EASI™ 12­lead ECG with a handheld computer refines cardiovascular diagnosis in general practice.

BACKGROUND: Electrocardiogram (ECG) is used to a small extent in general medicine, because of general practitioner (GP) apprehension about interpretation and time consumption. AIM: This study tested the hypothesis that user-friendly EASI ECG improves GP diagnosis of cardiovascular symptoms. METHOD: Patients over 18 years with recent cardiovascular symptoms or auscultation rhythm abnormalities were included in this prospective, multicentric study (10 practices, 17 GPs). ECG recordings were made with Cardiosecur® (4­lead ECG connected to a handheld computer for EASI™ processing). Besides clinical data, diagnosis/patient referral were noted before and after ECG and interpretation. GP diagnosis and ECG interpretation were compared with a reference diagnosis made by ECG specialist. RESULTS: There were 338 patients; 66% had cardiovascular risk factors. ECGs were performed for chest pain (41%), auscultation rhythm abnormalities (33%) or palpitations (19%). Average time to perform ECG was 4.7 ± 2.1 min, with possible home recordings. Compared with standard ECG, improvement provided by Cardiosecur® was scored 9/10 (range 7-10) by GPs. GPs correctly interpreted ECG normality/abnormality in 77% of patients. Diagnosis was correctly changed for 14% of patients thanks to the ECG, and wrongly changed for 2%. One new appropriate final diagnosis was achieved for 9 ECG recordings (p < 0.001). Diagnostic certainty increased 1.9 ± 2.1/10 (p < 0.001). ECG brought about changes in GP decision making: referral or treatment changed for 82 patients (24%) and complementary test for 69 patients (20%). CONCLUSION: The EASI™ algorithm coupled with a handheld computer facilitates ECG recordings in the primary care setting, providing improved diagnosis.

Can permanent His bundle pacing be safely started by operators new to this technique? Data from a multicenter registry.

BACKGROUND: Right ventricular pacing (RVP) induces ventricular asynchrony in patients with normal QRS and increases the risk of heart failure and atrial fibrillation in long term. His bundle pacing (HBP) is a physiological alternative to RVP, and could overcome its drawbacks. Recent studies assessed the feasibility and safety of HBP in expert centers with a vast experience of this technique. These results may not apply to less experienced centers. We aim to evaluate the feasibility and safety of permanent HBP performed by physicians who are new to this technique. METHODS: We included all patients who underwent pacemaker implantation with attempt of HBP in three hospitals between September 2017 and January 2020. Indication for HBP was left to operators' discretion. All the operators were new for HBP. His bundle (HB) electrical parameters were recorded at implant, 3- and 12-month follow-up. RESULTS: HBP was successful in 141 of 170 patients (82.9%); selective HBP was obtained in 96 patients and nonselective HBP in 45. The mean procedure and fluoroscopy durations were 67.0 ± 28.8 min, and 7.3 ± 8.1 min (3.1 ± 4.1 Gy·cm2 ), respectively. The mean HB paced QRS duration was 106 ± 18 ms. The mean HB capture threshold was 1.29 ± 0.77 V and did not increase at 3- and 12-month follow-up. The ventricular lead revision was required in five patients. Our results showed a rapid technical learning allowing a high procedure success rate (89.8%) after 15 procedures. CONCLUSION: HBP performed by operators new to this technique appeared feasible and safe. This should encourage HBP to be performed in patients expected to experience high RVP burden.

Very long-term outcomes after catheter ablation of atrioventricular nodal reentrant tachycardia: How does cryoenergy differ from radiofrequency?

INTRODUCTION: Either cryoenergy or radiofrequency can be used during atrioventricular nodal reentrant tachycardia (AVNRT) ablation. There are still limited data comparing their respective long-term efficacy (>1 year). This study sought to compare the very long-term outcomes of AVNRT ablation using radiofrequency or cryotherapy. METHODS: We retrospectively included all patients who had undergone a first AVNRT ablation in our institution between January 2010 and December 2017. The primary endpoint was recurrence of documented AVNRT. RESULTS: The study population consisted of 409 patients (274 females; mean age, 49.9 years). Ablation was performed using cryoenergy in 260 patients and radiofrequency in 149. High acute procedural success rate (>98%) was obtained and no permanent AV block was observed using both techniques. During a mean follow-up of 3.3 ± 2.3 years, documented AVNRT recurrence occurred in 24 (9.2%) and 4 patients (2.7%) in the cryoablation (CA) and radiofrequency (RF) group, respectively. The risk of AVNRT recurrence was significantly higher in the CA group as compared with the RF group (hazard ratio [HR] = 3.7; 95% confidence interval [CI], 1.3-5.9). Most of the recurrences after CA occurred between 1- and 6-year follow-up (14/24; 58.3%), with one-third of late recurrences after 3-year follow-up. In multivariable analysis, only Koch's triangle anatomical variant was associated with AVNRT recurrence after CA (HR = 6.7; 95% CI, 2.7-16.3). CONCLUSION: While AVNRT recurrence rates were similar at 1 year of follow-up regardless of the energy used, long-term efficacy appeared higher after radiofrequency ablation. Strikingly, recurrences occured much later after cryotherapy compared with radiofrequency ablation.

