Catheter ablation of atrial arrhythmias in cardiac amyloidosis: Impact on heart failure and mortality

BACKGROUND

Atrial arrhythmias (AA) commonly affect patients with cardiac amyloidosis (CA) and are a contributing risk factor for the development of heart failure (HF). This study sought to investigate the long-term efficacy and impact of catheter ablation on HF progression in patients with CA and AA.

METHODS

Thirty-one patients with CA and AA undergoing catheter ablation were retrospectively included (transthyretin-ATTR CA 61% and light chain-AL CA 39%). AA subtypes included atrial fibrillation (AFib) in 22 (paroxysmal in 10 and persistent in 12), atrial flutter (AFl) in 17 and atrial tachycardia (AT) in 11 patients. Long-term AA recurrence rates were evaluated along with the impact of sinus rhythm (SR) maintenance on HF and mortality.

RESULTS

AA recurrence was observed in 14 patients (45%) at a median of 3.5 months (AFib n = 8, AT n = 6, AFl = 0). Post-cardioversion, medical therapy or catheter ablation, 10 patients (32%) remained in permanent AA. Over a median follow-up of 19 months, all-cause mortality was 39% (n = 12): 3 with end-stage HF, 5 due to late complications of CA, 1 sudden cardiac death, 1 stroke, 1 COVID 19 (and one unknown). With maintenance of SR following catheter ablation, significant reductions in serum creatinine and natriuretic peptide levels were observed with improvements in NYHA class. Two patients required hospitalization for HF in the SR maintenance cohort compared to 5 patients in the AA recurrence cohort (p = 0.1). All 3 patients with deaths secondary to HF had AA recurrence compared to 11 out of the 28 patients whom were long-term survivors or deaths not related to HF (p = 0.04). All-cause mortality was not associated with AA recurrence.

CONCLUSION

This study demonstrates moderate long-term efficacy of SR maintenance with catheter ablation for AA in patients with CA. Improvements in clinical and biological status with positive trends in HF mortality are observed if SR can be maintained.

The real incidence of sudden death: Fair estimations or futile speculations?

BACKGROUND

The true incidence of sudden death remains undetermined, with controversial results from various publications over time and countries.

AIM

To investigate if different estimations would reach the values usually reported for France.

METHODS

Three different kinds of estimations were used. First, the number of resuscitated sudden deaths and necropsies for sudden death in the Haute-Garonne French administrative department (i.e. county) over the last 10years was expanded to the national level. Second, sudden death coding of death certificates was collected at the national level. Third, the total number of out-of-hospital cardiac arrests leading to any emergency call (with/without intervention) in Haute-Garonne over the last 10years was expanded to the national level.

RESULTS

There was a mean of 26 resuscitated sudden deaths and 145 necropsies for sudden death each year in Haute-Garonne, i.e. 12 to 14 sudden deaths for 100,000 inhabitants, and 7700 to 9400 sudden deaths yearly when related to the whole French population, according to the year of inclusion. Based on death certificates, a mean of 6584 sudden deaths was registered each year in France. Finally, there were about 600 yearly calls/interventions for out-of-hospital cardiac arrests in Haute-Garonne, i.e. 40 to 50 sudden deaths for 100,000 inhabitants, and 16,000 to 27,000 sudden deaths yearly for the whole French territory, according to the year of inclusion.

CONCLUSIONS

The incidence of sudden death ranges from 6500 to 27,000 in France according to the calculation methods. This huge difference raises the question of the true current incidence of sudden death, which may have been overestimated previously or may be underestimated in France. More straight prospective surveys are needed to solve this question, because of relevant implications for priorities that should be given to sudden death.

Prospective 1-year results of atrial fibrillation ablation using the pentaspline pulsed field ablation catheter: The initial French experience

BACKGROUND

Pulsed field ablation has recently emerged as an interesting non-thermal energy for atrial fibrillation ablation. At a time of rapid spread of this technology, there is still a lack of prospective real-life data.

AIM

To describe multicentre prospective safety and 1-year efficacy data in three of the first French centres to use pulsed field ablation.

METHODS

All consecutive patients undergoing a first pulsed field ablation were included prospectively. The primary outcome was freedom from documented atrial arrhythmia. The safety endpoint was a composite of major adverse events. Univariate and multivariable analyses, including patient and procedural characteristics, were performed to identify factors predictive of recurrence.

RESULTS

Between May 2021 and June 2022, 311 patients were included (paroxysmal atrial fibrillation in 53%, persistent atrial fibrillation in 35% and long-standing persistent atrial fibrillation in 11%). Additional non-pulmonary vein pulsed field ablation applications were performed in 104/311 patients. One-year freedom from arrhythmia recurrence was 77.6% in the overall population and was significantly higher in patients with paroxysmal atrial fibrillation (88.4%) compared with patients with persistent atrial fibrillation (69.7%; P<0.001) and those with long-standing persistent atrial fibrillation (49.0%; P<0.001). The major complication rate was 2.6% (tamponade in four patients, stroke in two patients and coronary spasm in one patient). Besides the usual predictors of recurrences (left atrium size, CHA2DS2-VASc score, type of atrial fibrillation), the presence of atrial fibrillation at procedure start was independently associated with arrhythmia recurrence (hazard ratio: 2.04, 95% confidence interval: 1.10-3.77).

CONCLUSION

In this prospective multicentre real-world study, pulsed field ablation for atrial fibrillation ablation seems to be associated with a good safety profile and rather favourable acute and 1-year success rates.

Impact of Left Atrial Posterior Wall Ablation During Pulsed-Field Ablation for Persistent Atrial Fibrillation

BACKGROUND

Pulmonary vein isolation (PVI) alone is insufficient to treat many patients with persistent atrial fibrillation (PersAF). Adjunctive left atrial posterior wall (LAPW) ablation with thermal technologies has revealed lack of efficacy, perhaps limited by the difficulty in achieving lesion durability amid concerns of esophageal injury.

OBJECTIVES

This study aims to compare the safety and effectiveness of PVI + LAPW ablation vs PVI in patients with PersAF using pulsed-field ablation (PFA).

METHODS

In a retrospective analysis of the MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-approval Clinical Use of Pulsed Field Ablation) registry, we studied consecutive PersAF patients undergoing post-approval treatment with a pentaspline PFA catheter. The primary effectiveness outcome was freedom from any atrial arrhythmia of ≥30 seconds. Safety outcomes included the composite of acute and chronic major adverse events.

