Superior vena cava isolation using a pentaspline pulsed-field ablation catheter: feasibility and safety in patients undergoing atrial fibrillation catheter ablation.

AIMS: Superior vena cava (SVC) isolation during atrial fibrillation catheter ablation is limited by the risk of collateral damage to the sinus node and/or the phrenic nerve. Due to its tissue-specificity, we hypothesized the feasibility and safety of pulsed-field ablation (PFA)-based SVC isolation. METHODS AND RESULTS: One hundred and five consecutive patients undergoing PFA-based AF catheter ablation were prospectively included. After pulmonary vein isolation (±posterior wall isolation and electrical cardioversion), SVC isolation was performed using a standardized workflow. Acute SVC isolation was achieved in 105/105 (100%) patients after 6 ± 1 applications. Transient phrenic nerve stunning occurred in 67/105 (64%) patients but without phrenic nerve palsy at the end of the procedure and at hospital discharge. Transient high-degree sinus node dysfunction occurred in 5/105 (4.7%) patients, with no recurrence at the end of the procedure and until discharge. At the 3-month follow-up visit, no complication occurred. CONCLUSION: SVC isolation using a pentaspline PFA catheter is feasible and safe.

Revealing the true nature of a parachute mitral valve during an ultra-trail race.

Pre-participation screening and management of congenital cardiac valvulopathy in competitive athletes can be challenging, particularly within the context of ultra-endurance disciplines. A 55-year-old female athlete without a reported history of cardiac disease exhibited clinical signs of cardiogenic pulmonary edema during a 156 km ultra-trail race. The echocardiographic assessment revealed the presence of a parachute mitral valve, with no evidence of mitral stenosis or regurgitation at rest, but it demonstrated severe dynamic mitral stenosis during exercise. In competitive athletes, the detection of rare valvulopathy should prompt a comprehensive cardiac evaluation aimed at assessing the potential for dynamic valvular dysfunction.

Usefulness of sleep apnea monitoring by pacemaker sensor in elderly patients with diastolic dysfunction.

BACKGROUND: Automated detection of sleep apnea (SA) by pacemaker (PM) has been proposed and exhibited good agreement with polysomnography to detect severe SA. We aimed to evaluate the usefulness of SA monitoring algorithm in elderly patients with diastolic dysfunction. METHODS: Consecutive patients referred to the Caen University Hospital for PM implantation between May 2016 and December 2018 presenting isolated diastolic dysfunction were eligible for the study. The respiratory disturbance index (RDI) measured by the PM, and the mean monthly RDI (RDIm), were compared to the apnea hypopnea index (AHI) assessed with portable monitor for severe SA diagnosis. RESULTS: During the study period, 68 patients were recruited, aged of 80.4 ± 8.2 years. 63 patients underwent polygraphy with a portable monitor: 57 presented SA (83.8%), including 16 with severe SA (23.5%). Eight were treated with continuous positive airway pressure (CPAP). We found the RDI cutoff value of 22 events/h to predict severe SA, with 71.4% sensitivity and 65.2%, specificity. The RDIm cutoff value to detect severe SA was 19 events/h, with a sensitivity of 60% and a specificity of 66%. There was a significant reduction in RDI (p = 0.041), RDIm (p = 0.039) and AHI (p = 0.002) after CPAP. Supraventricular arrhythmias were frequent in all patients, regardless of SA severity, considering either episodes occurrence or total burden. CONCLUSION: In a population of elderly patients with PM and diastolic dysfunction, the SA monitoring algorithm was able to detect severe SA, with good diagnostic performance values, but also to provide follow-up data for the patients treated with CPAP.

Conduction system pacing in France in 2022: A snapshot survey from the Working Group of Pacing and Electrophysiology of the French Society of Cardiology.