Periprocedural, early, and long-term risks of pacemaker implantation after atrioventricular nodal re-entry tachycardia ablation: a French nationwide cohort.

AIMS: Pacemaker implantation (PI) after atrioventricular nodal re-entry tachycardia (AVNRT) ablation is a dreadful complication. We aimed to assess periprocedural, early, and late risks for PI. METHODS AND RESULTS: All 27 022 patients who underwent latest AVNRT ablation in France from 2009 to 2017, were identified in the nationwide medicalization database. A control group of 305 152 patients hospitalized for arm, leg, or skin injuries with no history of AVNRT or supraventricular tachycardia were selected. After propensity score matching, both groups had mean age of 53 ± 18 years and were predominantly female (64%). During this 9-year period, 822 of 27 022 (3.0%) AVNRT patients underwent PI, with significant higher risk in propensity-matched AVNRT patients compared to propensity-matched controls [2.9% vs. 0.9%; hazard ratio 3.4 (2.9-3.9), P < 0.0001]. This excess risk was significant during all follow-up, including periprocedural (1st month), early (1-6 months), and late (>6 months) risk periods. Annualized late risk per 100 AVNRT patients was 0.2%. In comparison to controls, excess risk was 0.2% in <30-year-old AVNRT patients; 0.7% in 30-50-year-old; 1.1% in 50-70-year-old and 6.5% over 70-year-olds. Risk for PI was also significantly different according to three procedural factors: centres, experience, and ablation date, with a 30% decrease since 2015. CONCLUSION: Periprocedural, early, and late risks for PI were higher after AVNRT ablation compared to propensity-matched controls. Longer follow-up is needed as the excess risk seems to persist late after AVNRT ablation.

Pacemaker memory in post-TAVI patients: Who should benefit from permanent pacemaker implantation?

BACKGROUND: One of the most frequent complications of transcatheter aortic valve implantation (TAVI) is the occurrence of atrioventricular (AV) conduction disorders secondary to AV node or His bundle injury leading to permanent pacemaker implantation (PPI). The objective was to quantify the rate of ventricular pacing (VP), according to post-TAVI indication for PPI using recorded pacemaker memory. METHODS: From October 2009 to January 2017' all patients who had PPI following TAVI performed at Rouen University Hospital were included. Indications for PPI were: ≥ 1 episode of complete atrioventricular block (CAVB) or 2:1 atrioventricular block, and new-onset persistent left bundle branch block (NOP-LBBB) with either prolonged PR interval (> 200 ms) or HV interval (>70 ms). The primary endpoint was VP percentage at the first pacemaker interrogation (a VP percentage ≥ 1% was considered as significant). RESULTS: Out of 936 TAVI patients (Sapien-3' n = 379 [Edwards Lifesciences, Irvine, CA, USA]; Sapien-XT' n = 513; CoreValve' n = 44, Medtronic, Minneapolis, MN, USA), 87 (9.3%) had PPI. Eighty of these 87 patients were followed-up and analyzed. At the first pacemaker interrogation, a significant VP percentage was observed in 60/80 followed-up patients (75%), in 46/51 patients (90.2%) implanted for CAVB, and 12/23 patients (52.2%) implanted for NOP-LBBB associated with either prolonged PR or HV interval. No clinical predictive factor of significant VP percentage was found. CONCLUSION: In the post-TAVI period, our data support PPI in patients with CAVB even if paroxysmal. Our data also suggest PPI may be considered in patients with NOP-LBBB associated with either prolonged PR or HV interval.

Defining the pattern of initiation of monomorphic ventricular tachycardia using the beat-to-beat intervals recorded on implantable cardioverter defibrillators from the RAFT study: A computer-based algorithm.