RESULTS

Of the 547 patients with PersAF who underwent PFA, 131 (24%) received adjunctive LAPW ablation. Compared to PVI-alone, patients receiving adjunctive LAPW ablation were younger (65 vs 67 years of age, P = 0.08), had a lower CHA2DS2-VASc score (2.3 ± 1.6 vs 2.6 ± 1.6, P = 0.08), and were more likely to receive electroanatomical mapping (48.1% vs 39.0%, P = 0.07) and intracardiac echocardiography imaging (46.1% vs 17.1%, P < 0.001). The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmias was not statistically different between groups in the full (PVI + LAPW: 66.4%; 95% CI: 57.6%-74.4% vs PVI: 73.1%; 95% CI: 68.5%-77.2%; P = 0.68) and propensity-matched cohorts (PVI + LAPW: 71.7% vs PVI: 68.5%; P = 0.34). There was also no significant difference in major adverse events between the groups (2.2% vs 1.4%, respectively, P = 0.51).

CONCLUSIONS

In patients with PersAF undergoing PFA, as compared to PVI-alone, adjunctive LAPW ablation did not improve freedom from atrial arrhythmia at 12 months.

Systematic use of half normal saline during ablation of ventricular tachycardia in structural heart disease

BACKGROUND

Efficiency and safety of ablation using half normal saline (HNS) has been shown in refractory ventricular tachycardia (VT), but no evaluation in unselected larger populations has been made.

OBJECTIVE

To evaluate the efficiency and safety of systematic HNS ablation in VT ablation.

METHODS

All successive VT ablations in patients with structural heart disease from 2018 to 2021 used HNS in our center and were retrospectively included.

RESULTS

One hundred seventy-seven successive VT ablation procedures using HNS have been performed in 148 patients (91% males, mean 64 ± 12 years, ischemic cardiomyopathy 64%, left ventricular ejection fraction 38 ± 13%). A mean of 19 ± 7.5 min of RF was delivered, with a mean power of 44 ± 7 W. Relevant complications happened in 9% (strokes 2%, tamponades 3%, atrioventricular block during septal ablations 5%). Over a mean follow-up of 15 ± 9 months, VT recurred in 46%. Final recurrence rate after one or several procedures was 36% (18 months follow-up). Number of VT episodes decreased from 14 ± 35 before to 2.5 ± 10 after ablation (p < .0001) and number of ICD shocks decreased from 4.8 ± 6.8 to 1.5 ± 0.8 (p = .027).

CONCLUSION

Systematic use of HNS during VT ablations in patients with structural heart disease leads to long-term recurrences rates and complications in the range of what is reported using normal saline. Although controlled studies are needed for demonstrating the superiority of such attitude, the use of HNS in every scar-related VT ablation seems safe for standard cases and may be furthermore useful in case of refractory arrhythmias due to difficult-to-ablate substrates.

Clinical Outcomes by Sex After Pulsed Field Ablation of Atrial Fibrillation

Importance

Previous studies evaluating the association of patient sex with clinical outcomes using conventional thermal ablative modalities for atrial fibrillation (AF) such as radiofrequency or cryoablation are controversial due to mixed results. Pulsed field ablation (PFA) is a novel AF ablation energy modality that has demonstrated preferential myocardial tissue ablation with a unique safety profile.

Objective

To compare sex differences in patients undergoing PFA for AF in the Multinational Survey on the Methods, Efficacy, and Safety on the Postapproval Clinical Use of Pulsed Field Ablation (MANIFEST-PF) registry.

Design, Setting, and Participants

This was a retrospective cohort study of MANIFEST-PF registry data, which included consecutive patients undergoing postregulatory approval treatment with PFA to treat AF between March 2021 and May 2022 with a median follow-up of 1 year. MANIFEST-PF is a multinational, retrospectively analyzed, prospectively enrolled patient-level registry including 24 European centers. The study included all consecutive registry patients (age ≥18 years) who underwent first-ever PFA for paroxysmal or persistent AF.

Exposure

PFA was performed on patients with AF. All patients underwent pulmonary vein isolation and additional ablation, which was performed at the discretion of the operator.

Main Outcomes and Measures

The primary effectiveness outcome was freedom from clinically documented atrial arrhythmia for 30 seconds or longer after a 3-month blanking period. The primary safety outcome was the composite of acute (<7 days postprocedure) and chronic (>7 days) major adverse events (MAEs).

Results

Of 1568 patients (mean [SD] age, 64.5 [11.5] years; 1015 male [64.7%]) with AF who underwent PFA, female patients, as compared with male patients, were older (mean [SD] age, 68 [10] years vs 62 [12] years; P < .001), had more paroxysmal AF (70.2% [388 of 553] vs 62.4% [633 of 1015]; P = .002) but had fewer comorbidities such as coronary disease (9% [38 of 553] vs 15.9% [129 of 1015]; P < .001), heart failure (10.5% [58 of 553] vs 16.6% [168 of 1015]; P = .001), and sleep apnea (4.7% [18 of 553] vs 11.7% [84 of 1015]; P < .001). Pulmonary vein isolation was performed in 99.8% of female (552 of 553) and 98.9% of male (1004 of 1015; P = .90) patients. Additional ablation was performed in 22.4% of female (124 of 553) and 23.1% of male (235 of 1015; P = .79) patients. The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was similar in male and female patients (79.0%; 95% CI, 76.3%-81.5% vs 76.3%; 95% CI, 72.5%-79.8%; P = .28). There was also no significant difference in acute major AEs between groups (male, 1.5% [16 of 1015] vs female, 2.5% [14 of 553]; P = .19).

Conclusion and Relevance

Results of this cohort study suggest that after PFA for AF, there were no significant sex differences in clinical effectiveness or safety events.

Safety and Effectiveness of Pulsed Field Ablation to Treat Atrial Fibrillation: One-Year Outcomes From the MANIFEST-PF Registry

BACKGROUND

Pulsed field ablation is a novel nonthermal cardiac ablation modality using ultra-rapid electrical pulses to cause cell death by a mechanism of irreversible electroporation. Unlike the traditional ablation energy sources, pulsed field ablation has demonstrated significant preferentiality to myocardial tissue ablation, and thus avoids certain thermally mediated complications. However, its safety and effectiveness remain unknown in usual clinical care.

METHODS

MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-Approval Clinical Use of Pulsed Field Ablation) is a retrospective, multinational, patient-level registry wherein patients at each center were prospectively included in their respective center registries. The registry included all patients undergoing postapproval treatment with a multielectrode 5-spline pulsed field ablation catheter to treat atrial fibrillation (AF) between March 1, 2021, and May 30, 2022. The primary effectiveness outcome was freedom from clinical documented atrial arrhythmia (AF/atrial flutter/atrial tachycardia) of ≥30 seconds on the basis of electrocardiographic data after a 3-month blanking period (on or off antiarrhythmic drugs). Safety outcomes included the composite of acute (<7 days postprocedure) and latent (>7 days) major adverse events.

