregnancies (7.7%, 95% confidence interval [CI] 4.5-12.2) during pregnancy and in three others (1.5%, 95% CI 0.3-4.1) during 1-year follow-up. Most events (63.1%) occurred in the 16.3% of patients with unknown CVD before pregnancy. CONCLUSIONS: The management of pregnant patients with CVD within a cardio-obstetric team seems encouraging as we found a relatively low rate of cardiovascular events compared to the high-risk profile of our population. However, most of the remaining events occurred in patients without cardiac monitoring before pregnancy.

[Natural history and outcomes of atrial fibrillation]. / Histoire naturelle et risques evolutifs de la fibrillation atriale.

Atrial fibrillation occurs most of the time without any symptom. The first symptomatic episode may follow many silent episodes. The natural history of atrial fibrillation is relatively chaotic from paroxysmal to persistent and permanent atrial fibrillation. The consequence is that antithrombotic treatment depends on global thromboembolic risk and not on patient's perception of arrhythmia or sinus rhythm presentation. Unfortunately, the first appearance may be the most feared complication: stroke. Stroke due to atrial fibrillation are frequent, severe, with high mortality rate during hospitalization and during the following year. The severity of stroke during atrial fibrillation could explain a certain degree of cognitive decline. Heart failure is also a frequent atrial fibrillation complication due to sharing of common causes. Through those two complications, atrial fibrillation raises mortality rate. Less importantly, though leading to frequent hospitalizations, quality of life impairment is relatively frequent.

Clopidogrel increases bleeding complications in patients undergoing heart rhythm device procedures.

BACKGROUND: Management of antiplatelet therapy at the time of device implantation remains controversial. This study aimed to assess the risk of bleeding complications in patients receiving clopidogrel at the time of cardiac device surgery. METHODS: We performed a retrospective case-control study. Between 2004 and 2010, 101 consecutive patients receiving clopidogrel underwent cardiac device surgery (pacemaker or implantable cardioverter-defibrillator implantation, and generator replacement) in our institution. Controls were 1:1 matched on age, sex, device, type of procedure, number of leads implanted, and venous approach (cephalic or subclavian). A significant bleeding complication was defined as pocket hematoma requiring surgical evacuation or prolonged hospitalization, hemothorax, pericardial effusion, or tamponade. RESULTS: Bleeding complications occurred more frequently in patients receiving clopidogrel at the time of device procedure: 11.9% versus 4.0% (P = 0.037; odds radio [OR] 3.27 [1.02-10.5]). Significant bleeding complications were noted in 12 patients (11.9%) receiving clopidogrel, including two patients with pericardial effusion and one patient with hemothorax. Four controls (4.0%) had bleeding complications (three pocket hematomas and one pericardial effusion). The single factor associated with increased bleeding complications in patients receiving clopidogrel was subclavian puncture (P = 0.008). In the entire cohort (n = 202), multivariate analysis identified two independent predictors of significant bleeding complications: clopidogrel treatment at the time of surgery (P = 0.03; OR 3.7 [1.1-12.6]) and subclavian venous puncture (P = 0.03; OR 3.44 [1.1-10.4]). CONCLUSIONS: Clopidogrel treatment at the time of heart rhythm device procedures is associated with an increased risk of significant bleeding complications. Subclavian puncture seems to strongly increase hemorrhagic complications in this setting.

Basal exit site of clinical ventricular tachycardia is an independent predictor of antitachycardia pacing failure in implantable cardioverter-defibrillators recipients.

BACKGROUND: Little is known about predictors of antitachycardia pacing (ATP) failure in implantable cardioverter defibrillator (ICD) recipients. Distance between the stimulation site and the ventricular tachycardia (VT) site of origin may critically affect ATP effectiveness. We hypothesized that ATP may be less effective in ICD patients who had basal VT than in those who had apical VT. METHODS: We reviewed data from 52 patients with sustained monomorphic VT and left ventricular disease referred for ICD implantation. ATP was delivered exclusively at the right ventricular apex. The clinical VTs site of origin (basal, midventricular, or apical) was determined in each patient, using 12-lead electrocardiogram. VTs episodes treated with ATP during the 1-year follow-up were studied. ATP success rate (%), defined as the ratio between the number of successful ATP sequences and the number of delivered ATP sequences, was determined in each patient. RESULTS: VT exit site was apical in 19 patients (36%), basal in 18 patients (35%), and midventricular in 15 patients (29%). In those 52 patients, 1,393 ATP sequences, delivered to treat 761 VT episodes, were analyzed. ATP success rate was found to be associated with the VT site of origin (median [interquartile range]): basal (33%[11-67]), midventricular (50%[37-100]), apical (100%[41-100]) (P = 0.027). Multivariate analysis identified basal VT site of origin as an independent predictor of ATP failure (P = 0.023). CONCLUSION: ATP is less effective in ICD patients who had basal VT than in those who had apical VT before ICD implantation.

