Frédéric Anselme

The design of a percutaneous implantable prosthetic heart valve has become an important area for investigation. A percutaneously implanted heart valve (PHV) composed of 3 bovine pericardial leaflets mounted within a balloon-expandable stent was developed. After ex vivo testing and animal implantation studies, the first human implantation was performed in a 57-year-old man with calcific aortic stenosis, cardiogenic shock, subacute leg ischemia, and other associated noncardiac diseases. Valve replacement had been declined for this patient, and balloon valvuloplasty had been performed with nonsustained results.With the use of an antegrade transseptal approach, the PHV was successfully implanted within the diseased native aortic valve, with accurate and stable PHV positioning, no impairment of the coronary artery blood flow or of the mitral valve function, and a mild paravalvular aortic regurgitation. Immediately and at 48 hours after implantation, valve function was excellent, resulting in marked hemodynamic improvement. Over a follow-up period of 4 months, the valvular function remained satisfactory as assessed by sequential transesophageal echocardiography, and there was no recurrence of heart failure. However, severe noncardiac complications occurred, including a progressive worsening of the leg ischemia, leading to leg amputation with lack of healing, infection, and death 17 weeks after PHV implantation.Nonsurgical implantation of a prosthetic heart valve can be successfully achieved with immediate and midterm hemodynamic and clinical improvement. After further device modifications, additional durability tests, and confirmatory clinical implantations, PHV might become an important therapeutic alternative for the treatment of selected patients with nonsurgical aortic stenosis.

Early repolarization is a common electrocardiographic finding that is generally considered to be benign. Its potential to cause cardiac arrhythmias has been hypothesized from experimental studies, but it is not known whether there is a clinical association with sudden cardiac arrest.We reviewed data from 206 case subjects at 22 centers who were resuscitated after cardiac arrest due to idiopathic ventricular fibrillation and assessed the prevalence of electrocardiographic early repolarization. The latter was defined as an elevation of the QRS-ST junction of at least 0.1 mV from baseline in the inferior or lateral lead, manifested as QRS slurring or notching. The control group comprised 412 subjects without heart disease who were matched for age, sex, race, and level of physical activity. Follow-up data that included the results of monitoring with an implantable defibrillator were obtained for all case subjects.Early repolarization was more frequent in case subjects with idiopathic ventricular fibrillation than in control subjects (31% vs. 5%, P<0.001). Among case subjects, those with early repolarization were more likely to be male and to have a history of syncope or sudden cardiac arrest during sleep than those without early repolarization. In eight subjects, the origin of ectopy that initiated ventricular arrhythmias was mapped to sites concordant with the localization of repolarization abnormalities. During a mean (+/-SD) follow-up of 61+/-50 months, defibrillator monitoring showed a higher incidence of recurrent ventricular fibrillation in case subjects with a repolarization abnormality than in those without such an abnormality (hazard ratio, 2.1; 95% confidence interval, 1.2 to 3.5; P=0.008).Among patients with a history of idiopathic ventricular fibrillation, there is an increased prevalence of early repolarization.

To the Editor: Lamin A/C gene mutations are associated with various disorders,1,2 including cardiac abnormalities characterized by atrial fibrillation, conduction-system disturbances, sudden death,...

Abstract 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.