RESULTS

At 24 European centers (77 operators) pulsed field ablation was performed in 1568 patients with AF: age 64.5±11.5 years, female 35%, paroxysmal/persistent AF 65%/32%, CHA₂DS₂-VASc 2.2±1.6, median left ventricular ejection fraction 60%, and left atrial diameter 42 mm. Pulmonary vein isolation was achieved in 99.2% of patients. After a median (interquartile range) follow-up of 367 (289-421) days, the 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was 78.1% (95% CI, 76.0%-80.0%); clinical effectiveness was more common in patients with paroxysmal AF versus persistent AF (81.6% versus 71.5%; P=0.001). Acute major adverse events occurred in 1.9% of patients.

CONCLUSIONS

In this large observational registry of the postapproval clinical use of pulsed field technology to treat AF, catheter ablation using pulsed field energy was clinically effective in 78% of patients with AF.

Correlations Between Endocardial Voltage Mapping, Diagnosis, and Genetics in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy

The relations between endocardial voltage mapping and the genetic background of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) have not been investigated so far. A total of 97 patients with proved or suspected ARVC who underwent 3-dimensional endocardial mapping and genetic testing have been retrospectively included. Presence, localization, and size of scar areas were correlated to ARVC diagnosis and the presence of a pathogenic variant. A total of 78 patients (80%) presented with some bipolar or unipolar scar on endocardial voltage mapping, whereas 43 carried pathogenic variants (44%). Significant associations were observed between presence of endocardial scars on voltage mapping and previous or inducible ventricular tachycardia, right ventricular function and dimensions, or electrocardiogram features of ARVC. A total of 60 of the 78 patients (77%) with an endocardial scar fulfilled the criteria for a definitive arrhythmogenic right ventricular dysplasia diagnosis versus 8 of 19 patients (42%) without scar (p = 0.003). Patients with a definitive diagnosis of ARVC had more scars from any location and the scars were larger in patients with ARVC. In the 68 patients with a definitive diagnosis of ARVC, the presence of any endocardial scar was similar whether an ARVC-causal mutation was present or not. Only scar extent was significantly greater in patients with pathogenic variants. There was no difference in the presence and characteristics of scars in PKP2 mutated versus other mutated patients. The 3-dimensional endocardial mapping could have an important role for refining ARVC diagnosis and may be able to detect minor forms with otherwise insufficient criteria for diagnosis. The trend for larger scar extent were observed in mutated patients, without any difference according to the mutated genes.

Hemodynamical consequences and tolerance of sustained ventricular tachycardia

AIMS

Factors underlying clinical tolerance and hemodynamic consequences of monomorphic sustained ventricular tachycardia (VT) need to be clarified.

METHODS

Intra-arterial pressures (IAP) during VT were collected in patients admitted for VT ablation and correlated to clinical, ECG and baseline echocardiographical parameters.

RESULTS

114 VTs from 58 patients were included (median 67 years old, 81% ischemic heart disease, median left ventricular ejection fraction 30%). 61 VTs were untolerated needing immediate termination (54%). VT tolerance was tightly linked to the evolution of IAPs. Faster VT rates (p<0.0001), presence of resynchronization therapy (p = 0.008), previous anterior myocardial infarction (p = 0.009) and more marginally larger baseline QRS duration (p = 0.1) were independently associated with VT tolerance. Only an inferior myocardial infarction was more often present in patients with only tolerated VTs vs patients with only untolerated VTs in multivariate analysis (OR 3.7, 95% CI 1.4-1000, p = 0.03). In patients with both well-tolerated and untolerated VTs, a higher VT rate was the only variable independently associated with untolerated VT (p = 0.02). Two different patterns of hemodynamic profiles during VT could be observed: a regular 1:1 relationship between electrical (QRS) and mechanical (IAP) events or some dissociation between both. VT with the second pattern were more often untolerated compared to the first pattern (78% vs 29%, p<0.0001).

CONCLUSION

This study helps to explain the large variability in clinical tolerance during VT, which is clearly related to IAP. VT tolerance may be linked to resynchronization therapy, VT rate, baseline QRS duration and location of myocardial infarction.

Externalized Reusable Permanent Pacemaker for Prolonged Temporary Cardiac Pacing in Critical Cardiac Care Units: An Observational Monocentric Retrospective Study

INTRODUCTION

The use of temporary cardiac pacing is frequent in critical care units for severe bradycardia or electrical storm, but may be associated with frequent and potentially severe complications, especially when indwelling for several days. In some cases, transient indication or ongoing contraindication for a permanent pacemaker justifies prolonged temporary pacing. In that case, the implantation of an active-fixation lead connected to an externalized pacemaker represents a valuable option to increase safety and patient comfort. Yet, evidence remains scarce. We aimed to describe the population receiving prolonged temporary cardiac pacing (PTCP) and their outcomes.

METHODS

We retrospectively included all consecutive patients, admitted to our hospital from 2016 to 2021, who underwent PTCP. We collected in-hospital and six-month outcomes.

RESULTS

Forty-six patients (median age of 73, 63% male) were included, and twenty-nine (63%) had prior heart disease. Indications for PTCP were found: seventeen (37%) potentially reversible high-grade conduction disorders, fourteen (30%) indications for permanent pacemaker but ongoing infection, seven (15%) cardiac implantable electronic device infections requiring extraction in pacing-dependent patients, seven (15%) severe vagal hyperreactivity in prolonged critical care hospitalizations, and one (2%) recurrent sustained ventricular tachycardia requiring overdrive pacing. The median PTCP duration was nine (5-13) days. Ten (22%) patients exhibited at least one complication during hospitalization. Twenty-six (56.5%) patients required definite device implantation (twenty-five pacemakers and one cardioverter-defibrillator) and twenty (43.5%) did not (fifteen PTCP device removal for recovery and five deaths under PTCP). At six months, two (5%) deaths and two (5%) new infections of a definite implanted device occurred, all in patients with initial active infection.

CONCLUSION

The use of prolonged temporary cardiac pacing, with an active -fixation lead connected to an externalized pacemaker, is possible and reasonable; this would allow for the possible recovery or resolution of contraindication for definite device implantation.

Phase analysis for ventricular arrhythmia prediction: A retrospective monocentric cohort study

BACKGROUND

Prediction of ventricular arrhythmias (VA) mostly relies on left ventricular ejection fraction (LVEF), but with limited performance. New echocardiographic parameters such as mechanical dispersion have emerged, but acoustic window sometimes precludes this measurement. Nuclear imaging may be an alternative. We aimed to assess the ability of mechanical dispersion, measured with phase standard deviation (PSD) on radionuclide angiocardiography (RNA), to predict VAs.

