Safety, feasibility, and prognostic value of stress perfusion CMR in patients with MR-conditional pacemaker.

AIMS: To assess the safety, feasibility, and prognostic value of stress cardiovascular magnetic resonance (CMR) in patients with pacemaker (PM). METHODS AND RESULTS: Between 2008 and 2021, we conducted a bi-centre longitudinal study with all consecutive patients with MR-conditional PM referred for vasodilator stress CMR at 1.5 T in the Institut Cardiovasculaire Paris Sud and Lariboisiere University Hospital. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or non-fatal myocardial infarction. Cox regression analyses were performed to determine the prognostic value of CMR parameters. The quality of CMR was rated by two observers blinded to clinical details. Of 304 patients who completed the CMR protocol, 273 patients (70% male, mean age 71 ± 9 years) completed the follow-up (median [interquartile range], 7.1 [5.4-7.5] years). Among those, 32 experienced a MACE (11.7%). Stress CMR was well tolerated with no significant change in lead thresholds or pacing parameters. Overall, the image quality was rated good or excellent in 84.9% of segments. Ischaemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 11.71 [95% CI: 4.60-28.2]; and HR: 5.62 [95% CI: 2.02-16.21], both P < 0.001). After adjustment for traditional risk factors, ischaemia and LGE were independent predictors of MACE (HR: 5.08 [95% CI: 2.58-14.0]; and HR: 2.28 [95% CI: 2.05-3.76]; both P < 0.001). CONCLUSION: Stress CMR is safe, feasible and has a good discriminative prognostic value in consecutive patients with PM.

Ventricular fibrillation in acute myocardial infarction: 20-year trends in the FAST-MI study.

AIMS: Sudden cardiac arrest remains a major complication of acute myocardial infarction (AMI) and is frequently related to ventricular fibrillation (VF). Incidence and impact of VF among patients hospitalized for AMI were evaluated. METHODS AND RESULTS: Data from the FAST-MI programme consisting of 5 French nationwide prospective cohort studies between 1995 and 2015 were analysed, totally including 14 423 patients with AMI (66 ± 14 years, 72% males, 59% ST-elevation myocardial infarction). Overall, proportion of patients presenting in-hospital VF decreased from 3.9% in 1995 to 1.8% in 2015 (P < 0.001). One-year mortality decreased from 60.7% to 24.6% (P < 0.001). However, compared with patients who did not develop VF, the over-risk of 1-year mortality associated with VF was stable over time [hazard ratio (HR) 6.78, 95% confidence interval (CI) 5.03-9.14 in 1995 and HR 6.64, 95% CI 4.20-10.49 in 2015, P = 0.52]. This increased mortality in the VF group was mainly related to fatal events occurring prior to hospital discharge, representing 86.2% of 1-year mortality, despite the very low rate of implantable cardioverter defibrillator in the VF group (2.6%). CONCLUSION: This study demonstrates that in-hospital VF incidence and mortality in the setting of AMI have significantly decreased over the past 20 years. Nevertheless, VF remained steadily associated with approximately a 10-fold increased relative risk of in-hospital mortality, without an impact on post-discharge mortality. Beyond long-term cardiac defibrillation strategy, these results emphasize the need to identify in-hospital interventions to further reduce mortality in VF patients. STUDY REGISTRATION: ClinicalTrials.gov Identifier: NCT00673036, NCT01237418, NCT02566200.

Evaluation of an Ambulatory ECG Analysis Platform Using Deep Neural Networks in Routine Clinical Practice.