BACKGROUND: Conduction system pacing (CSP) is an emerging and promising approach for physiological ventricular pacing. While data from randomized controlled trials are scarce, use of His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP) has increased in France. AIM: To perform a national snapshot survey for cardiac electrophysiologists to evaluate adoption of CSP in France. METHODS: An online survey, distributed to every senior cardiac electrophysiologist in France, was conducted in November 2022. RESULTS: A total of 120 electrophysiologists completed the survey. Eighty-three (69%) respondents reported experience in undertaking CSP procedures and 27 (23%) were planning to start performing CSP in the coming 2 years. The implantation techniques and criteria used for successful implantation differed significantly among operators. The most frequent indications for HBP and LBBAP were high-degree atrioventricular block with left ventricular ejection fraction (LVEF) < 40% (24 and 82%, respectively) or with LVEF ≥ 40% (27 and 74%, respectively), and after failure of a coronary sinus left ventricular lead (27 and 71%, respectively). The limitations respondents most frequently perceived when performing HBP were bad sensing/pacing parameters (45%), increased procedure duration (41%) and risk of lead dislodgement (30%). The most frequently perceived limitations to performing LBBAP were absence of guidelines or consensus (31%), lack of medical training (23%) and increased procedure duration (23%). CONCLUSIONS: Our national survey-based study supports wide adoption of CSP in France. CSP is currently used as a second-line approach for both antibradycardia and resynchronization indications, with important variations regarding implantation techniques and criteria for measuring success.

Recurrent acute myocarditis: An under-recognized clinical entity associated with the later diagnosis of a genetic arrhythmogenic cardiomyopathy.

Background: Myocardial inflammation has been consistently associated with genetic arrhythmogenic cardiomyopathy (ACM) and it has been hypothesized that episodes mimicking acute myocarditis (AM) could represent early inflammatory phases of the disease. Objective: We evaluated the temporal association between recurrent acute myocarditis (RAM) episodes and the later diagnosis of a genetic ACM. Materials and methods: Between January 2012 and December 2021, patients with RAM and no previous cardiomyopathy were included (Recurrent Acute Myocarditis Registry, NCT04589156). A follow-up visit including clinical evaluation, resting and stress electrocardiogram, cardiac magnetic resonance imaging, and genetic testing was carried out. Endpoints of the study was the incidence of both ACM diagnosis criteria and ACM genetic mutation at the end of follow-up. Results: Twenty-one patients with RAM were included and follow-up was completed in 19/21 patients (90%). At the end of follow-up, 3.3 ± 2.9 years after the last AM episode, 14/21 (67%) patients with an ACM phenotype (biventricular: 10/14, 71%; left ventricular: 4/14, 29%) underwent genetic testing. A pathogenic or likely pathogenic mutation was found in 8/14 patients (57%), 5/8 in the Desmoplakin gene, 2/8 in the Plakophillin-2 gene, and 1/8 in the Titin gene. Family history of cardiomyopathy or early sudden cardiac death had a positive predictive value of 88% for the presence of an underlying genetic mutation in patients with RAM. Conclusion: RAM is a rare entity associated with the latter diagnosis of an ACM genetic mutation in more than a third of the cases. In those patients, RAM episodes represent early inflammatory phases of the disease. Including RAM episodes in ACM diagnosis criteria might allow early diagnosis and potential therapeutic interventions.

Vascular entrapment of a multipolar basket catheter (OrionTM ) during catheter ablation.

The IntellaMap OrionTM (Boston Scientific) is a 64-electrode basket catheter allowing for ultrahigh-density mapping of complex cardiac arrhythmias. We report the case of a basket catheter vascular entrapment, requiring surgical removal.

Atrial fibrillation detection by the subcutaneous defibrillator: real-world clinical performances and implications from a multicentre study.