METHODS

This retrospective monocentric observational study included all patients who underwent a tomographic RNA from 2015 to 2019. Phase analysis yielded PSD and follow-up was examined to identify VAs, heart transplantation, and death.

RESULTS

The study population consisted of 937 patients, mainly with LVEF ≤ 35% (425, 45%). Most had ischemic (334, 36%) or dilated cardiomyopathies (245, 26%). We identified 86 (9%) VAs. PSD was strongly associated with the occurrence of VA [hazard ratio per 10 ms increase (HR10) 1.12 (1.09-1.16)], heart transplantation [HR10 1.09 (1.06-1.12)], and death [HR10 1.03 (1.00-1.05)]. The association between PSD and VA persisted after adjustment for age, sex, QRS duration, LVEF, global longitudinal strain (GLS), and echocardiography-assessed mechanical dispersion.

CONCLUSION

The occurrence of ventricular arrhythmias was predicted by mechanical dispersion assessed by RNA, even after adjustment for LVEF and GLS.

Correlations between endocardial voltage mapping, diagnosis and genetic in patients with arrhythmogenic right ventricular cardiomyopathy

Background

The relations between voltage mapping and diagnosis or genetic background of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) have not been investigated so far.

Objective

To investigate if diagnosis or genetic background were linked to voltage mapping in ARVC.

Method

97 patients with proved or suspected ARVC undergoing 3D endocardial mapping and genetic testing have been retrospectively included. Presence, localisation and extension of low voltage areas were correlated to ARVC diagnosis and presence of a culprit mutation.

Results

68 patients (70%) fulfilled ARVC diagnosis according to the Task Force criteria and 43 (44%) had ARVC-causal mutations. 78 (80%) presented with some bipolar or unipolar endocardial scar. 60/ 78 patients with endocardial scar (77%) fulfilled the criteria for a definitive ARVC diagnosis versus 8/19 patients without scar (42%) (p=0.003).

In the 68 patients with a definitive diagnosis of ARVC, the presence of endocardial scar was similar whether an ARVC-causal mutation was present or not (35/40 vs 25/28, p=ns). While there was slightly more infero-lateral scars in patients carrying a pathogenic genetic variant (34/40 vs 18/28, p=0.04), there was no difference for right ventricular outflow tract (24/40 vs 17/28) and apical scars (12/40 vs 11/28) or for multiple scars (26/35 vs 14/25 patients with scars). Scar extension was greater in patients with pathogenic variants (bipolar 12±10 vs 6±10%, p=0.02, and unipolar 22±13 vs 12±15%, p=0.01).

Conclusion

3D endocardial mapping could have an important role for refining ARVC diagnosis. Trends for larger and more infero-lateral scars were observed in mutated patients, without difference according to the mutated genes.

Funding Acknowledgement

Type of funding sources: None.

Ventricular tachycardia ablation as an alternative to implantable cardioverter-defibrillators in patients with preserved ejection fraction: current status and future prospects

INTRODUCTION

The occurrence of a sustained monomorphic ventricular tachycardia in patients with structural heart disease is a class 1 indication for ICD because of the expected relevant risk of sudden death. However, if this concerns selected patients with preserved left ventricular function and well-tolerated arrhythmias is still poorly known.

AREAS COVERED

In this article, we review the available data about the natural history of nonimplanted patients with structural heart disease and sustained ventricular tachycardia and the possible role of catheter ablation alone in this population.

EXPERT OPINION

In structural heart disease patients with well-tolerated sustained ventricular tachycardia and preserved LVEF, catheter ablation alone, without ICD implantation, does not seem to carry an important risk of sudden death and the prognosis of these patients is mainly nonarrhythmic. Randomized prospective trials are urgently needed for evaluating the place of first choice ablation without ICD implantation in these populations.

Multi-national survey on the methods, efficacy, and safety on the post-approval clinical use of pulsed field ablation (MANIFEST-PF)

AIMS

Pulsed field ablation (PFA) is a novel atrial fibrillation (AF) ablation modality that has demonstrated preferential tissue ablation, including no oesophageal damage, in first-in-human clinical trials. In the MANIFEST-PF survey, we investigated the 'real world' performance of the only approved PFA catheter, including acute effectiveness and safety-in particular, rare oesophageal effects and other unforeseen PFA-related complications.

METHODS AND RESULTS

This retrospective survey included all 24 clinical centres using the pentaspline PFA catheter after regulatory approval. Institution-level data were obtained on patient characteristics, procedure parameters, acute efficacy, and adverse events. With an average of 73 patients treated per centre (range 7-291), full cohort included 1758 patients: mean age 61.6 years (range 19-92), female 34%, first-time ablation 94%, paroxysmal/persistent AF 58/35%. Most procedures employed deep sedation without intubation (82.1%), and 15.1% were discharged same day. Pulmonary vein isolation (PVI) was successful in 99.9% (range 98.9-100%). Procedure time was 65 min (38-215). There were no oesophageal complications or phrenic nerve injuries persisting past hospital discharge. Major complications (1.6%) were pericardial tamponade (0.97%) and stroke (0.4%); one stroke resulted in death (0.06%). Minor complications (3.9%) were primarily vascular (3.3%), but also included transient phrenic nerve paresis (0.46%), and TIA (0.11%). Rare complications included coronary artery spasm, haemoptysis, and dry cough persistent for 6 weeks (0.06% each).

CONCLUSION

In a large cohort of unselected patients, PFA was efficacious for PVI, and expressed a safety profile consistent with preferential tissue ablation. However, the frequency of 'generic' catheter complications (tamponade, stroke) underscores the need for improvement.

Premature Ventricular Contractions and Ultra-High-Definition Mapping. Contribution and Limits

Background

The utility of ultra-high definition mapping (UHDM) for ablation of premature ventricular contractions (PVC) remains undetermined. The aim of this study was to investigate UHDM for PVC ablation, and additionally to compare to conventional technique.

Methods

Twenty patients investigated using UHDM were prospectively included and analyzed. Electrophysiological caracteristics and results were compared to 40 patients ablated using fluoroscopy only.