Background: An accurate estimation of the risk of life-threatening (LT) ventricular tachyarrhythmia (VTA) in patients with LMNA mutations is crucial to select candidates for implantable cardioverter-defibrillator implantation. Methods: We included 839 adult patients with LMNA mutations, including 660 from a French nationwide registry in the development sample, and 179 from other countries, referred to 5 tertiary centers for cardiomyopathies, in the validation sample. LTVTA was defined as (1) sudden cardiac death or (2) implantable cardioverter defibrillator–treated or hemodynamically unstable VTA. The prognostic model was derived using the Fine-Gray regression model. The net reclassification was compared with current clinical practice guidelines. The results are presented as means (SD) or medians [interquartile range]. Results: We included 444 patients, 40.6 (14.1) years of age, in the derivation sample and 145 patients, 38.2 (15.0) years, in the validation sample, of whom 86 (19.3%) and 34 (23.4%) experienced LTVTA over 3.6 [1.0–7.2] and 5.1 [2.0–9.3] years of follow-up, respectively. Predictors of LTVTA in the derivation sample were: male sex, nonmissense LMNA mutation, first degree and higher atrioventricular block, nonsustained ventricular tachycardia, and left ventricular ejection fraction (https://lmna-risk-vta.fr). In the derivation sample, C-index (95% CI) of the model was 0.776 (0.711–0.842), and the calibration slope 0.827. In the external validation sample, the C-index was 0.800 (0.642–0.959), and the calibration slope was 1.082 (95% CI, 0.643–1.522). A 5-year estimated risk threshold ≥7% predicted 96.2% of LTVTA and net reclassified 28.8% of patients with LTVTA in comparison with the guidelines-based approach. Conclusions: In comparison with the current standard of care, this risk prediction model for LTVTA in laminopathies significantly facilitated the choice of candidates for implantable cardioverter defibrillators. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03058185.

No study has so far compared Amulet with the new Watchman FLX in terms of residual left atrial appendage (LAA) patency or clinical outcomes in patients undergoing percutaneous LAA closure.In the investigator-initiated SWISS APERO trial (Comparison of Amulet Versus Watchman/FLX Device in Patients Undergoing Left Atrial Appendage Closure), patients undergoing LAA closure were randomly assigned (1:1) open label to receive Amulet or Watchman 2.5 or FLX (Watchman) across 8 European centers. The primary end point was the composite of justified crossover to a nonrandomized device during LAA closure procedure or residual LAA patency detected by cardiac computed tomography angiography (CCTA) at 45 days. The secondary end points included procedural complications, device-related thrombus, peridevice leak at transesophageal echocardiography, and clinical outcomes at 45 days.Between June 2018 and May 2021, 221 patients were randomly assigned to Amulet (111 [50.2%]) or Watchman (110 [49.8%]), of whom 25 (22.7%) patients included before October 2019 received Watchman 2.5, and 85 (77.3%) patients received Watchman FLX. The primary end point was assessable in 205 (92.8%) patients and occurred in 71 (67.6%) patients receiving Amulet and 70 (70.0%) patients receiving Watchman, respectively (risk ratio, 0.97 [95% CI, 0.80-1.16]; P=0.713). A single justified crossover occurred in a patient with Amulet who fulfilled LAA patency criteria at 45-day CCTA. Major procedure-related complications occurred more frequently in the Amulet group (9.0% versus 2.7%; P=0.047) because of more frequent bleeding (7.2% versus 1.8%). At 45 days, the peridevice leak rate at transesophageal echocardiography was higher with Watchman than with Amulet (27.5% versus 13.7%, P=0.020), albeit none was major (ie, >5 mm), whereas device-related thrombus was detected in 1 (0.9%) patient with Amulet and 3 (3.0%) patients with Watchman at CCTA and in 2 (2.1%) and 5 (5.5%) patients at transesophageal echocardiography, respectively. Clinical outcomes at 45 days did not differ between the groups.Amulet was not associated with a lower rate of the composite of crossover or residual LAA patency compared with Watchman at 45-day CCTA. Amulet, however, was associated with lower peridevice leak rates at transesophageal echocardiography, higher procedural complications, and similar clinical outcomes at 45 days compared with Watchman. The clinical relevance of CCTA-detected LAA patency requires further investigation.URL: https://www.gov; Unique identifier: NCT03399851.