Background Holter analysis requires significant clinical resources to achieve a high-quality diagnosis. This study sought to assess whether an artificial intelligence (AI)-based Holter analysis platform using deep neural networks is noninferior to a conventional one used in clinical routine in detecting a major rhythm abnormality. Methods and Results A total of 1000 Holter (24-hour) recordings were collected from 3 tertiary hospitals. Recordings were independently analyzed by cardiologists for the AI-based platform and by electrophysiologists as part of clinical practice for the conventional platform. For each Holter, diagnostic performance was evaluated and compared through the analysis of the presence or absence of 5 predefined cardiac abnormalities: pauses, ventricular tachycardia, atrial fibrillation/flutter/tachycardia, high-grade atrioventricular block, and high burden of premature ventricular complex (>10%). Analysis duration was monitored. The deep neural network-based platform was noninferior to the conventional one in its ability to detect a major rhythm abnormality. There were no statistically significant differences between AI-based and classical platforms regarding the sensitivity and specificity to detect the predefined abnormalities except for atrial fibrillation and ventricular tachycardia (atrial fibrillation, 0.98 versus 0.91 and 0.98 versus 1.00; pause, 0.95 versus 1.00 and 1.00 versus 1. 00; premature ventricular contractions, 0.96 versus 0.87 and 1.00 versus 1.00; ventricular tachycardia, 0.97 versus 0.68 and 0.99 versus 1.00; atrioventricular block, 0.93 versus 0.57 and 0.99 versus 1.00). The AI-based analysis was >25% faster than the conventional one (4.4 versus 6.0 minutes; P<0.001). Conclusions These preliminary findings suggest that an AI-based strategy for the analysis of Holter recordings is faster and at least as accurate as a conventional analysis by electrophysiologists.

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.

Preventing the risk of coronary injury in posteroseptal accessory pathway ablation in children: different strategies and advantages of fluoroscopy integrated 3D-mapping system (CARTO-UNIVU™).

PURPOSE: To evaluate various strategies in order to minimize the risk of coronary injury during posteroseptal accessory pathways ablation in children. METHODS: We retrospectively reviewed 68 posteroseptal accessory pathways ablation procedures (20 decremental and 48 typical accessory pathways) performed in 62 pediatric patients at our institution between July 2009 and December 2016. Only posteroseptal accessory pathways targeted near or within the coronary sinus were included and ablation was mostly performed using irrigated tip radiofrequency. RESULTS: Median patient age was 11 years with a median body weight of 39 kg. Thirty patients underwent a coronary angiogram, 21 were coupled to the 3D navigation system CARTO-UNIVU™. The coronary angiogram showed a distance of less than 5 mm between the coronary artery and the ablation site in 40% of our cases; 3 patients had a coronary injury related to RF ablation, 6 patients were switched for cryoablation, 3 patients received limited RF energy (20 W). There were no demographic data predicting the proximity of the coronary artery to the ablation site. CONCLUSION: Ablation of posteroseptal accessory pathways specifically in children carries a risk of coronary artery injury which is probably underestimated. The use of merged 3D images and coronary angiograms, the reduction of RF energy or the switch to cryoablation are possible alternatives to limit the risk of coronary injury.

Influence of advancing age on clinical presentation, treatment efficacy and safety, and long-term outcome of inducible paroxysmal supraventricular tachycardia without pre-excitation syndromes: A cohort study of 1960 patients included over 25 years.