Arrhythmia onset pattern may have important implications on morbidity, recurrent implantable cardioverter defibrillator (ICD) shocks, and mortality, given the proposed correlation between initiation pattern and arrhythmia mechanism. Therefore, we developed and tested a computer-based algorithm to differentiate the pattern of initiation based on the beat-to-beat intervals of the ventricular tachycardia (VT) episodes in ICD recordings from the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT). Intervals on intracardiac electrograms from ICDs were analyzed backwards starting from the marker of VT detection, comparing each interval with the average tachycardia cycle length. If the morphology of the beat initiating the VT was similar to the morphology of the VT itself, the episode was considered sudden. If the morphology of the beat initiating the VT was not similar to the morphology of the VT itself, the episode was considered non-sudden. The capability of the algorithm to classify the pattern of initiation based only on the beat-to-beat intervals allows for the classification and analysis of large datasets to further investigate the clinical importance of classifying VT initiation. If analysis of the VT initiation proves to be of clinical value, this algorithm could potentially be integrated into ICD software, which would make it easily accessible and potentially helpful in clinical decision-making.

RVOT premature ventricular contractions induce significant anatomical displacement during 3D mapping: A cause of mid-term ablation failure?

BACKGROUND: Catheter ablation is a first-line treatment for symptomatic right ventricular outflow tract (RVOT) premature ventricular complexes (PVCs). There is evidence of displacement of the ablation target site during PVCs relative to the location in sinus rhythm (SR). AIM: To analyse the extent of displacement induced by RVOT PVCs and its effect on the ablation sites and the mid-term efficacy of ablation. METHODS: In this multicentre French study, we retrospectively included 18 consecutive adults referred for ablation of RVOT PVCs using a three-dimensional (3D) mapping system. PVC activation maps were performed conventionally (initial map), then each PVC activation point was manually reannotated considering the 3D location on a previous SR beat (corrected map). The ablation-site locations on the initial or the corrected area, including the 10 best activation points, were analysed. Mid-term efficacy was evaluated. RESULTS: The direction of map shift during PVCs relative to the map in SR occurred along a vertical axis in 16 of 18 patients. The mean activation-point displacement for each of the 18 mapped chambers was 5.6±2.2mm. Mid-term recurrence of RVOT PVCs occurred in 5 (28%) patients. In all patients with recurrences, no significant ablation lesion was located on the corrected (true) site of origin. CONCLUSIONS: RVOT PVCs induce a vertical anatomical shift that can mislead physicians about the true location of the arrhythmia's site of origin. Our study highlights the association between mid-term PVC recurrence and the absence of spatial overlap between ablation points and the corrected site of origin.

His-bundle pacing and atrioventricular nodal ablation for noncontrolled atrial arrhythmia: A technical challenge with major clinical benefits.

BACKGROUND: His-bundle pacing (HBP) is an appealing alternative to right ventricular pacing in patients referred for permanent ventricular pacing and atrioventricular nodal ablation (AVNA) because it preserves physiological ventricular activation. Only limited data regarding HBP combined with AVNA are available in the literature. OBJECTIVE: The purpose of this study was to provide further evidence on the feasibility and efficacy of this therapeutic approach in patients with uncontrolled atrial arrhythmia. METHODS: We prospectively included all patients who had undergone AVNA after HBP in 3 different hospitals between 2017 and 2022. RESULTS: AVNA following HBP lead implantation was performed in 75 patients. Complete atrioventricular (AV) block was obtained in 58 patients (77%), and significant modulation of AV nodal conduction (heart rate <60 bpm) was obtained in 12 patients (16%). AVNA failure was observed in 5 patients (7%). Recording of an atrial signal by the HBP lead was more frequently observed in patients with AVNA modulation/failure than in patients with complete AV block (11/17 vs 5/58; P <.001). No lead dislodgment occurred during the AVNA procedures. Acute His-bundle (HB) capture threshold increase >1 V occurred in 11 patients (15%), with return to baseline value on day 1 in 9 patients. New York Heart Association functional class and left ventricular ejection fraction significantly improved from baseline to last follow-up (3.0 ± 0.7 vs 1.6 ± 0.5; P <.001; and 47% ± 14% vs 60% ± 9%; P <.0001, respectively). CONCLUSION: AVNA combined with HBP for noncontrolled atrial arrhythmia was feasible and clinically efficient. Implanting the HB lead on the ventricular aspect of the tricuspid annulus avoiding atrial signal recording can facilitate AVNA.