Brugada syndrome is a genetic disease associated with sudden cardiac death that is characterized by ventricular fibrillation and right precordial ST segment elevation on ECG. Loss-of-function mutations in SCN5A, which encodes the predominant cardiac sodium channel alpha subunit NaV1.5, can cause Brugada syndrome and cardiac conduction disease. However, SCN5A mutations are not detected in the majority of patients with these syndromes, suggesting that other genes can cause or modify presentation of these disorders. Here, we investigated SCN1B, which encodes the function-modifying sodium channel beta1 subunit, in 282 probands with Brugada syndrome and in 44 patients with conduction disease, none of whom had SCN5A mutations. We identified 3 mutations segregating with arrhythmia in 3 kindreds. Two of these mutations were located in a newly described alternately processed transcript, beta1B. Both the canonical and alternately processed transcripts were expressed in the human heart and were expressed to a greater degree in Purkinje fibers than in heart muscle, consistent with the clinical presentation of conduction disease. Sodium current was lower when NaV1.5 was coexpressed with mutant beta1 or beta1B subunits than when it was coexpressed with WT subunits. These findings implicate SCN1B as a disease gene for human arrhythmia susceptibility.

Sudden cardiac death is frequent in patients with lamin A/C gene (LMNA) mutations and may be related to ventricular arrhythmias (VA).To evaluate a strategy of prophylactic implantable cardioverter-defibrillator (ICD) implantation in LMNA mutation carriers with significant cardiac conduction disorders.Forty-seven consecutive patients (mean age 38 ± 11 years; 26 men) were prospectively enrolled between March 1999 and April 2009. Prophylactic ICD implantation was performed in patients with significant cardiac conduction disorders: patients requiring permanent pacing for bradycardia or already implanted with a pacemaker at the initial presentation, or patients with a PR interval of >0.24 seconds and either complete left bundle branch block or nonsustained ventricular tachycardia.Twenty-one (45%) patients had significant conduction disorders and received a prophylactic ICD. Among ICD recipients, no patient died suddenly and 11 (52%) patients required appropriate ICD therapy during a median follow-up of 62 months. Left ventricular ejection fraction was ≥45% in 9 patients at the time of the event. Among the 10 patients without malignant VA, device memory recorded nonsustained ventricular tachycardia in 8 (80%). The presence of significant conduction disorders was the only factor related to the occurrence of malignant VA (hazard ratio 5.20; 95% confidence interval 1.14-23.53; P = .03).Life-threatening VAs are common in patients with LMNA mutations and significant cardiac conduction disorders, even if left ventricular ejection fraction is preserved. ICD is an effective treatment and should be considered in this patient population.

We evaluated the incidence of conduction abnormalities and requirement for permanent pacemaker in patients undergoing transcatheter aortic valve implantation (TAVI) with the Edwards Sapien prosthesis. In 2009, >8,000 patients were treated with TAVI using 1 of the 2 commercialized models of bioprosthesis (Edwards Sapien, Edwards Lifesciences, Irvine, California; and CoreValve, Medtronic, Irvine, California). Occurrence of conduction abnormalities including complete atrioventricular block requiring permanent pacemaker has been reported after TAVI with the 2 models of valve, more frequently with the CoreValve. We analyzed standard 12-lead electrocardiograms of 69 consecutive patients in whom an Edwards Sapien prosthesis was successfully implanted. Electrocardiograms were examined before treatment, at day 1, and at 1-month follow-up. Heart rate, PR and QT intervals and QRS duration were measured and the presence of a first-, second-, or third-degree atrioventricular block was documented. There was a slight increase in heart rate and a discrete decrease in QT interval at day 1. These values had returned to baseline values at 1 month. There was no change in PR interval but a transitory increase in QRS duration was noted. Frequency of left bundle branch block increased from 14.5% at baseline to 27.5% at day 1 with a decreased incidence at day 30 (21.3%). Permanent pacemaker was required in only 3 patients (4.3%). In conclusion, in our experience, conductive disorders and requirement of a definitive pacemaker after implantation of an Edwards Sapien aortic bioprosthesis are infrequent. The physical properties of this prosthesis may explain this observation.