Stereotactic Radioablation for Ventricular Tachycardia in the Setting of Electrical Storm.

BACKGROUND: Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy for treating refractory ventricular tachycardia (VT) despite optimal medical treatment and catheter ablation. However, data on the use of SBRT in patients with electrical storm (ES) is lacking. The aim of this study was to assess the clinical outcomes associated with SBRT in the context of ES. METHODS: This retrospective study included patients who underwent SBRT in the context of ES from March 2020 to March 2021 in one tertiary center (CHU Lille). The target volume was delineated according to a predefined workflow. The efficacy was assessed with the following end points: sustained VT recurrence, VT reduced with antitachycardia pacing, and implantable cardioverter defibrillator shock. RESULTS: Seventeen patients underwent SBRT to treat refractory VT in the context of ES (mean 67±12.8 age, 59% presenting ischemic heart disease, mean left ventricular ejection fraction: 33.7± 9.7%). Five patients presented with ES related to incessant VT. Among these 5 patients, the time to effectiveness ranged from 1 to 7 weeks after SBRT. In the 12 remaining patients, VT recurrences occurred in 7 patients during the first 6 weeks following SBRT. After a median 12.5 (10.5-17.8) months follow-up, a significant reduction of the VT burden was observed beyond 6 weeks (-91% [95% CI, 78-103]), P<0.0001). The incidence of implantable cardioverter defibrillator shock and antitachycardia pacing was 36% at 1 year. CONCLUSIONS: SBRT is associated with a significant reduction of the VT burden in the event of an ES; however, prospective randomized control trials are needed. In patients without incessant VT, recurrences are observed in half of patients during the first 6 weeks. VT tolerance and implantable cardioverter defibrillator programming adjustments should be integrated as part of an action plan defined before SBRT for each patient.

Incidence and predictors of mortality after an electrical storm in the ICU.

AIMS: For assessing predictors of early mortality following hospitalization for electrical storm (ES), only limited data are available. The purpose of this study was to assess the incidence and predictors of early mortality following hospitalization in the intensive care unit (ICU) for ES in a large retrospective study. METHODS AND RESULTS: In this retrospective study, we included all patients who were hospitalized for ES from July 2015 to May 2020 in our tertiary centre. A total of 253 patients were included. The median age was 66 [56; 73], and 64% had ischemic cardiomyopathy. A total of 37% of patients presented hemodynamic instability requiring catecholamine at admission. A total of 17% of patients presented an acute reversible cause for ES. The one-year mortality was 34% (95% CI, 30-43%), mostly driven by heart failure (HF). The multivariable Cox's regression model identified age, left ventricular ejection fraction, right ventricle dysfunction, haemoglobin level as independent predictors of one-year mortality. The use of catecholamine at admission was identified as the only variable related to the initial management of ES associated with an increased 30-day mortality risk (HR: 7.95 (95%CI, 3.18-19.85). CONCLUSION: In patients admitted for ES in ICU, the one-year mortality remains high and mostly driven by HF. The use of catecholamine at admission is associated with a seven-fold risk for mortality within 30 days. In such patients, the potential use of VT ablation can be questioned and a careful action plan regarding invasive HF-related therapy could be considered.

High liver fibrosis scores in metabolic dysfunction-associated fatty liver disease patients are associated with adverse atrial remodeling and atrial fibrillation recurrence following catheter ablation.