AIMS: No data exist concerning the clinical performances of the subcutaneous implantable cardioverter-defibrillator (S-ICD) atrial fibrillation (AF) detection algorithm. We aimed to study the performances and implications of the latter in a 'real-world' setting. METHODS AND RESULTS: Between July 2017 and August 2019, 155 consecutive S-ICD recipients were included. Endpoint of the study was the incidence of de novo or recurrent AF using a combined on-site and remote-monitoring follow-up approach. After a mean follow-up of 13 ± 8 months, 2531 AF alerts were generated for 55 patients. A blinded analysis of the 1950 subcutaneous electrocardiograms available was performed. Among them 47% were true AF, 23% were premature atrial contractions or non-sustained AF, 29% were premature ventricular contractions or non-sustained ventricular tachycardia, and 1% were misdetection. Fourteen percent (21/155) patients had at least one correct diagnosis of AF by the S-ICD algorithm. One patient presented symptomatic paroxysmal AF not diagnosed by the S-ICD algorithm (false negative patient). Patient-based sensitivity, specificity, positive, and negative predictive values were respectively 95%, 74%, 38%, and 99%. Among patients with at least one correct diagnosis of AF, 38% (8/21) had subsequent clinical implications (anticoagulation initiation or rhythm control therapies). CONCLUSION: The S-ICD AF detection algorithm yields a high sensitivity for AF diagnosis. Low specificity and positive predictive value contribute to a high remote monitoring-notification workload and underline the necessity of a manual analysis. Atrial fibrillation diagnosis by the S-ICD AF detection algorithm might lead to significant therapeutic adjustments.

Clinical outcomes after primary prevention defibrillator implantation are better predicted when the left ventricular ejection fraction is assessed by cardiovascular magnetic resonance.

BACKGROUND: The left ventricular ejection fraction (LVEF) is the key selection criterion for an implanted cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death. LVEF is usually assessed by two-dimensional echocardiography, but cardiovascular magnetic resonance (CMR) imaging is increasingly used. The aim of our study was to evaluate whether LVEF assessment using CMR imaging (CMR-LVEF) or two-dimensional echocardiography (2D echo-LVEF) may predict differently the occurrence of clinical outcomes. METHODS: In this retrospective study, we reviewed patients referred for primary prevention ICD implantation to Caen University Hospital from 2005 to 2014. We included 173 patients with either ischemic (n = 120) or dilated cardiomyopathy (n = 53) and who had undergone pre-ICD CMR imaging. The primary composite end point was the time to death from any cause or first appropriate device therapy. RESULTS: The mean CMR-LVEF was significantly lower than the mean 2D echo-LVEF (24% ± 6 vs 28% ± 6, respectively; p < 0.001). CMR-LVEF was a better independent predictive factor for the occurrence of the primary composite endpoint with a cut-off value of 22% (Hazard Ratio [HR] = 2.22; 95% CI [1.34-3.69]; p = 0.002) than 2D echo-LVEF with a cut-off value of 26% (HR = 1.61; 95% CI [0.99-2.61]; p = 0.056). Combination of the presence of scar with CMR-LVEF< 22% improved the predictive value for the occurrence of the primary outcome (HR = 2.58; 95% CI [1.54-4.30]; p < 0.001). The overall survival was higher among patients with CMR-LVEF≥22% than among patients with CMR-LVEF< 22% (p = 0.026), whereas 2D echo-LVEF was not associated with death. CONCLUSIONS: CMR-LVEF is better associated with clinical outcomes than 2D echo-LVEF in primary prevention using an ICD. Scar identification further improved the outcome prediction. The combination of CMR imaging and echocardiography should be encouraged in addition to other risk markers to better select patients.

Prevalence and significance of fragmented QRS complex in lead V1 on the surface electrocardiogram of healthy athletes.

