Stereotactic radiosurgery for ablation of ventricular tachycardia in the setting of electrical storm

Funding Acknowledgements

Type of funding sources: None.

Introduction

Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy to treat refractory VT despite optimal medical treatment and/or catheter ablation (CA). However data in the setting of ES are lacking.

Objectives

The aim of this study was to assess the clinical outcomes associated with SBRT in the setting of ES.

Methods

This retrospective study included patients who underwent SBRT in the setting of ES from March 2019 to March 2021 in one tertiary center (CHU Lille). Target volume was delineated according to a predefined workflow. The efficacy was assessed with the following endpoints: sustained VT recurrence, VT reduced with ATP or ICD shock.

Results

17 patients underwent SBRT to treat refractory VT in the setting of ES (Mean age: 67±12.8, 59% presenting ischemic heart disease, mean LVEF: 33.7± 9.7%). After a median follow-up of 7 [5; 16] months, a reduction in VT burden was observed in all patients after a 6-week blanking period. 6 patients presented an increase of the VT burden from week 2 to week 6 following SBRT despite an initial reduction of VT burden. No patient experienced ICD shocks beyond 6 weeks.

Conclusion

SBRT is efficient in treating recurrent VT in the setting of ES with failure and/or contraindication to CA. One third of patient present a transient increase in VT burden during a 6 weeks blanking period. Therefore, VT tolerance should be integrated as part of an action plan defined upstream to SBRT for each patient.

Does left atrial appendage morphology have any impact on the results of percutaneous closure?

Introduction

Transcatheter left atrial appendage (LAA) occlusion is an alternative treatment in patients with atrial fibrillation (AF), high CHADSVASC Score and a contra-indication to anticoagulants. This retrospective cohort study aims to evaluate the impact of LLA morphology on procedure outcomes.

Methods

Patients from eight French centers who underwent left atrial appendage occlusion from February 2012 to January 2017 were included in this retrospective cohort study. LLA morphology was described by preoperative cardiac computed tomography (CT). Clinical data and Transoesophageal echocardiography (TEE) or CT results were collected during follow-up.

Results

Among 469 included patients, LAA morphologies were described in 215 cases 45.8%), 150 patients (70%) were implanted with Watchman devices, 57 (26%) with Amplatzer devices and 8 procedures (4%) failed. LAA Morphology was Chicken Wing (34%), Windsock (45%), cauliflower (18%) and 3% had another morphology including Cactus.

There was no difference in patient characteristics between the different morphology groups. Mean follow-up was 9.6±11 months, during which 190 patients underwent LAA imaging (TEE in 171 and CT in 19 patients). There was no significant difference in the failure rate (p=0.72), duration of the procedure (p=0.065), peri-device leak (p=0.83) device-related thrombus (p=0.96) and the occurrence of stroke (p=1) during follow-up.

Conclusion

LLA morphology did not influence complication occurrence after occlusion in this cohort.

Funding Acknowledgement

Type of funding source: None

P999Major adverse events with percutaneous left atrial appendage closure in patients with atrial fibrillation in real life setting

Methods

We analysed data from all AF patients treated with Watchman or Amplatzer LAA closure according to European guidelines in 8 French cardiology departments. Antithrombotic management was decided for each patient on an individual basis. A Cox regression model was used for multivariable analysis of major adverse events. Yearly rate of ischemic stroke during follow-up was calculated and compared to that expected for a same risk score population. Yearly rate of bleeding was extrapolated from that reported with the HASBLED score.

Results

A total of 469 consecutive AF patients (299 males, 74.9±8.9 years old, mean CHA2DS2-VASc score 4.5±1.4, HASBLED score 3.7±1.0) received LAA closure from March 2012 to January 2017. There were 272 Watchman devices (58%) and 197 ACP devices (42%) implanted. At discharge, 36% received a single anti platelet therapy (APT), 23% received dual APT, 29% received OAC and no APT, 5% received OAC plus APT and 8% received no antithrombotic therapy. Mean follow up was 11.4 months (median 7, interquartile 3–22 months) during which 70 major adverse events (19 ischemic strokes, 18 major haemorrhages and 33 deaths) were recorded in 69 patients. The annual rate of ischemic stroke was 3.96%, which translates into a 13% relative risk reduction (95% CI −59 to 52%) as compared with the calculated stroke rate for similar CHA2DS2-VASc score after adjustment for exposure to APT and OAC. The annual rate of major bleeding in the study was 3.75%, which corresponds to a 48% relative risk reduction (95% CI 9 to 70%) as compared with the rate that would have been expected based on a comparable HAS-BLED score. Yearly rate of mortality was 7.4% (2.5 to 3 fold higher than in previous randomized trials) and the rate of non-cardiovascular death was 82%. None of the baseline characteristics was predictive of major adverse events, neither in univariate nor in multivariable analysis, which highlights the difficulty in identifying a risk of unfavourable outcome with simple tools.