Various types of complications have been reported after atrial fibrillation (AF) ablation using radiofrequency energy, but those have not been well defined when using cryoballoon ablation technique. The objective of this prospective study was to assess types, incidence, and outcome of complications after cryoballoon pulmonary vein isolation (PVI).This prospective monocentric study included 66 consecutive patients (39 males, age 57 ± 11 years) who underwent cryoballoon PVI for symptomatic paroxysmal AF. Phrenic nerve (PN) integrity was assessed by pacing from the superior vena cava during isolation of the right PVs. Before discharge, all patients were subjected to 24-hour Holter electrocardiograms, echocardiography, and esophagogastroduodenoscopy. Cardiac MRI was scheduled between 1 and 3 months postprocedure. At 3.7 ± 1.7 months after ablation, patients underwent clinical review and 24-hour Holter electrocardiograms. The mean number of cryoballoon applications was 10.0 ± 2.1 per patient and 2.5 ± 1.0 per vein. A 28 mm cryoballoon was used in 49 patients (74%) and a 23 mm cryoballoon in the remaining 17 patients (26%). Twelve complications (18%) attributing to collateral nervous damage were noticed in 9 patients: asymptomatic gastroparesis was observed in 6 patients (9%), transient PN palsy (PNP) in 5 (8%), and symptomatic inappropriate sinus tachycardia requiring beta-blocker treatment in 1 (1%). Neither cryoballoon-related esophageal ulceration nor PV stenosis was observed.Gastroparesis and PNP could be observed in a significant number of cases after cryoballoon ablation of AF. These complications are likely due to cryo-induced damages to nervous structures surrounding the heart.

The benefit related to the use of preprocedural computed tomography angiography (CCTA) on top of periprocedural echocardiography to plan percutaneous left atrial appendage closure (LAAC) procedures is still unclear.The authors sought to evaluate the impact of preprocedural CCTA on LAAC procedural success.In the investigator-initiated SWISS-APERO (Comparison of Amplatzer Amulet and Watchman Device in Patients Undergoing Left Atrial Appendage Closure) trial, patients undergoing echocardiography-guided LAAC were randomly assigned to receive the Amulet (Abbott) or Watchman 2.5/FLX (Boston Scientific) device across 8 European centers. According to the study protocol ongoing at the time of the procedure, the first operators had (CCTA unblinded group) or did not have (CCTA blinded group) access to preprocedural CCTA images. In this post hoc analysis, we compared blinded vs unblinded procedures in terms of procedural success defined as complete left atrial appendage occlusion as evaluated at the end of LAAC (short-term) or at the 45-day follow-up (long-term) without procedural-related complications.Among 219 LAACs preceded by CCTA, 92 (42.1%) and 127 (57.9%) were assigned to the CCTA unblinded and blinded group, respectively. After adjusting for confounders, operator unblinding to preprocedural CCTA remained associated with a higher rate of short-term procedural success (93.5% vs 81.1%; P = 0.009; adjusted OR: 2.76; 95% CI: 1.05-7.29; P = 0.040) and long-term procedural success (83.7% vs 72.4%; P = 0.050; adjusted OR: 2.12; 95% CI: 1.03-4.35; P = 0.041).In a prospective multicenter cohort of clinically indicated echocardiography-guided LAACs, unblinding of the first operators to preprocedural CCTA images was independently associated with a higher rate of both short- and long-term procedural success. Further studies are needed to better evaluate the impact of preprocedural CCTA on clinical outcomes.

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee. Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; P =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19–10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 ( P =0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96–40.95]). Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03837574.

Complete bidirectional isthmus conduction block (CBIB) was initially assessed by sequential detailed activation mapping at both sides of the ablation line during proximal coronary sinus and anteroinferior right atrium pacing. Mapping only the ablation line ("on-site" atrial potential analysis) was recently reported as a means of CBIB identification. The study was designed to compare these 2 techniques prospectively regarding the diagnosis of CBIB.In 76 consecutive patients (mean age, 63.4+/-10.5 years), typical atrial flutter ablation was performed using either the activation mapping technique (group I) or on-site atrial potential analysis (group II). Criteria for CBIB using on-site atrial potential analysis was the recording of parallel, widely spaced double atrial potentials along the ablation line. The CBIB criterion was retrospectively searched using the alternative technique at the end of the procedure. In successful patients, the mean radiofrequency delivery duration was longer in group II (845+/-776 versus 534+/-363 s; P:=0.03). On-site, clear-cut, widely spaced double atrial potentials and activation mapping suggesting CBIB were concomitantly observed in only 47 patients (54%), and ambiguous/atypical double potentials were recorded in 31 patients (39%).Although feasible, the on-site atrial potential analysis seemed to be inferior to the classic activation mapping technique, mainly because of the ambiguity of electrogram interpretation along the ablation line. However, when combined with the activation mapping technique, it provided additional information regarding isthmus conduction properties in some cases. Therefore, optimally, both methods should be used concomitantly.