AIM: To investigate the influence of increasing age on clinical presentation, treatment and long-term outcome in patients with inducible paroxysmal supraventricular tachycardia (SVT) without pre-excitation syndromes. METHODS: Clinical and electrophysiological study (EPS) data, as well as long-term clinical outcome (mean follow-up 2.4±4.0 years) were collected in patients referred for regular tachycardia with inducible SVT during EPS without pre-excitation. RESULTS: Among 1960 referred patients, 301 patients (15.4%) were aged ≥70 (70-97). In this subset, anticoagulants were prescribed in 49 patients following an erroneous diagnosis of atrial tachycardia and 14 were previously erroneously diagnosed with ventricular tachycardia because of wide QRS. Ablation was performed more frequently in patients ≥70 despite more frequent failure and complications. During follow-up, higher risks of AF, stroke, pacemaker implantation and death were observed in patients ≥70 whereas SVT recurrences were similar in both age groups. In multivariable analysis, age ≥70 was independently associated with higher risks of SVT-related adverse events prior to ablation (OR = 1.93, 1.41-2.62, p<0.001), conduction disturbances (OR = 11.27, 5.89-21.50, p<0.001), history of AF (OR = 2.18, 1.22-3.90, p = 0.009) and erroneous diagnosis at baseline (OR = 9.14, 5.93-14.09, p<0.001) as well as high rates of procedural complications (OR = 2.13, 1.19-3.81, p = 0.01) and ablation failure (OR = 1.68, 1.08-2.62, p = 0.02). In contrast, age ≥70 was not significantly associated with a higher risk of AF in multivariable analysis. CONCLUSIONS: A sizeable proportion of patients with inducible SVT without pre-excitation syndromes are elderly. These patients exhibit higher risks of erroneous tachycardia diagnosis prior to EPS as well as failure and/or complication of ablation, but similar risk of SVT recurrence. These results support performing transesophageal EPS in most patients and intracardiac EPS in selected patients. EPS may furthermore prove useful in elderly patients with regular tachycardia, mainly by avoiding treatment based on an erroneous diagnosis.

Follow-up of children or teenagers with paroxysmal supraventricular tachycardia, but without pre-excitation syndrome.

BACKGROUND: Paroxysmal supraventricular tachycardia (SVT) is considered benign in children if the electrocardiogram in sinus rhythm is normal, but causes anxiety in parents, children and doctors. AIMS: To report on the clinical and electrophysiological data from children with SVT, their follow-up and management. METHODS: Overall, 188 children/teenagers (mean age 15±2.8 years) with a normal electrocardiogram in sinus rhythm were studied for SVT, and followed for 2.3±4 years. RESULTS: SVT was poorly tolerated in 30/188 children (16.0%). SVT was related to atrioventricular nodal reentrant tachycardia (AVNRT) (n=133) or atrioventricular reentrant tachycardia (AVRT) over a concealed accessory pathway (n=55; 29.3%). Ablation of the slow pathway (n=66) or the accessory pathway (n=43) was performed without general anaesthesia, 2±3 years after initial evaluation. Failure or refusal to continue occurred in 18/109 (16.5%) children: 7/66 with AVNRT (10.6%), 11/43 with AVRT (25.6%) (P<0.001). Symptoms of SVT recurred in 20/91 children (22.0%) with apparently successful ablation: 6/91 (6.6%) had real SVT recurrence; 14/91 (15.4%) had only a sinus tachycardia, more frequent in AVNRT (11/59; 18.6%) than AVRT (3/32; 9.4%) (P<0.05). In 13 children treated with an antiarrhythmic drug (AAD), SVT recurred in four; two presented AAD-related syncope. In 66 untreated children, one death was noted after excessive AAD infusion to stop SVT; the others remained asymptomatic or had well-tolerated SVT. CONCLUSIONS: At the time of ablation, SVT management remains difficult in children. Indications for ablation are more common in AVRT than in AVNRT, but failures are frequent; 22.0% remained symptomatic after successful ablation, but false recurrences were frequent (15.4%). Without ablation, one third had a spontaneous favourable evolution.

Prediction of atrial fibrillation in patients with supraventricular tachyarrhythmias treated with catheter ablation or not. Classical scores are not useful.