Results

2541±2033 EGMs and 331±240 PVC beats were recorded for each patient. Surfaces of isochronal activations were 2.3±1.7 and 6.9±6.1 cm² (first 10 and 20 ms). Local scar was present in 40% and local block in 65%. Areas of pace-mapping > 95, 90 and 85% concordance were 1.5±3.4, 2.1±3.9 and 3.3±5 cm². Mean distance between the ablation site and the site of best pace-mapping or of earliest activation was 8±8 mm and 5±7 mm. Pre-potential was noted in 17% vs 26% controls (ns). QS pattern was present in 83% vs 83% controls (ns), and earliest activation was - 31±50 vs - 25±14 ms in controls (ns). Procedure (100±36 vs 190±51 min, p< 0.0001) and fluoroscopy duration (15±9 vs 24±9 min, p=0.005) were shorter in controls. Acute success was achieved in 65% patients with UHDM and in 72% controls (p=ns) with lower residual PVC burden in the control group. Over a follow-up of 19±12 months, long-term success was similar between groups (65 vs 68%).

Conclusions

UHDM may reveal poorly recognized activation features and PVC mechanism. In this series, conventional mapping was quicker and did clinically as well as UHDM.

The prevalence of left and right bundle branch block morphology ventricular tachycardia amongst patients with arrhythmogenic cardiomyopathy and sustained ventricular tachycardia: insights from the European Survey on Arrhythmogenic Cardiomyopathy

AIMS

In arrhythmogenic cardiomyopathy (ACM), sustained ventricular tachycardia (VT) typically displays a left bundle branch block (LBBB) morphology while a right bundle branch block (RBBB) morphology is rare. The present study assesses the VT morphology in ACM patients with sustained VT and their clinical and genetic characteristics.

METHODS AND RESULTS

Twenty-six centres from 11 European countries provided information on 954 ACM patients who had ≥1 episode of sustained VT spontaneously documented during patients' clinical course. Arrhythmogenic cardiomyopathy was defined according to the 2010 Task Force Criteria, and VT morphology according to the QRS pattern in V1. Overall, 882 (92.5%) patients displayed LBBB-VT alone and 72 (7.5%) RBBB-VT [alone in 42 (4.4%) or in combination with LBBB-VT in 30 (3.1%)]. Male sex prevalence was 79.3%, 88.1%, and 56.7% in the LBBB-VT, RBBB-VT, and LBBB + RBBB-VT groups, respectively (P = 0.007). First RBBB-VT occurred 5 years after the first LBBB-VT (46.5 ± 14.4 vs 41.1 ± 15.8 years, P = 0.011). An implanted cardioverter-defibrillator was more frequently implanted in the RBBB-VT (92.9%) and the LBBB + RBBB-VT groups (90%) than in the LBBB-VT group (68.1%) (P < 0.001). Mutations in PKP2 predominated in the LBBB-VT (65.2%) and the LBBB + RBBB-VT (41.7%) groups while DSP mutations predominated in the RBBB-VT group (45.5%). By multivariable analysis, female sex was associated with LBBB + RBBB-VT (P = 0.011) while DSP mutations were associated with RBBB-VT (P < 0.001). After a median follow-up of 103 (51-185) months, death occurred in 106 (11.1%) patients with no intergroup difference (P = 0.176).

CONCLUSION

RBBB-VT accounts for a significant proportion of sustained VTs in ACM. Sex and type of pathogenic mutations were associated with VT type, female sex with LBBB + RBBB-VT, and DSP mutation with RBBB-VT.

Incidence, epidemiology, diagnosis and prognosis of atrio-oesophageal fistula following percutaneous catheter ablation: a French nationwide survey

AIMS

Rate, incidence, risk factors, and optimal management of atrio-oesophageal fistula (AOF) after catheter ablation for atrial fibrillation (AF) remain obscure.

METHODS AND RESULTS

All French centres performing AF ablation were identified and surveys were sent concerning the number of procedures, eventual cases of AOF, and characteristics of such cases. Eighty-two of the 103 centres (80%) performing AF ablation in France were included, with a total of 129 286 AF ablations since 2006 (93% of the whole procedures in France). Thirty-three AOF were reported (reported rate 0.026% per procedure) with a stable reported annual incidence despite the increasing number of procedures. Sensitivity of computed tomography (CT) scan for AOF was 81%. Mortality was 60%, significantly lower in case of surgical corrective therapy (31 vs. 93%, P = 0.001).

CONCLUSION

The reported rate of AOF after AF ablation in this nationwide survey was 0.026%, with a stable reported annual incidence over time. A normal CT scan does not rule out the diagnosis and should be repeated in case of suspicion. Prognosis remains poor with a mortality of 60% and crucially dependant of immediate surgical correction. No clear protective strategy has been proven effective.

Wearable cardioverter-defibrillator in patients with a transient risk of sudden cardiac death: the WEARIT-France cohort study

Aims 

We aimed to provide contemporary real-world data on wearable cardioverter-defibrillator (WCD) use, not only in terms of effectiveness and safety but also compliance and acceptability.

Methods and results 

Across 88 French centres, the WEARIT-France study enrolled retrospectively patients who used the WCD between May 2014 and December 2016, and prospectively all patients equipped for WCD therapy between January 2017 and March 2018. All patients received systematic education session through a standardized programme across France at the time of initiation of WCD therapy and were systematically enrolled in the LifeVest Network remote services. Overall, 1157 patients were included (mean age 60 ± 12 years, 16% women; 46% prospectively): 82.1% with ischaemic cardiomyopathy, 10.3% after implantable cardioverter-defibrillator explant, and 7.6% before heart transplantation. Median WCD usage period was 62 (37–97) days. Median daily wear time of WCD was 23.4 (22.2–23.8) h. In multivariate analysis, younger age was associated with lower compliance [adjusted odds ratio (OR) 0.97, 95% confidence interval (CI) 0.95–0.99, P < 0.01]. A total of 18 participants (1.6%) received at least one appropriate shock, giving an incidence of appropriate therapy of 7.2 per 100 patient-years. Patient-response button allowed the shock to be aborted in 35.7% of well-tolerated sustained ventricular arrhythmias and in 95.4% of inappropriate ventricular arrhythmia detection, finally resulting in an inappropriate therapy in eight patients (0.7%).

Conclusion

Our real-life findings reinforce previous studies on the efficacy and safety of the WCD in the setting of transient high-risk group in selected patients. Moreover, they emphasize the fact that when prescribed appropriately, in concert with adequate patient education and dedicated follow-up using specific remote monitoring system, compliance with WCD is high and the device well-tolerated by the patient.

Accuracy of automatic abnormal potential annotation for substrate identification in scar-related ventricular tachycardia

INTRODUCTION

Ultrahigh-density mapping for ventricular tachycardia (VT) is increasingly used. However, manual annotation of local abnormal ventricular activities (LAVAs) is challenging in this setting. Therefore, we assessed the accuracy of the automatic annotation of LAVAs with the Lumipoint algorithm of the Rhythmia system (Boston Scientific).