Despite the low long‐term incidence of high‐degree atrioventricular (AV) block and the known negative effects of ventricular pacing, programming of the AAI mode in patients with sinus node dysfunction (SND) remains exceptional. A new pacing mode was, therefore, designed to combine the advantages of AAI with the safety of DDD pacing. AAIsafeR behaves like the AAI mode in absence of AV block. First‐ and second‐degree AV blocks are tolerated up to a predetermined, programmable limit, and conversion to DDD takes place in case of high‐degree AV block. From DDD, the device may switch back to AAI, provided AV conduction has returned. The safety of AAIsafeR was examined in 43 recipients (70 ± 12‐year old, 24 men) of dual chamber pacemakers implanted for SND or paroxysmal AV block. All patients underwent 24‐hour ambulatory electrocardiographic recordings before hospital discharge and at 1 month of follow‐up with the AAIsafeR mode activated. No AAIsafeR‐related adverse event was observed. At 1 month, the device was functioning in AAIsafeR in 28 patients (65%), and the mean rate of ventricular pacing was 0.2%± 0.4%. Appropriate switches to DDD occurred in 15 patients (35%) for frequent, unexpected AV block. AAIsafeR mode was safe and preserved ventricular function during paroxysmal AV block, while maintaining a very low rate of ventricular pacing. The performance of this new pacing mode in the prevention of atrial fibrillation will be examined in a large, controlled study.

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

This study aimed to assess the impact of pulmonary valve replacement (PVR) on ventricular arrhythmias burden in a population of tetralogy of Fallot (TOF) patients with continuous cardiac monitoring by implantable cardioverter-defibrillators (ICDs).Sudden cardiac death is a major cause of death in TOF, and right ventricular overload is commonly considered to be a potential trigger for ventricular arrhythmias.Data were analyzed from a nationwide French ongoing study (DAI-T4F) including all TOF patients with an ICD since 2000. Survival data with recurrent events were used to compare the burden of appropriate ICD therapies before and after PVR in patients who underwent PVR over the study period.A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% male) were included from 40 centers. Over a median follow-up period of 6.8 (interquartile range: 2.5 to 11.4) years, 26 patients (15.8%) underwent PVR. Among those patients, 18 (69.2%) experienced at least 1 appropriate ICD therapy. When considering all ICD therapies delivered before (n = 62) and after (n = 16) PVR, the burden of appropriate ICD therapies was significantly lower after PVR (HR: 0.21; 95% confidence interval [CI]: 0.08 to 0.56; p = 0.002). Respective appropriate ICD therapies rates per 100 person-years were 44.0 (95% CI: 35.7 to 52.5) before and 13.2 (95% CI: 7.7 to 20.5) after PVR (p < 0.001). In the overall cohort, PVR before ICD implantation was also independently associated with a lower risk of appropriate ICD therapy in primary prevention patients (HR: 0.29 [95% CI: 0.10 to 0.89]; p = 0.031).In this cohort of high-risk TOF patients implanted with an ICD, the burden of appropriate ICD therapies was significantly reduced after PVR. While optimal indications and timing for PVR are debated, these findings suggest the importance of considering ventricular arrhythmias in the overall decision-making process. (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator [DAI-T4F]; NCT03837574).