BACKGROUND: Atrial fibrillation (AF) and other supraventricular tachyarrhythmias (SVTA) [atrial flutter (AFL), atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT) and preexcitation syndrome (PS)] are frequently associated. We assessed the AF occurrence frequency and predictors according to the nature of SVTA and completion of SVTA ablation. METHODS AND RESULTS: 4169 patients were referred for SVTA (typical AVNRT: 1338, AVRT over a concealed accessory pathway: 329, atypical AVNRT: 205, AFL: 1321; PS: 976); mean age was 50±20years; electrophysiological study (EPS) was systematic; patients were followed for a mean duration of 3±4.5years. Ablation of SVTA was performed in 2949 patients (71%) and 1220 patients were not treated or treated with antiarrhythmic drugs. AF developed in 469 patients (11.2%). In the multivariable model, AF prior to ablation, history of AF, nature of SVTA (AFL), and presence of heart disease were associated with a high risk of AF during follow-up. Presence of heart failure, old age, diabetes and vascular disease were not predictive of AF. Ablation was a weak but significant factor of AF prevention. A score based on nature of SVTA, presence of heart disease and history of AF is proposed. CONCLUSIONS: AF occurrence in patients with SVTA cannot be predicted by the presence of heart failure, old age, diabetes and vascular disease, but only by the following criteria, presence of heart disease, history of AF and nature of the SVTA (SVTA).

Influence of advancing age on clinical presentation, treatment efficacy and safety, and long-term outcome of pre-excitation syndromes: a retrospective cohort study of 961 patients included over a 25-year period.

OBJECTIVES: There are very little data on pre-excitation syndrome (PS) in the elderly. We investigated the influence of advancing age on clinical presentation, treatment and long-term outcome of PS. SETTING: Single-centre retrospective study of patient files. PARTICIPANTS: In all, 961 patients (72 patients ≥60 years (mean 68.5±6), 889 patients <60 years (mean 30.5±14)) referred for overt pre-excitation and indication for electrophysiological study (EPS) were followed for 5.3±5 years. Usual care included 24 h Holter monitoring, echocardiography and EPS. Patients underwent accessory pathway (AP) ablation if necessary. PRIMARY AND SECONDARY OUTCOME MEASURES: Occurrence of atrial fibrillation (AF) or procedure-induced adverse event. RESULTS: Electrophysiological data and recourse to AP ablation (43% vs 48.5%, p=0.375) did not significantly differ between the groups. Older patients more often had symptomatic forms (81% vs 63%, p=0.003), history of spontaneous AF (8% vs 3%, p=0.01) or adverse presentation (poorly tolerated arrhythmias: 18% vs 7%, p=0.0009). In multivariable analysis, patients ≥60 years had a significantly higher risk of history of AF (OR=4.2, 2.1 to 8.3, p=0.001) and poorly tolerated arrhythmias (OR=3.8, 1.8 to 8.1, p=0.001). Age ≥60 years was associated with an increased major AP ablation complication risk (10% vs 1.9%, p=0.006). During follow-up, occurrence of AF (13.9% vs 3.6%, p<0.001) and incidence of poorly tolerated tachycardia (4.2% vs 0.6%, p=0.001) were more frequent in patients ≥60 years, although frequency of ablation failure or recurrence was similar (20% vs 15.5%, p=0.52). In multivariable analysis, patients ≥60 years had a significantly higher risk of AF (OR=2.9, 1.2 to 6.8, p≤0.01). CONCLUSIONS: In this retrospective monocentre study, patients ≥60 years referred for PS work up appeared at higher risk of AF and adverse presentation, both prior and after the work up. These results suggest that, in elderly patients, the decision for EPS and AP ablation should be discussed in light of their suspected higher risk of events and ablation complications. However, these findings should be further validated in future prospective multicentre studies.

Predictors and prognostic significance of tachycardiomyopathy: insights from a cohort of 1269 patients undergoing atrial flutter ablation.