Clinical Significance of Global Wasted Work in Patients with Heart Failure Receiving Cardiac Resynchronization Therapy.

BACKGROUND: The relationship between myocardial work assessment using pressure-strain loops by echocardiography before cardiac resynchronization therapy (CRT) and response to CRT has been recently revealed. Among myocardial work parameters, the impact of left ventricular myocardial global wasted work (GWW) on response to CRT and outcome following CRT has been seldom studied. Hence, the authors evaluated the relationship between preprocedural GWW and outcome in a large prospective cohort of patients with heart failure (HF) and reduced ejection fraction receiving CRT. METHODS: The study included 249 patients with HF. Myocardial work indices including GWW were calculated using speckle-tracking strain two-dimensional echocardiography using pressure-strain loops. End points of the study were (1) response to CRT, defined as left ventricular reverse remodeling and/or absence of hospitalization for HF, and (2) all-cause death during follow-up. RESULTS: Median follow-up duration was 48 months (interquartile range, 43-54 months). Median preoperative GWW was 281 mm Hg% (interquartile range, 184-388 mm Hg%). Preoperative GWW was associated with CRT response (area under the curve, 0.74; P < .0001), and a 200 mm Hg% threshold discriminated CRT nonresponders from responders with 85% specificity and 50% sensitivity, even after adjustment for known predictors of CRT response (adjusted odds ratio, 4.03; 95% CI, 1.91-8.68; P < .001). After adjustment for established predictors of outcome in patients with HF with reduced ejection fraction receiving CRT, GWW < 200 mm Hg% remained associated with a relative increased risk for all-cause death compared with GWW ≥ 200 mm Hg% (adjusted hazard ratio, 2.0; 95% CI, 1.1-3.9; P = .0245). Adding GWW to a baseline model including known predictors of outcome in CRT resulted in an improvement of this model (χ2 to improve 4.85, P = .028). The relationship between GWW and CRT response and outcome was stronger in terms of size effect and statistical significance than for other myocardial work indices. CONCLUSIONS: Low preoperative GWW (<200 mm Hg%) is associated with absence of CRT response in CRT candidates and with a relative increased risk for all-cause death. GWW appears to be a promising parameter to improve selection for CRT of patients with HF with reduced ejection fraction.

Acute correction of electromechanical dyssynchrony and response to cardiac resynchronization therapy.

AIMS: Echocardiographic measures of dyssynchrony at baseline have not demonstrated a good ability to predict response to cardiac resynchronization therapy (CRT). The purpose of this study was to determine if the acute correction of electromechanical dyssynchrony, assessed by the change in simple pulsed-Doppler measures, was related to CRT response at 6 months. METHODS AND RESULTS: Echocardiography was performed at baseline and at pre-discharge after CRT implantation. Intraventricular, interventricular, and atrioventricular dyssynchrony were evaluated by the left pre-ejection interval (LPEI), the interventricular mechanical delay, and the ratio of left ventricular filling time to RR interval, respectivelxy. A patient was considered responder if he/she was alive without hospitalization for heart failure and had an absolute increase of left ventricular ejection fraction (LVEF) >5 points. Forty-eight patients (mean age 67 ± 11 years, 73% male, mean LVEF 30 ± 5%) were included. CRT led to an acute correction of intraventricular and interventricular dyssynchrony but not to an acute correction of atrioventricular dyssynchrony. There were 31 (65%) responders at 6 months. Two factors were independently associated with CRT response in multivariate analysis: ischemic cardiomyopathy (odds ratio 0.19, 95% confidence interval 0.04-0.87; P= 0.032) and delta LPEI (odds ratio 1.03 per 1 ms decrease, 95% confidence interval 1.01-1.05; P = 0.007). By receiver operating characteristic analysis, the optimal cut-off value of delta LPEI was -16 ms. The proportion of responders in patients without ischemic cardiomyopathy and with a delta LPEI greater than -16 ms was 85%. CONCLUSIONS: Acute correction of intraventricular electromechanical dyssynchrony evaluated by the LPEI predicted CRT response at 6 months.

Epicardial fat thickness predicts atrial fibrillation recurrence after a first pulmonary vein isolation procedure using a second-generation cryoballoon.