AIMS: Limited data exist concerning fragmented QRS complexes (fQRSs) on the surface electrocardiogram (ECG) of apparently healthy athletes. We aimed to study the prevalence and significance of fQRS in lead V1 (fQRSV1), representing right ventricular (RV) activation, regarding training-induced RV morphological remodelling. METHODS AND RESULTS: Between January 2017 and August 2019, 434 consecutive non-sedentary subjects underwent preparticipation cardiovascular screening, including a 12-lead ECG. Three hundred and ninety-three apparently healthy subjects were included, 119 of them were athletes (defined as performing ≥8 h/week for the last 6 months) and 274 were non-athletes. All athletes underwent two-dimensional transthoracic echocardiography. Fragmented QRS complex in lead V1 pattern was defined as a narrow (<120 ms) and quadriphasic QRS complex in lead V1. Fragmented QRS complex in lead V1 was more frequent in athletes compared with non-athletes (22% vs. 5.1%, P < 0.001) and was independently associated with the athlete status [adjusted odds ratio (aOR) = 4.693, 95% confidence interval (95% CI) 2.299-9.583; P < 0.001], the endurance category (aOR = 2.522, 95% CI 1.176-5.408; P = 0.017), and age (aOR = 0.962, 95% CI 0.934-0.989; P = 0.007) in multivariate analysis. In the subgroup of athletes, fQRSV1 was independently associated with mean RV outflow tract diameter (aOR = 1.458, 95% CI 1.105-1.923; P = 0.008) and age (aOR = 0.941, 95% CI 0.894-0.989; P = 0.017) in multivariate analysis. CONCLUSION: Fragmented QRS complex in lead V1 is a newly described, frequent, ECG pattern in young and apparently healthy athletes and is associated with training-induced RV remodelling.

Safety of uninterrupted direct oral anticoagulants for ambulatory common atrial flutter catheter ablation: A propensity score-matched cohort study.

BACKGROUND: Same-day home discharge after common atrial flutter catheter ablation (CAFCA) is a feasible, safe, and cost-effective practice, but there are currently no data for patients treated with direct oral anticoagulants (DOAs). OBJECTIVE: We evaluated the safety, efficacy, and feasibility of ambulatory CAFCA in patients treated with DOAs compared with those treated with vitamin K antagonists (VKAs). METHODS: Patients scheduled for isolated and elective ambulatory CAFCA in our tertiary university center between 2009 and 2019 were included. Propensity score for anticoagulant type was calculated from age, sex, body mass index, HAS-BLED and CHA2DS2-VASc scores, chronic kidney disease, associated antiplatelet treatment, procedure duration, and number of femoral venipunctures. RESULTS: Propensity score matching yielded 820 patients (mean age 67 ± 11 years). Catheter ablation was performed under uninterrupted VKA (n = 410; international normalized ratio 2.5 ± 0.6) or uninterrupted DOA (n = 410). The procedural success rate was 91%, and the effective same-day discharge rate was 93%. The occurrence of the primary end point, defined as any early and clinically significant bleeding (Bleeding Academic Research Consortium classification ≥ 2) at 1 week, was similar between patients treated with DOAs and those treated with VKAs (2.9% vs 3.7%; P = .70). Female sex, high HAS-BLED score, and prolonged procedure duration were independently associated with the primary end point. CONCLUSION: Uninterrupted DOA regimens are safe for patients undergoing ambulatory CAFCA in a high-volume center with a dedicated ambulatory unit and standardized procedural and postoperative management.

Predictors of clinical outcomes after cardiac resynchronization therapy in patients ≥75 years of age: a retrospective cohort study.