BACKGROUND: Atrial flutter-related tachycardiomyopathy (AFL-TCM) is a rare and treatable cause of heart failure. Little is known about its epidemiology and long-term prognosis. Our aims are to determine the prevalence, predictors and outcomes of AFL-TCM. METHODS AND RESULTS: A total of 1269 patients were referred for radiofrequency ablation of AFL between January 1996 and September 2014; 184 had reduced left ventricular ejection fraction (LVEF <40%). At 6 months after AFL ablation, 103 patients (8.1% of the population, 56% of patients with baseline LVEF <40%) had marked LVEF improvement: these were considered to have AFL-TCM. Patients with persisting reduced LVEF were considered to have systolic dysfunction unrelated to AFL. Patients were followed for a median (percentile25-75 ) of 1.15 (0.4-2.8) years. Patients with AFL-TCM were younger, had lower prevalence of ischaemic cardiomyopathy and used less antiarrhythmic drugs than patients with systolic dysfunction unrelated to AFL. In multivariable analysis, ischemic cardiomyopathy [odds ratio (OR) = 0.32, 95% confidence interval (CI) 0.15-0.68) P = 0.003] and prescription of antiarrhythmic drug before ablation [OR = 0.41, 95% CI 0.20-0.84, P = 0.02] were significantly associated with a lower probability of LVEF improvement during follow-up. Patients with AFL-TCM had similar survival to patients without systolic dysfunction at baseline [hazard ratio (HR) = 0.96 95% CI 0.34-2.65, P = 0.929], whereas patients with systolic dysfunction unrelated to AFL had higher mortality rates compared with patients without systolic dysfunction at baseline [HR = 2.88, 95% CI 1.45-5.72, P = 0.002]. CONCLUSIONS: Marked LVEF improvement was observed in 56% of patients with baseline LVEF <40% at 6 months after ablation. These patients had similar survival to patients without baseline systolic dysfunction, whereas patients who remained with LVEF <40% had a threefold increase in mortality rates.

Electrophysiological study generally is negative in patients <40 years suspected of supraventricular tachycardia but also complaining of chest pain and/or syncope.

BACKGROUND: The diagnosis of paroxysmal supraventricular tachycardia (SVT) frequently is a dilemma. Electrophysiological study (EPS) is the only means to evaluate the nature of symptoms when noninvasive studies remain negative. Our objectives were to determine the clinical factors of negativity or positivity of (EPS) in patients suspected of SVT. METHODS: EPS was performed in 2650 patients complaining of tachycardia and suspected of SVT. Transesophageal EPS consisted of programmed atrial stimulation in control state and after isoproterenol. Patients were followed from 1 month to 18 years (2.93 ± 4 years). RESULTS: SVT was induced in 1944 patients, age 48 ± 19.5. EPS remained negative in 706 patients, age 34 ± 17 (p<0.0001). Age <40 years, feeling of dizziness/syncope or chest pain associated with tachycardia, the absence of heart disease or short PR interval was more frequent in patients with negative EPS (respectively 64, 42, 26, 96, 88.5%) than in patients with induced SVT (34, 14, 4, 88, 59%) (p<0.0001).The positive predictive value for the prediction of a negative EPS of age <40, chest pain, syncope or their association was 63.5, 42, 26.5, 11% and negative predictive value was 66, 86, 94.5, 99.5%. At multivariate analysis, age <40 (0.000, OR 2.79), the presence of syncope associated with tachycardia (0.000, OR 5.075) or chest pain (0.000, OR 17.923) was an independent factor of negative EPS. CONCLUSIONS: Among patients complaining of nondocumented tachycardia, suspected of SVT, the association of tachycardia with chest pain and/or syncope and age <40 years generally was correlated with a negative EPS and did not indicate initially invasive studies. In the remaining patients transesophageal EPS is indicated.

AV nodal reentrant tachycardia or AV reentrant tachycardia using a concealed bypass tract-related adverse events.