METHODS AND RESULTS

One hundred consecutive patients undergoing catheter ablation of scar-related VT were studied. Areas with LAVAs and ablation sites were manually annotated during the procedure and compared with automatically annotated areas using the Lumipoint features for detecting late potentials (LP), fragmented potentials (FP), and double potentials (DP). The accuracy of each automatic annotation feature was assessed by re-evaluating local potentials within automatically annotated areas. Automatically annotated areas matched with manually annotated areas in 64 cases (64%), identified an area with LAVAs missed during manual annotation in 15 cases (15%), and did not highlight areas identified with manual annotation in 18 cases (18%). Automatic FP annotation accurately detected LAVAs regardless of the cardiac rhythm or scar location; automatic LP annotation accurately detected LAVAs in sinus rhythm, but was affected by the scar location during ventricular pacing; automatic DP annotation was not affected by the mapping rhythm, but its accuracy was suboptimal when the scar was located on the right ventricle or epicardium.

CONCLUSION

The Lumipoint algorithm was as/more accurate than manual annotation in 79% of patients. FP annotation detected LAVAs most accurately regardless of mapping rhythm and scar location. The accuracy of LP and DP annotations varied depending on mapping rhythm or scar location.

Autonomic cardiac innervation: impact on the evolution of arrhythmias in inherited cardiac arrhythmia syndromes

The autonomic nervous system (ANS) is an essential component of arrhythmogenicity, especially in the absence of structural heart disease and channelopathy. In this article, the authors review the role and characteristics of ANS in various channelopathies. Some of these, such as most long QT syndromes and catecholaminergic polymorphic ventricular tachycardia, are highly dependent on sympathetic activation, while parasympathetic tone is an important factor for arrhythmias in other channelopathies such as Brugada syndrome or early repolarisation syndrome. Recent advances highlighting the subtle role of ANS in channelopathies are presented here, demonstrating that all is far from being so simple and straightforward and revealing some paradoxical behaviours of channelopathies in relation to discrete ANS imbalance.

Relationships between left ventricular mass and QRS duration in diverse types of left ventricular hypertrophy

AIMS

Hypertrophic cardiomyopathy (HCM) may be associated with very narrow QRS, while left ventricular hypertrophy (LVH) may increase QRS duration. We investigated the relationships between QRS duration and LV mass (LVM) in subtypes of abnormal LV wall thickness.

METHODS AND RESULTS

Automated measurement of LVM on MRI was correlated to automated measurement of QRS duration on ECG in HCM, left ventricular non compaction (LVNC), left ventricular hypertrophy (LVH), and controls with healthy hearts. Uni and multivariate analyses were performed between groups including explanatory variables expected to influence LVM and QRS duration. The relationships between QRS duration and LVM were further studied within each group. Two hundred and twenty-one HCM, 28 LVNC, 16 LVH, and 40 controls were retrospectively included. Mean QRS duration was 92 ms for HCM, 104 for LVNC, 110 for LVH, and 92 for controls (P < 0.01). Mean LVM was 100, 90, 108, and 68 g/m2 (P < 0.01). QRS duration, LVM, hypertension, maximal wall thickness, and late gadolinium enhancement were significantly linked to HCM in multivariate analysis (w/wo bundle branch block). An independent negative correlation was found between LVM and QRS duration in the HCM group, while the relationship was reverse in LVNC, LVH, and controls.

CONCLUSION

QRS duration increases with LVM in LVNC, LVH, or in healthy hearts, while reverse relationship is present in HCM. These relationships were independent from other parameters. These results warrant additional investigations for refining diagnosis criteria for HCM in the future.

Incidence, epidemiology, risk factors and prognosis of atrio-esophageal fistula following percutaneous catheter ablation. An exhaustive natiowide registry

Introduction

A rare but often fatal complication of atrial fibrillation (AF) ablation is the formation of an atrioesophageal fistula (AEF) whose true prevalence and risk factors remain obscure.

Objective

To determine incidence, epidemiology, risk factors and prognosis of AEF using a – as exhaustive as possible – nationwide survey

Method

All French centers performing AF ablation were identified and survey were sent concerning the habits, techniques of AF ablation and eventual cases of AEF.

Results

82 of the 103 centers (80%) performing ablation of AF in France were included in the study performing 129286 ablations from 2006 (93% of the total AF ablation in France). 33 AEF were declared (26 AEF and 4 esopericardial fistula) (0.026% risk per procedure) with a stable annual incidence over time, unchanged after the advent of thermal probe. Sensititvity of CT scan for AEF diagnosis was 81%. Mortality was 60%, significantly lower in case of surgical mangement (31 vs 93%, p=0.001). No case of AEF happened after cryoablation and only two AEF occurred in redo ablation. In multivariate analysis, lack of use of contact force catheters and the realization of posterior/roof ablation lines emerged as independent factors associated with the risk of AEF with OR 23.6 (95% CI [4.5; 21]) p=0.0002 and OR 3.7 (95% CI [1.1, 13]) p=0.04) while the lack of thermal probes remained of borderline significance.

Conclusion

The rate of AEF after AF ablation in a nationwide and well exhaustive survey can be evaluated to 0.026% with an annual incidence remaining stable over time. A normal CT scan does not rule out the diagnosis. Prognosis remains poor with a mortality of 60% and crucially dependant of immediate surgical correction.

Funding Acknowledgement

Type of funding source: None

Relations between voltage mapping and diagnosis and genetics in patients with arrhythmogenic right ventricular cardiomyopathy

Introduction

Relations between voltage mapping and diagnosis or genetic background in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) have not been investigated so far.

Objective

We investigate if diagnosis or genetic background were linked to voltage mapping in ARVC.

Method

70 patients with proved or suspected ARVC undergoing 3D endocardial mapping and genetic testing have been retrospectively included. Localisation and extension of bipolar low voltage areas were correlated to ARVC diagnosis and presence of a culprit mutation.

Results

44/70 fulfilled ARVC Task Force criteria and 25/70 had culprit mutations. Endocardial (38/44 vs 16/26, p=0.02) and especially infero-lateral scars (31/44 vs 9/26, p=0.003) were more often present in patients fulfilling Task force criteria vs suspected ARVC, with larger scars (area 23±27 vs 8±11 cm2, p=0.04, perimeter 17±10 vs 11±7 cm, p=0.03) (sensitivity 86%). Mutated patients had more infero-lateral (19/25 vs 21/45, p=0.01), multiple (12/20 vs 11/34, p=0.04) and larger scars (perimeter 21±10 vs 12±7 cm, p=0.01) vs non mutated patients. In patients with ARVC diagnosed according to the Task Force criteria, there was a trend toward more infero-lateral (p=0.09) and larger scars (p=0.08) in mutated cases. PKP2-mutated cases tended to have less ourflow tract (p=0.08) and less multiple scars (p=0.09) vs other mutations.