BACKGROUND: Cardiac resynchronization therapy has been shown to benefit selected patients with heart failure and reduced ejection fraction. Older patients have been underrepresented in randomized trials. This study was conducted to determine whether predictive factors for cardiac resynchronization therapy outcomes differ in patients older and younger than 75 years of age. METHODS: Consecutive patients who received a cardiac resynchronization device cardiac resynchronization therapy between 2013 and 2016 in our center were retrospectively included in this cohort study. The primary endpoint was cardiac resynchronization therapy effectiveness, which was defined as survival for one year with both no heart failure hospitalization and improvement by one or more NYHA class. The secondary endpoints were mortality, complications, and device therapies. RESULTS: Among the 243 patients included, 102 were ≥ 75 years old. Cardiac resynchronization therapy effectiveness was observed in 70 patients (50%) < 75 years old and in 48 patients (47%) ≥75 years old (p = 0.69). NYHA class ≥III (OR = 6.02; CI95% [1.33-18.77], p = 0.002) was a predictive factor for cardiac resynchronization therapy effectiveness only in the ≥75-year-old group, while atrial fibrillation was independently negatively associated with the primary endpoint in the < 75-year-old group (OR = 0.28; CI95% [0.13-0.62], p = 0.001). The one-year mortality rate was 14%, with no difference between age groups. Rescue cardiac resynchronization therapy and atrial fibrillation were independent predictive factors for mortality in both age groups. Eighty-two complications occurred in 45 patients (19%), with no difference between groups. Defibrillator use and QRS duration were independent predictive factors for complications in both age groups. There was no difference between groups considering device therapies. CONCLUSION: At one year, cardiac resynchronization therapy response is not compromised by patient age. In older patients, highly symptomatic individuals with NYHA class ≥III have better outcomes after cardiac resynchronization therapy.

Rationale and Design for a Monocentric Prospective Study: Sleep Apnea Diagnosis Using a Novel Pacemaker Algorithm and Link With Aldosterone Plasma Level in Patients Presenting With Diastolic Dysfunction (SAPAAD Study).

Previous studies showed good agreement between pacemaker respiratory disturbance index (RDI) and polysomnography for diagnosis of severe sleep apnea (SA). The aim of this study is to investigate the diagnostic accuracy of RDI compared with apnea-hypopnea index (AHI) from a cardiorespiratory sleep study for the diagnosis of severe SA within patients requiring a pacemaker and meeting diastolic dysfunction criteria. Secondary objectives are as follows: correlation between plasma aldosterone level and SA severity, diagnostic accuracy of RDI for moderate SA, prevalence of SA among patients with diastolic dysfunction, occurrence of arrhythmias, and improvement of RDI with continuous positive airway pressure therapy. We designed a monocentric prospective nonrandomized study of prevalent cases to include 68 patients with a 6-month follow-up. Both RDI and AHI will be compared 2 months after implantation and after 1 month of continuous positive airway pressure treatment in patients with severe SA. This is the first study that examines diagnostic accuracy of pacemaker algorithm for the diagnosis of SA and correlation with plasma aldosterone levels in patients with diastolic dysfunction. Protocol version: V04. 04/04/2017 Trial registration: ClinicalTrials.gov NCT02751021.

Staggered Multiple-PRF Ultrafast Color Doppler.

Color Doppler imaging is an established pulsed ultrasound technique to visualize blood flow non-invasively. High-frame-rate (ultrafast) color Doppler, by emissions of plane or circular wavefronts, allows severalfold increase in frame rates. Conventional and ultrafast color Doppler are both limited by the range-velocity dilemma, which may result in velocity folding (aliasing) for large depths and/or large velocities. We investigated multiple pulse-repetition-frequency (PRF) emissions arranged in a series of staggered intervals to remove aliasing in ultrafast color Doppler. Staggered PRF is an emission process where time delays between successive pulse transmissions change in an alternating way. We tested staggered dual- and triple-PRF ultrafast color Doppler, 1) in vitro in a spinning disc and a free jet flow, and 2) in vivo in a human left ventricle. The in vitro results showed that the Nyquist velocity could be extended to up to 6 times the conventional limit. We found coefficients of determination r(2) ≥ 0.98 between the de-aliased and ground-truth velocities. Consistent de-aliased Doppler images were also obtained in the human left heart. Our results demonstrate that staggered multiple-PRF ultrafast color Doppler is efficient for high-velocity high-frame-rate blood flow imaging. This is particularly relevant for new developments in ultrasound imaging relying on accurate velocity measurements.