OBJECTIVES: To jointly study paroxysmal supraventricular tachycardia (SVT)-related adverse events (AE) and ablation-related complications, with specific emphasis on the predictors of SVT-related AE as well as their significance by investigating their association with long-term mortality. METHODS: 1770 patients were included, aged 6 to 97, with either atrioventricular nodal reentrant tachycardia (AVNRT) or orthodromic atrioventricular reciprocal tachycardia (AVRT) mediated by concealed accessory pathway, consecutively referred for SVT work-up in a tertiary care center. RESULTS: SVT-related AE were identified in 339 patients (19%). Major AEs were identified in 23 patients (1%; 15 cardiac arrests or ventricular arrhythmias requiring cardioversion and 8 hemodynamic collapses). Other AE were related to syncope (n=236), acute coronary syndrome (n=57) and heart failure/rhythmic cardiomyopathy (n=21). In multivariable analysis, higher age, heart disease and requirement of isoproterenol to induce SVT were independently associated with a higher risk for SVT-related AE. During follow-up (2.8±3.0years), death occurred more frequently in patients with SVT-related AE, especially in patients with major adverse events (p<0.001). In multivariable analysis, major SVT-related AE remained significantly associated with occurrence of death (HR=6.72, IC=(2.58-17.52), p<0.001) independently of age and presence of underlying heart disease. Major SVT-related AE in the whole population referred for SVT were more frequent than immediate major ablation complications in patients undergoing SVT ablation (5/1186 vs. 23/1770, p=0.02). CONCLUSIONS: SVT-related AE are independent predictors of mortality and are more frequent than immediate major ablation complications in patients undergoing SVT ablation. The present findings support systematically performing SVT ablation in patients with SVT-related adverse events.

Risk and outcome after ablation of isthmus-dependent atrial flutter in elderly patients.

PURPOSE OF THE RESEARCH: To study the influence of age on the clinical presentation and long-term outcome of patients referred for atrial flutter (AFL) ablation. Age-related differences have been reported regarding the prognosis of arrhythmias. METHODS: A total of 1187 patients with a mean age 65±12 years consecutively referred for AFL ablation were retrospectively analyzed in the study. RESULTS: 445 (37.5%) patients were aged ≥70 (range 70 to 93) among which 345 were aged 70 to 79 years (29.1%) and 100 were aged ≥80 (8.4%). In multivariable analysis, AFL-related rhythmic cardiomyopathy and presentation with 1/1 AFL were less frequent (respectively adjusted OR = 0.44, 0.27-0.74, p = 0.002 and adjusted OR = 0.29, 0.16-0.52, p<0.0001). AFL ablation-related major complications were more frequent in patients ≥70 although remained lower than 10% (7.4% in ≥70 vs. 4.2% in <70, adjusted OR = 1.74, 1.04-2.89, p = 0.03). After 2.1±2.7 years, AFL recurrence was less frequent in patients ≥70 (adjusted OR = 0.54, 0.37-0.80, p = 0.002) whereas atrial fibrillation (AF) occurrence was as frequent in the 70-79 and ≥80 age subsets. As expected, cardiac mortality was higher in older patients. Patients aged ≥80 also had a low probability of AFL recurrence (5.0%) and AF onset (19.0%). CONCLUSIONS: Older patients represent 37.5% of patients referred for AFL ablation and displayed a <10% risk of ablation-related complications. Importantly, AFL recurrences were less frequent in patients ≥70 while AF occurrence was as frequent as in patients <70. Similar observations were made in patients ≥80 years. AFL ablation appears to be safe and efficient and should not be ruled out in elderly patients.

Age-related location of manifest accessory pathway and clinical consequences.

BACKGROUND: Accessory pathway (AP) ablation is not always easy. Our purpose was to assess the age-related prevalence of AP location, electrophysiological and prognostic data according to this location. METHODS: Electrophysiologic study (EPS) was performed in 994 patients for a pre-excitation syndrome. AP location was determined on a 12 lead ECG during atrial pacing at maximal preexcitation and confirmed at intracardiac EPS in 494 patients. RESULTS: AP location was classified as anteroseptal (AS)(96), right lateral (RL)(54), posteroseptal (PS)(459), left lateral (LL)(363), nodoventricular (NV)(22). Patients with ASAP or RLAP were younger than patients with another AP location. Poorly-tolerated arrhythmias were more frequent in patients with LLAP than in other patients (0.009 for ASAP, 0.0037 for RLAP, <0.0001 for PSAP). Maximal rate conducted over AP was significantly slower in patients with ASAP and RLAP than in other patients. Malignant forms at EPS were more frequent in patients with LLAP than in patients with ASAP (0.002) or PSAP (0.001). Similar data were noted when AP location was confirmed at intracardiac EPS. Among untreated patients, poorly-tolerated arrhythmia occurred in patients with LLAP (3) or PSAP (6). Failures of ablation were more frequent for AS or RL AP than for LL or PS AP. CONCLUSIONS: AS and RLAP location in pre-excitation syndrome was more frequent in young patients. Maximal rate conducted over AP was lower than in other locations. Absence of poorly-tolerated arrhythmias during follow-up and higher risk of ablation failure should be taken into account for indications of AP ablation in children with few symptoms.