Conclusion

3D endocardial mapping could have an important role for ARVC diagnosis and may be able to detect minor forms with otherwise insufficiant criteria for diagnosis. More frequent and larger infero-lateral scars are present in mutated patients with bordeline differences according to the mutated genes.

Funding Acknowledgement

Type of funding source: None

Long-Lasting Ventricular Fibrillation in Humans ECG Characteristics and Effect of Radiofrequency Ablation

BACKGROUND

Studies of ventricular fibrillation (VF) in humans are limited because of the short available duration. We sought to study surface ECG waveforms and effect of ablation in long-lasting VF in patients with left assist devices.

METHODS

Continuous 12-lead ECG of 5 episodes of long-lasting VF occurring in 3 patients with left ventricular assist device were analyzed. Spectral analysis (dominant frequency) and quantification of waveform amplitude, regularity (Unbiased Regularity Index), and complexity (Nondipolar Index) were performed over a median of 24 minutes of VF. Radiofrequency ablation was performed during VF in 2 patients.

RESULTS

There was a significant increase in dominant frequency between VF onset and termination but none of the other parameters significantly changed. Some VF parameters varied from patient to patient and from lead to lead. Dominant frequency decreased after radiofrequency ablation in both cases and VF terminated spontaneously shortly after ablation in one case. The previously incessant VFs in these 2 patients did not recur afterward.

CONCLUSIONS

VF rate increases over time in patients with left ventricular assist devices and is lowered by ablation. Long-lasting VF may be modified or even terminated by ablation.

Coagulation and heparin requirements during ablation in patients under oral anticoagulant drugs

BACKGROUND

Anticoagulation during catheter ablation should be closely monitored with activated clotting time (ACT). However vitamin K antagonists (VKA) or direct oral anticoagulant drugs (DOAC) may act differently on ACT and on heparin needs. The aim of this study was to compare ACT and heparin requirements during catheter ablation under various oral anticoagulant drugs and in controls.

METHODS

Sixty consecutive patients referred for ablation were retrospectively included: group I (n = 15, VKA), group 2 (n = 15, uninterrupted rivaroxaban), group 3 (n = 15, uninterrupted apixaban), and group 4 (n = 15, controls). Heparin requirements and ACT were compared throughout the procedure.

RESULTS

Heparin requirements during the procedure were significantly lower in patients under VKA compared to DOAC, but similar between DOAC patients and controls.Activated clotting time values were significantly higher in patients under VKA compared to DOAC and similar in DOAC patients versus controls. Furthermore, anticoagulation control as evaluated by the number/proportion of ACT> 300 as well as the time passed over 300 seconds was significantly better in patients under VKA versus DOAC, without significant differences between DOAC and controls. Finally, the number of patients/ACT with excessive ACT values was significantly higher in VKA versus DOAC patients versus controls.There was no significant difference between rivaroxaban and apixaban for ACT or heparin dosing throughout the procedure.

CONCLUSION

Vitamin K antagonists allowed less heparin requirement despite reaching higher ACT values and more efficient anticoagulation control (with more excessive values) compared to patients under DOAC therapy and to controls. There was no difference in heparin requirements or ACT between DOAC patients and controls.

Creation of sinus rhythm and paced maps using a single acquisition step: the "one acquisition-two maps" technique-a feasibility study

PURPOSE

Scars and abnormal electrograms may significantly differ according to the activation wavefront. We propose a new fast technique for reliable comparison between sinus rhythm and ventricular pacing using a single map acquisition and the Rhythmia™ 3D mapping system.

METHODS

A special programming of the external stimulator was assuring full stable regular paced-beat bigeminy during spontaneous rhythm. A first map was acquired for the spontaneous cardiac beat. Then the window of detection was moved to the following paced beat, and a second map was available after recalculation by the system, depicting activation and voltage of the paced cardiac beat at the same locations, with an exactly the same number of beats in both maps.

RESULTS

Thirty patients with structural heart disease referred for ablation of ventricular tachycardia underwent this protocol, who were compared with 19 similar patients undergoing repeated maps. Duration of the mapping was significantly shorter compared to controls (34 ± 12 vs 57 ± 14 min, p < 0.0001) without differences in the number of electrograms (6978 ± 7067 vs 9554 ± 4424 for sinus rhythm map and 6610 ± 7240 vs 7783 ± 3804 for paced map, p = ns for both). The technique cannot be completed in five patients (17%), because of arrhythmogenicity, mechanical right bundle branch block, hemodynamical impairment, or bradycardia.

CONCLUSION

We propose a novel technique for performing maps during sinus rhythm and ventricular pacing using a single acquisition. Beside time saving, this will allow more strict comparisons between different activation wavefronts.

Hybrid surgical ablation for persistent or long standing persistent atrial fibrillation: A French single centre experience

BACKGROUND

Hybrid ablation for the treatment of atrial fibrillation is a single combined procedure consisting in a minimally thoracoscopic surgical ablation followed by a catheter ablation. This promising technique is recommended in persistent atrial fibrillation according to the current guidelines but is not routinely performed in France, mainly due to the absence of reimbursement by the French National Health Insurance.

AIMS

The aim of this prospective and single-centre study was to analyse, for the first time in France, the feasibility, efficacy and complication rates of hybrid ablation in patients with persistent atrial fibrillation.

METHODS

Hybrid ablation was performed in 15 consecutive patients (13 men, mean age 61±6 years) with persistent (7 patients) or long standing persistent (8 patients) atrial fibrillation.

RESULTS

Hybrid ablation was completed in 14/15 patients. Eleven patients returned in sinus rhythm during the procedure. Two patients (13%) had major per-procedural complications and 2 had minor complications. During an average follow-up of 25±6 months, 6 patients (40%) underwent a redo catheter ablation because of atrial tachycardia, mainly peri-mitral atrial flutter. At 1 year follow up, 14/15 patients were in sinus rhythm, including 11 free of antiarrhythmic drugs.

Chest pain in Brugada syndrome: Prevalence, correlations, and prognosis role

BACKGROUND

Brugada syndrome (BrS) is sometimes diagnosed because of chest pain. Prevalence and characteristics of such BrS patients are unknown.

METHODS

A total of 200 BrS probands were retrospectively included. BrS diagnosis made because of chest pain (n = 34, 17%) was compared to the other ones.