Although aortic valve replacement is undoubtedly the treatment of choice for aortic valve stenosis, balloon aortic valvuloplasty may represent the only possible treatment for some frail elderly patients who may have additional medical problems. We evaluated immediate and 1-year results of balloon aortic valvuloplasty in 86 patients ≥80 years with severe aortic stenosis. Mean age was 84±3 years. Forty-four % were 85 years or older. Mean gradient decreased from 68 to 26 mmHg and valve area increased from 0⋅53 to 0⋅96 cm2 (P<0⋅05). There were two per-procedural deaths. No local vascular complication was observed During the follow-up (13±9 months), 27 patients died, four had repeat balloon aortic valvuloplasty and eight underwent aortic valve replacement. Persistent clinical improvement was observed in 78% of the surviving patients. One-year actuarial survival rate was 73%. Balloon aortic valvuloplasty appears to be a safe and valuable technique in cases where surgery cannot be performed or carries a very high risk.

Background Ventricular arrhythmias (VAs) can occur after continuous flow left ventricular assist device (LVAD) implantation as a single arrhythmic event or as electrical storm (ES) with multiple repetitive VA episodes. Objective We aimed at analyzing the incidence, predictors, and clinical impact of ES in LVAD recipients. Methods Patients analyzed were those included in the multicenter ASSIST-ICD observational study. ES was consensually defined as occurrence of ≥3 separate episodes of sustained VAs within a 24-hour interval. Results Of 652 patients with an LVAD, 61 (9%) presented ES during a median follow-up period of 9.1 (interquartile range [IQR] 2.5–22.1) months. The first ES occurred after 17 (IQR 4.0–56.2) days post LVAD implantation, most of them during the first month after the device implantation (63%). The incidence then tended to decrease during the initial years of follow-up and increased again after the third year post LVAD implantation. History of VAs before LVAD implantation and heart failure duration > 84 months were independent predictors of ES. The occurrence of ES was associated with an increased early mortality since 20 patients (33%) died within the first 2 weeks of ES. Twenty-two patients (36.1%) presented at least 1 recurrence of ES, occurring 43.0 (IQR 8.0–69.0) days after the initial ES. Patients experiencing ES had a significantly lower 1-year survival rate than did those free from ES (log-rank, P = .039). Conclusion There is a significant incidence of ES in patients with an LVAD. The short-term mortality after ES is high, and one-third of patients will die within 15 days. Whether radiofrequency ablation of arrhythmias improves outcomes would require further studies. Ventricular arrhythmias (VAs) can occur after continuous flow left ventricular assist device (LVAD) implantation as a single arrhythmic event or as electrical storm (ES) with multiple repetitive VA episodes. We aimed at analyzing the incidence, predictors, and clinical impact of ES in LVAD recipients. Patients analyzed were those included in the multicenter ASSIST-ICD observational study. ES was consensually defined as occurrence of ≥3 separate episodes of sustained VAs within a 24-hour interval. Of 652 patients with an LVAD, 61 (9%) presented ES during a median follow-up period of 9.1 (interquartile range [IQR] 2.5–22.1) months. The first ES occurred after 17 (IQR 4.0–56.2) days post LVAD implantation, most of them during the first month after the device implantation (63%). The incidence then tended to decrease during the initial years of follow-up and increased again after the third year post LVAD implantation. History of VAs before LVAD implantation and heart failure duration > 84 months were independent predictors of ES. The occurrence of ES was associated with an increased early mortality since 20 patients (33%) died within the first 2 weeks of ES. Twenty-two patients (36.1%) presented at least 1 recurrence of ES, occurring 43.0 (IQR 8.0–69.0) days after the initial ES. Patients experiencing ES had a significantly lower 1-year survival rate than did those free from ES (log-rank, P = .039). There is a significant incidence of ES in patients with an LVAD. The short-term mortality after ES is high, and one-third of patients will die within 15 days. Whether radiofrequency ablation of arrhythmias improves outcomes would require further studies.