Factors of negativity of electrophysiological study in children and teenagers complaining of tachycardia and prognostic significance.

When non-invasive studies remain negative, the diagnosis of unexplained tachycardia in the young is a dilemma. The purpose of the study was to determine the factors of negativity of transesophageal electrophysiological study (EPS) in children/teenagers complaining of tachycardia and the prognostic value. Two hundred and seventy-three children with a normal ECG in sinus rhythm, aged from 6 to 19 years (15 ± 3), complained of tachycardia. Transesophageal EPS consisted of atrial stimulation in control state and after isoproterenol. Supraventricular tachycardia (SVT) was induced in 149 patients (group I) and EPS remained negative in 124 (group II). Age did not differ (15 ± 3 vs 15 ± 3). Female gender and familial history of SVT were as frequent in group I (47, 11%) than in group II (55%, p = 0.15; 7%;p = 0.2). Feeling of dizziness/syncope with tachycardia was less frequent in group I (12%) than in group II (48%) (p < 0.0001). Feeling of chest pain with tachycardia was less frequent in group I (2%) than in group II (28%) (p < 0.0001). The presence of non-cardiac disease was less frequent in group I (1.3%) than in group II (6.4%) (p < 0.025). Patients with negative study remained free of SVT after a follow-up of 3.5 ± 3 years, but one had a complete AV block. In children with apparently normal ECG in sinus rhythm, who complained of tachycardia clinical history (association with syncope, chest pain, or the presence of another disease) can predict negativity of EPS with a relatively high accuracy; EPS may not be necessary. In very symptomatic patients, transesophageal EPS, which is inexpensive and non-invasive, might be performed to stop investigations.

Recurrences of symptoms after AV node re-entrant tachycardia ablation: a clinical arrhythmia risk score to assess putative underlying cause.

PURPOSE OF THE RESEARCH: To identify clinical factors associated with the probability for each arrhythmic mechanism causing recurring symptoms after atrioventricular nodal re-entrant tachycardia (AVNRT) ablation. Slow pathway radiofrequency ablation is used to treat AVNRT. After ablation, recurrence of symptoms due to AVNRT or other arrhythmias can occur. RESULTS: We studied 835 patients successfully treated with AVNRT ablation. Variables associated with each specific arrhythmia underlying symptom recurrence were studied by logistic regression. During a mean follow-up of 2.2 ± 2 years, 136 (16%) patients had a recurrence of symptoms. Following invasive and non-invasive studies, symptoms were mostly attributed to sinus tachycardia, recurrence of AVNRT and atrial arrhythmias (respectively 4.7%, 5.2% and 6.1%). Older age and history of atrial fibrillation were associated with a markedly increased risk of symptom recurrence due to atrial arrhythmias (OR=15.58, 7.09-35.22, p<0.001) whereas younger age was associated with a higher risk of sinus tachycardia. A simple 3-item clinical score based on age categories and atrial fibrillation history efficiently predicted atrial arrhythmia (C-Index=0.82, 0.75-0.89) and sinus tachycardia (C-Index=0.83, 0.75-0.90). 8.3% of patients with scores=0 had atrial arrhythmias whereas 100% of patients with scores ≥4 had atrial arrhythmias. CONCLUSIONS: While recurrence of symptoms after successful AVNRT ablation is relatively frequent (16%), true AVNRT recurrence accounts for only 1/3 of these recurrences. A simple clinical score based on age and history of atrial fibrillation enables efficient risk stratification for symptom recurrence attributable to atrial arrhythmias and inappropriate sinus tachycardia.