RESULTS

BrS probands with diagnosis because of chest pain had significantly more often smoker habits, increased body mass index, and familial history of coronary artery disease but less frequently previous resuscitated sudden death/syncope or atrial fibrillation. Presence of coronary spasm and familial coronary artery disease were independently associated with BrS diagnosed because of chest pain. They presented more often with spontaneous type 1 ST elevation (59% vs 26%, P = .0004) and higher ST elevation during the episode of chest pain compared to other patients or compared to baseline electrocardiogram after chest pain resumption. ST elevation during chest pain was lower compared to ajmaline test. A total of 20% of them had significant coronary artery disease and four (11%) had coronary spasm, and they experienced more often recurrent chest pain episodes (24% vs 5%, P = .0002). Presence of chest pain at BrS diagnosis was not correlated to future arrhythmic events in univariate analysis. Only previous sudden cardiac death (SD)/syncope and familial SD were still significantly associated with outcome in multivariate analysis.

CONCLUSION

Chest pain is a common cause for BrS diagnosis, although major part is not apparently explained by ischemic heart disease. Mechanisms leading to chest main remain unknown in the other ones. ST elevation is higher in this situation but does not seem to carry poor prognosis.

Feasibility of fast ventricular tachycardia mapping using the Rhythmia ™ system in a patient with an Impella ™

Use of 3D navigation systems may be sometimes impossible in patients with left ventricular assist devices because of major electromagnetical interferences with some 3D systems based on magnetic localization. Mapping with the Rhythmia ™ system in patients implanted with an Impella ™ is described to be non feasible. We relate how to overcome this technical issues in this case.

Atrial fibrillation and subtype of atrial fibrillation in cardiac amyloidosis: clinical and echocardiographic features, impact on mortality

Background: Atrial fibrillation (AF) commonly affects patients with cardiac amyloidosis (CA). Amyloid deposition within the left atrium may be responsible for the subtype of AF in either permanent or non-permanent form. The prognostic implications of AF and its clinical subtype according to the type of CA are still controversial in this population. This study sought to investigate the prevalence, incidence and prognostic implications of AF and the clinical subtype of AF (permanent or non-permanent) in patients with CA. Methods: Two hundred and thirty-eight patients with CA and full medical records were retrospectively enrolled in the study: About 115 (48%) with light chain (AL) amyloidosis and 123 (52%) with transthyretin amyloidosis (ATTR). Patient's medical records were reviewed to establish baseline prevalence, incidence and impact on all-cause and cardiovascular mortality during follow-up of AF. Results: One hundred and four (44%) patients had history of AF at the time of diagnosis: 62 (60%) permanent and 42 (40%) non-permanent. There were 30 (26%) and 74 (60%) patients with history of AF among patients with AL and ATTR (including 5 hereditary and 69 wild-type), respectively (p<.0001). During the follow-up, 48 new patients developed AF (29, 12 and 7 among patients with AL, wild-type ATTR and hereditary ATTR). After adjustment for age, survival was similar in patients with or without history of AF (HR 0.87 (95% CI, 0.60 to 1.27; p = .467). AF had no impact on cardiovascular mortality. Among the 152 patients with history of AF included in the whole study, there were 75 (49%) patients with permanent AF. After adjustment for age, survival was similar in patients with permanent and non-permanent AF: HR 1.29 (95% CI, 0.84 to 1.99; p = .251). The results were the same among patients with AL or wild-type amyloidosis. Subtype of AF had no impact on cardiovascular mortality. Conclusions: AF is common in patients with CA. However, AF and clinical subtype of AF have no impact on all-cause mortality, whatever the type of amyloidosis.

Correlations between arrhythmogenic substrate and noninvasive risk stratification in ischemic heart disease patients modifications by radiofrequency ablation

INTRODUCTION

Several noninvasive risk factors for ventricular arrhythmias have been described in postmyocardial infarction (MI) patients, whose relationships with scar characteristics and modifications by ablation are unknown.

METHODS

Twenty-two patients with previous MI referred for ventricular tachycardia ablation were prospectively included. ECG, heart rate variability (HRV), signal-averaged ECG (SA-ECG), and T wave alternans (TWA) were performed before and after radiofrequency ablation. Scar areas were correlated to preablation parameters. Pre and postablation parameters were furthermore compared.

RESULTS

Left ventricular ejection fraction and some spectral and time-domain HRV parameters were significantly correlated to the scar areas. QRS duration was larger after vs before ablation (120 ± 29 vs 105 ± 22 msec, P = .01). No significant modification in time or spectral domain of HRV was observed. There was no significant change in TWA and SA-ECG before and after ablation. Borderline decreases in quantitative TWA parameters were noted in patients with positive TWA and successful ablation procedure.

CONCLUSION

Some noninvasive risk factors were linked to the scar areas, but few were significantly modified after ablation. Larger populations are needed to demonstrate significant differences or correlations.

Early Ventricular Arrhythmias After LVAD Implantation Is the Strongest Predictor of 30-Day Post-Operative Mortality

OBJECTIVES

This study aimed to evaluate incidence, clinical significance, and predictors of early ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients.

BACKGROUND

LVAD implantation is increasingly used in patients with end-stage heart failure. Early VAs may occur during the 30-day post-operative period, but many questions remain unanswered regarding their incidence and clinical impact.

METHODS

This observational study was conducted in 19 centers between 2006 and 2016. Early VAs were defined as sustained ventricular tachycardia and/or ventricular fibrillation occurring <30 days post-LVAD implantation and requiring appropriate implantable cardioverter-defibrillator therapy, external electrical shock, or medical therapy.

RESULTS

A total of 652 patients (median age: 59.8 years; left ventricular ejection fraction: 20.7 ± 7.4%; HeartMate 2: 72.8%; HeartWare: 19.5%; Jarvik 2000: 7.7%) were included in the analysis. Early VAs occurred in 162 patients (24.8%), most frequently during the first week after LVAD implantation. Multivariable analysis identified history of VAs prior to LVAD and any combined surgery with LVAD as 2 predictors of early VAs. The occurrence of early VAs with electrical storm was the strongest predictor of 30-day post-operative mortality, associated with a 7-fold increase of 30-day mortality. However, in patients discharged alive from hospital, occurrence of early VAs did not influence long-term survival.

CONCLUSIONS

Early VAs are common after LVAD implantation and increase 30-day post-operative mortality, without affecting long-term survival. Further studies will be needed to analyze whether pre- or pre-operative ablation of VAs may improve post-operative outcomes. (Determination of Risk Factors of Ventricular Arrhythmias After Implantation of Continuous Flow Left Ventricular Assist Device With Continuous Flow Left Ventricular Assist Device [ASSIST-ICD]; NCT02873169).