In repaired tetralogy of Fallot (TOF), little is known about characteristics of patients with rapid ventricular tachycardia (VT). Also, whether patients with a first episode of nonrapid VT may subsequently develop rapid VT or ventricular fibrillation (VF) has not been addressed.The objectives of this study were to compare patients with rapid VT/VF with those with nonrapid VT and to assess the evolution of VT cycle lengths (VTCLs) overtime.Data were analyzed from a nationwide registry including all patients with TOF and implantable cardioverter-defibrillator (ICD) since 2000. Patients with ≥1 VT episode with VTCL ≤250 ms (240 beats/min) formed the rapid VT/VF group.Of 144 patients (mean age 42.0 ± 12.7 years; 104 [72%] men), 61 (42%) had at least 1 VT/VF episode, including 28 patients with rapid VT/VF (46%), during a median follow-up of 6.3 years (interquartile range 2.2-10.3 years). Compared with patients in the nonrapid VT group, those in the rapid VT/VF group were significantly younger at ICD implantation (35.2 ± 12.6 years vs 41.5 ± 11.2 years; P = .04), had more frequently a history of cardiac arrest (8 [29%] vs 2 [6%]; P = .02), less frequently a history of atrial arrhythmia (11 [42%] vs 22 [69%]; P = .004), and higher right ventricular ejection fraction (43.3% ± 10.3% vs 36.6% ± 11.2%; P = .04). The median VTCL of VT/VF episodes was 325 ms (interquartile range 235-429 ms). None of the patients with a first documented nonrapid VT episode had rapid VT/VF during follow-up.Patients with TOF and rapid VT/VF had distinct clinical characteristics. The relatively low variation of VTCL over time suggests a room for catheter ablation without a backup ICD in selected patients with well-tolerated VT.

Recent developments in imaging, mapping, and ablation techniques have shown that the epicardial region of the heart is a key player in the occurrence of ventricular arrhythmic events in several cardiac diseases, such as Brugada syndrome, arrhythmogenic cardiomyopathy, or dilated cardiomyopathy. At the atrial level as well, the epicardial region has emerged as an important determinant of the substrate of atrial fibrillation, pointing to common underlying pathophysiological mechanisms. Alteration in the gradient of repolarization between myocardial layers favouring the occurrence of re-entry circuits has largely been described. The fibro-fatty infiltration of the subepicardium is another shared substrate between ventricular and atrial arrhythmias. Recent data have emphasized the role of the epicardial reactivation in the formation of this arrhythmogenic substrate. There are new evidences supporting this structural remodelling process to be regulated by the recruitment of epicardial progenitor cells that can differentiate into adipocytes or fibroblasts under various stimuli. In addition, immune-inflammatory processes can also contribute to fibrosis of the subepicardial layer. A better understanding of such 'electrical fragility' of the epicardial area will open perspectives for novel biomarkers and therapeutic strategies. In this review article, a pathophysiological scheme of epicardial-driven arrhythmias will be proposed.

Very few data have been published on the use of subcutaneous implantable cardioverter-defibrillators (S-ICDs) in patients with congenital heart disease (CHD).The aim of this study was to analyze outcomes associated with S-ICDs in patients with CHD.This nationwide French cohort including all patients with an S-ICD was initiated in 2020 by the French Institute of Health and Medical Research. Characteristics at implantation and outcomes were analyzed in patients with CHD.From October 12, 2012, to December 31, 2019, among 4,924 patients receiving an S-ICD implant in 150 centers, 101 (2.1%) had CHD. Tetralogy of Fallot, univentricular heart, and dextro-transposition of the great arteries represented almost one-half of the population. Patients with CHD were significantly younger (age 37.1 ± 15.4 years vs 50.1 ± 14.9 years; P < 0.001), more frequently female (37.6% vs 23.0%; P < 0.001), more likely to receive an S-ICD for secondary prevention (72.3% vs 35.9%; P < 0.001), and less likely to have severe systolic dysfunction of the systemic ventricle (28.1% vs 53.1%; P < 0.001). Over a mean follow-up period of 1.9 years, 16 (15.8%) patients with CHD received at least 1 appropriate shock, with all shocks successfully terminating the ventricular arrhythmia. The crude risk of appropriate S-ICD shock was twice as high in patients with CHD compared with non-CHD patients (annual incidences of 9.0% vs 4.4%; HR: 2.1; 95% CI: 1.3-3.4); however, this association was no longer significant after propensity matching (especially considering S-ICD indication, P = 0.12). The burden of all complications (HR: 1.2; 95% CI: 0.7-2.1; P = 0.4) and inappropriate shocks (HR: 0.9; 95% CI: 0.4-2.0; P = 0.9) was comparable in both groups.In this nationwide study, patients with CHD represented 2% of all S-ICD implantations. Our findings emphasize the effectiveness and safety of S-ICD in this particularly high-risk population. (S-ICD French Cohort Study [HONEST]; NCT05302115).