[Novel oral anticoagulants in patients with atrial fibrillation, how to avoid accidents?]. / Nouveaux anticoagulants oraux chez les patients atteints de fibrillation atriale, comment éviter les accidents ?

Know the indications of these new drugs, and respect them. Do not confuse easiness of administration and absence of precautions. Renal function: a key parameter before and during treatment. Know when to use a low-dose drug regimen. Cardioversion: lack of safety evidence for some drugs. Drug interactions: beware of P-glycoprotein and cytochrome P450.

A case series of patients with poorly-tolerated arrhythmias related to a preexcitation syndrome and presenting with atypical ECG.

UNLABELLED: The aim of study was to report different and unusual patterns of preexcitation syndrome (PS) noted in patients referred for studied for poorly-tolerated arrhythmias and their frequency. Electrophysiologic study (EPS) is an easy means to identify a patient with PS at risk of serious events. However the main basis for this diagnosis is the ECG which associates short PR interval and widening of QRS complex with a delta wave. METHODS: ECGs of 861 patients in whom PS related to an atrioventricular accessory pathway (AP) was identified at electrophysiological study (EPS), were studied. RESULTS: The most frequent unusual presentation (9.6%) was the PS presenting with a normal or near normal ECG, noted preferentially for left lateral AP and rarely for posteroseptal or right lateral location. More exceptional (0.1%) was the presence of a long PR interval, which did not exclude a rapid conduction over AP. The association of a complete AV block with symptomatic tachycardias was exceptional (0.3%) and was shown related to a rapid conduction over AP after isoproterenol. Most of the presented patients were at high-risk at EPS. CONCLUSION: The diagnosis of PS is not always evident and symptoms should draw attention to minor abnormalities and lead to enlarge indications of EPS, only means to confirm or not PS.

Risk of atrial fibrillation after atrial flutter ablation: impact of AF history, gender, and antiarrhythmic drug medication.

INTRODUCTION: Atrial fibrillation (AF) and flutter (AFL) are frequently associated. We assessed the frequency and identified the predictors of AF occurrence after AFL ablation. METHODS AND RESULTS: A total of 1,121 patients referred for AFL ablation were followed for a mean duration of 2.1 ± 2.7 years. Antiarrhythmic drugs were stopped after ablation in patients with no AF prior to ablation, or continued otherwise. A total of 356 patients (31.7%) had a history of AF prior to AFL ablation. Patients with AF prior to ablation were more likely to be females (OR = 1.35, CI = 1.00-1.83, P = 0.05). After ablation, 260 (23.2%) patients experienced AF. In the multivariable model, AF prior to ablation (OR = 1.90, CI = 1.42-2.54, P < 0.001) and female gender (OR = 1.77, CI = 1.29-2.42, P < 0.001) were associated with a higher risk of AF after ablation. In patients without prior AF, class I antiarrhythmics and amiodarone prior to AFL ablation were independently associated with higher risk of AF after ablation (OR = 2.11, CI = 1.15-3.88, P = 0.02 and OR = 1.60, CI = 1.08-2.36, P = 0.02, respectively). In patients who experienced AF after ablation, 201/260 (77.3%) had a CHA2DS2-VASc ≥1. Two patients with AF prior to ablation had a stroke during the follow-up whereas none of the patients without AF prior to ablation had a stroke. CONCLUSIONS: AF occurrence after AFL ablation is frequent (>20%), especially in patients with a history of AF, in female patients, and in patients treated with class I antiarrythmics/amiodarone prior to AFL. Since most patients who experience AF after AFL ablation have a CHA2DS2-VASc ≥1, the decision to stop anticoagulants after ablation should be considered on an individual basis.