Background: A number of epidemiological studies have suggested an association between metabolic dysfunction-associated fatty liver disease (MAFLD) and the incidence of atrial fibrillation (AF). However, the pathogenesis leading to AF in the context of MAFLD remains unclear. We therefore aimed at assessing the impact of MAFLD and liver fibrosis status on left atrium (LA) structure and function. Methods: Patients with a Fatty Liver Index (FLI) >60 and the presence of metabolic comorbidities were classified as MAFLD+. In MAFLD+ patients, liver fibrosis severity was defined using the non-alcoholic fatty liver disease (NAFLD) Fibrosis Score (NFS), as follows: MAFLD w/o fibrosis (NFS ≦ -1.455), MAFLD w/indeterminate fibrosis (-1.455 < NFS < 0.675), and MAFLD w/fibrosis (NFS ≧ 0.675). In the first cohort of patients undergoing AF ablation, the structural and functional impact on LA of MAFLD was assessed by LA strain analysis and endocardial voltage mapping. Histopathological assessment of atrial fibrosis was performed in the second cohort of patients undergoing cardiac surgery. Finally, the impact of MAFLD on AF recurrence following catheter ablation was assessed. Results: In the AF ablation cohort (NoMAFLD n = 123; MAFLD w/o fibrosis n = 37; MAFLD indeterm. fibrosis n = 75; MAFLD w/severe fibrosis n = 10), MAFLD patients with high risk of F3-F4 liver fibrosis presented more LA low-voltage areas as compared to patients without MAFLD (16.5 [10.25; 28] vs 5.0 [1; 11] low-voltage areas p = 0.0115), impaired LA reservoir function assessed by peak left atrial longitudinal strain (19.7% ± 8% vs 8.9% ± 0.89% p = 0.0268), and increased LA volume (52.9 ± 11.7 vs 43.5 ± 18.0 ml/m2 p = 0.0168). Accordingly, among the MAFLD patients, those with a high risk of F3-F4 liver fibrosis presented a higher rate of AF recurrence during follow-up (p = 0.0179). In the cardiac surgery cohort (NoMAFLD n = 12; MAFLD w/o fibrosis n = 5; MAFLD w/fibrosis n = 3), an increase in histopathological atrial fibrosis was observed in MAFLD patients with a high risk of F3-F4 liver fibrosis (p = 0.0206 vs NoMAFLD; p = 0.0595 vs MAFLD w/o fibrosis). Conclusion: In conclusion, we found that liver fibrosis scoring in MAFLD patients is associated with adverse atrial remodeling and AF recurrences following catheter ablation. The impact of the management of MAFLD on LA remodeling and AF ablation outcomes should be assessed in dedicated studies.

Contributions of remote monitoring to the follow-up of implantable cardioverter-defibrillator leads under advisory.

AIMS: Automatic daily transmission of data from implantable cardioverter-defibrillators (ICDs) enables the remote monitoring of device status and leads function. We report on a 2-year experience with remote monitoring in 40 recipients of high-voltage ICD leads, prone to fracture and under advisory since October 2007. METHODS AND RESULTS: The ICDs were remotely monitored as well as systematically interrogated in the ambulatory department every 3 months. The patients were also seen in case of abnormal lead impedance, or other manifestations consistent with lead dysfunction. Over a mean follow-up of 22 ± 4 months after ICD implantation, four lead dysfunctions were suspected because of remotely transmitted oversensing of noise artifacts, abrupt rise in pacing impedance, or both. A lead fracture needing lead replacement was confirmed in three patients (7.5%), two of them before any inappropriate therapy and one after the delivery of three inappropriate shocks. No lead failure was observed in the remaining 36 patients, either at the time of ambulatory visits or during remote monitoring. CONCLUSION: Remote monitoring allowed the early and reliable detection of ICD leads failure without requiring any patient intervention.

Usefulness of remote monitoring for the early detection of back-up mode in implantable cardioverter defibrillators.

BACKGROUND: Reversion of an implantable cardioverter defibrillator (ICD) to back-up mode degrades the operating capabilities of the device, puts patients at risk and requires rapid intervention by a manufacturer's technician. AIM: To illustrate the usefulness of remote monitoring of ICDs for the early detection of reversion to back-up mode. METHODS: In our centre, all patients implanted with an ICD, with or without resynchronisation, were offered remote monitoring as soon as the technology became available. Alerts triggered by the remote monitoring system were included prospectively in a register. During a mean follow-up of 5.7±1.3 years, a total of 1594 patients with an ICD (441 with resynchronisation function) followed with remote monitoring were included in the register. RESULTS: Among 15,874 alerts, only 10 were related to a reversion to back-up mode. Among those, seven reversions were caused by radiotherapy, two were fake events and one was caused by magnetic resonance imaging. Except for the two fake events, the eight other patients had an emergency admission for the resetting and reprogramming of their ICD. None of the reversion to back-up mode alerts was followed by a clinical alert (i.e. a shock alert) before the ICD problem was resolved. CONCLUSIONS: Reversion to back-up mode is a very rare event, accounting for 0.06% of total alerts; remote monitoring facilitates the early detection of this critical event to resolve the problem faster than the next scheduled follow-up. Remote monitoring can prevent serious damage to the patient and avoids systematic ambulatory control of the ICD after each radiotherapy session.