BACKGROUND: Atrial fibrillation is the most common arrhythmia in adults. A relationship between epicardial adipose tissue and atrial fibrillation has recently been reported. AIM: To evaluate the impact of epicardial fat thickness on the outcome of patients who underwent a first pulmonary vein isolation procedure using a second-generation cryoballoon. METHODS: From February 2012 to February 2017, all patients who underwent a first pulmonary vein isolation procedure using a second-generation cryoballoon at Rouen University Hospital were included. Data were collected retrospectively. Epicardial fat thickness was assessed by cardiac magnetic resonance imaging. The primary endpoint was documented atrial fibrillation recurrence at 4 months. RESULTS: A first pulmonary vein isolation procedure using a second-generation cryoballoon was performed in 288 patients; among them, 231 patients (80.2%) underwent cardiac magnetic resonance imaging. Epicardial fat thickness could be measured accurately in 206 patients (71.5%). Recurrence of atrial fibrillation at 4 months occurred in 32/206 patients (15.5%). In the multivariable analysis, factors predictive of atrial fibrillation recurrence at 4 months were: epicardial fat thickness (hazard ratio 1.96, 95% confidence interval 1.20-3.18; P=0.007), the presence of high left atrium enlargement (hazard ratio 4.63, 95% confidence interval 1.17-18.38; P=0.03) and atrial fibrillation recurrence before hospital discharge (hazard ratio 7.55, 95% confidence interval 2.50-22.81; P<0.001). CONCLUSION: Epicardial fat thickness is a predictive factor for atrial fibrillation recurrence after a first pulmonary vein isolation procedure using a second-generation cryoballoon.

Pattern of initiation of monomorphic ventricular tachycardia and implications on tachycardia mechanism.

The incidence of sudden cardiac death, predominantly caused by ventricular tachycardia and ventricular fibrillation, is high in patients with congestive heart failure. Implantable cardiac defibrillators have improved survival in this population but defibrillator shocks can lead to low quality of life and heart failure progression. The current management of recurrent ventricular tachycardia includes ablation and anti-arrhythmic drugs and both are associated with high recurrence rates. Better understanding the mechanism of ventricular tachycardia allowing individualization of treatment may improve outcomes. Re-entry is currently accepted as the mechanism of the majority of monomorphic ventricular tachycardias in patients with congestive heart failure, being responsible for more than 90% of the ventricular tachycardia in patients with ischemic cardiomyopathy. On the other hand, some studies show a greater participation of focal arrhythmias in the genesis of ventricular tachycardia in this population. The pattern of initiation of ventricular tachycardia is divided into sudden, when the first beat of the tachycardia is morphologically similar to the rest of the tachycardia, and non-sudden, when its morphology is dissimilar. An association between the pattern of the initiation and the mechanism of ventricular tachycardia has been proposed. The pattern of initiation of ventricular tachycardia is a readily available from data stored in current generation implantable cardiac defibrillators. The association with tachycardia mechanism may allow individualization of the therapy, however evidence is lacking and further research is required.

Trends over the past 4 years in population characteristics, 30-day outcomes and 1-year survival in patients treated with transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is recommended in patients with severe aortic stenosis that is either inoperable or at high-risk for surgical valve replacement. AIMS: To evaluate trends in the feasibility and safety of transfemoral TAVI over the past 4 years. METHODS: Between 2010 and 2013, all consecutive patients undergoing TAVI in our institution were included in a prospective registry. Population characteristics and 30-day and 1-year outcomes were analysed. Outcomes were classified according to the Valve Academic Research Consortium-2. RESULTS: Overall, 429 patients underwent TAVI; transfemoral access was used in 368 (85.7%). The proportion of patients treated via a transfemoral approach increased (70.1% to 89.9%; P<0.0001) and the use of prior balloon aortic valvuloplasty decreased (44.7% to 11.2%; P<0.0001). The mean logistic EuroSCORE decreased significantly from 19.4±10.9% to 15.8±8.7% (P=0.01). The 30-day mortality rate did not change significantly (6.4% vs. 5.6%; P=0.99). Similarly, rates of major vascular complications (12.8% vs. 15.4%; P=0.87) and stroke (2.1% vs. 1.4%; P=0.75) remained unchanged. Mean length of stay after TAVI decreased significantly from 8.9±11.3 days to 4.8±4.7 days (P=0.002) and 72 (50.3%) patients were discharged early in 2013. One-year survival increased significantly from 81.0% to 94.4% (P=0.03). CONCLUSIONS: Over the past 4 years, TAVI has been increasingly performed using a transfemoral approach. Treated patients are at lower-risk with less co-morbidity. Thirty-day mortality and complications remained unchanged, but length of stay after TAVI and 1-year mortality decreased dramatically.