Conclusions

AF patients treated with LAA closure may have a lower risk of stroke and bleeding events compared to their theoretical risk. However, our findings indicate that a high rate of major adverse events is observed in these patients during follow-up. This questions the suggested cost-effectiveness of the procedure (with models based on previous trials) for a real-life perspective. A better identification of patients with a relevant benefit of LAA closure is needed among those with long-term anticoagulation contraindication, both for an optimal management of each patient on an individual basis and for a global perspective with limited healthcare resources.

European survey on efficacy and safety of duty-cycled radiofrequency ablation for atrial fibrillation

AIMS

Duty-cycled radiofrequency ablation (RFA) has been used for atrial fibrillation (AF) for around 5 years, but large-scale data are scarce. The purpose of this survey was to report the outcome of the technique.

METHODS AND RESULTS

A survey was conducted among 20 centres from seven European countries including 2748 patients (2128 with paroxysmal and 620 with persistent AF). In paroxysmal AF an overall success rate of 82% [median 80%, interquartile range (IQR) 74-90%], a first procedure success rate of 72% [median 74% (IQR 59-83%)], and a success of antiarrhythmic medication of 59% [median 60% (IQR 39-72%)] was reported. In persistent AF, success rates were significantly lower with 70% [median 74% (IQR 60-92%)]; P = 0.05) as well as the first procedure success rate of 58% [median 55% (IQR 47-81%)]; P = 0.001). The overall success rate was similar among higher and lower volume centres and were not dependent on the duration of experience with duty-cycled RFA (r = -0.08, P = 0.72). Complications were observed in 108 (3.9%) patients, including 31 (1.1%) with symptomatic transient ischaemic attack or stroke, which had the same incidence in paroxysmal and persistent AF (1.1 vs. 1.1%) and was unrelated to the case load (r = 0.24, P = 0.15), bridging anticoagulation to low molecular heparin, routine administration of heparin over the long sheath, whether a transoesophageal echocardiogram was performed in every patient or not and average procedure times.

CONCLUSION

Duty-cycled RFA has a self-reported success and complication rate similar to conventional RFA. After technical modifications a prospective registry with controlled data monitoring should be conducted to assess outcome.

Post-operative use of heparin increases morbidity of pacemaker implantation

AIMS

The objective of this study is to characterize the incidence of peri-operative severe adverse events (AEs) related to the post-operative use of heparin in patients undergoing pacemaker surgery.

METHODS AND RESULTS

We retrospectively compared the outcome of 38 patients with mechanical valves (MVs) and 76 patients with atrial fibrillation (AF) with control cases matched for gender, age, and surgical details. Heparin was systematically used post-operatively in MV patients, but left to clinical judgment in AF patients. The relative risk for severe haemorrhagic AEs was 11 (CI 1.5-81.1, P < 0.01) in the MV group when compared with matched controls and 8 (CI 1.0-62.5, P < 0.05) in the AF group. Overall, the relative risk of heparin use in the post-operative period was 14 (CI 1.88-104, P = 0.0006) and the post-operative stay was prolonged from 7 days in this group when compared with control cases (P < 0.0001).The variables associated with haemorrhage were the delay to restart heparin after surgery and the presence of an MV.

CONCLUSION

Post-operative use of heparin increases morbidity of pacemaker implantation. A different approach to management of these patients is possible.

[New concepts of anticoagulant therapy of atrial fibrillation]

The news concerning anticoagulant therapy is very rich. It was also keenly awaited in view of the real imperfection of antivitamin K drugs on which the present strategy of prevention of thromboembolic risk related to atrial fibrillation is based. The new anticoagulants have differing targets identified from the physiological mechanism of coagulation and the physiopathology of thrombosis.