Three cases of twiddler's syndrome in patients with an abdominally implanted cardioverter defibrillator (ICD) and an endocardial lead system are reported. The condition was detected when an increase in pacing threshold or lead impedance was noted at routine follow-up. Successful revision was possible in all patients; however, a recurrence in one patient necessitated removal of the device. Elderly female patients with some degree of obesity appear most susceptible. Minimizing pocket size and suturing of the device to the fascia should decrease the chance of developing this problem.

The coronary arterial system has been the subject of greater investigation than its venous system due to the importance of human coronary artery disease. With the advent of new percutaneous treatments, the anatomy of the coronary venous system has increasing relevancy. We compared the organization of the coronary venous circulation in three species commonly used in research and compared these to normal humans using both macroscopic anatomic and angiographic studies.The anatomy of five explanted hearts from healthy dogs, pigs, and sheep were studied macroscopically, and 10 explanted hearts per animal species and 10 clinically normal human were examined by angiography.Animal hearts were injected with latex and dissected macroscopically. The coronary venous system of humans was evaluated from clinical angiographic studies. In the animal hearts, a retrograde angiographic study was performed via a Foley catheter in the coronary sinus.The general organization of the coronary venous circulation was similar among humans, dogs, sheep, and pigs. Despite overall similarities to humans, animal hearts demonstrated the absence of the oblique vein of the left atrium and differences in position and organization of venous valves; venous diameters; number of tributary veins; and presence of an anastomosis between the left and right (human anterior and posterior) venous tree. The left azygos of the pig and sheep joined the coronary sinus.Anatomical differences must be considered when planning biomedical and veterinary studies incorporating cardiac veins. This study provides baseline data regarding structure and organization of the cardiac venous system.

Magnetic resonance imaging (MRI) has become the reference imaging technique for the management of a large number of diseases. The number of MRI examinations increases every year, simultaneously with the number of patients receiving a cardiac electronic implantable device (CEID). The presence of a CEID was considered an absolute contraindication for MRI for many years. The progressive replacement of conventional pacemakers and defibrillators by "magnetic resonance (MR)-conditional" CEIDs and recent data on the safety of MRI in patients with "MR-non-conditional" CEIDs have gradually increased the demand for MRI in patients with a CEID. However, some risks are associated with MRI in CEID carriers, even with MR-conditional devices, because these devices are not "MR safe". Specific programming of the device in "MR mode" and monitoring patients during MRI remain mandatory for all patients with a CEID. A standardized patient workflow based on an institutional protocol should be established in each institution performing such examinations. This joint position paper of the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the French Society of Diagnostic and Interventional Cardiac and Vascular Imaging describes the effect of and risks associated with MRI in CEID carriers. We propose recommendations for patient workflow and monitoring and CEID programming in MR-conditional, "MR-conditional non-guaranteed" and MR-non-conditional devices. L'imagerie par résonance magnétique (IRM) est devenue l'imagerie de référence pour le diagnostic d'un grand nombre de pathologies. Le nombre d'examens IRM est en augmentation constante, parallèlement au nombre de patients implantés avec un dispositif électronique cardiaque implantable (DECI). L'IRM était considérée comme une contre-indication absolue à l'IRM jusqu'à il y a quelques années. Le remplacement progressif des stimulateurs et des défibrillateurs conventionnels par des dispositifs « IRM compatibles sous conditions » ainsi que les données récentes sur la sécurité des examens IRM chez les patients porteurs de dispositifs « non-IRM compatible » ont considérablement accru la demande d'examens IRM chez les patients porteurs de DECI. Cependant, les IRM peuvent être associés à certains risques chez les porteurs de DECI, y compris ceux « IRM compatibles sous conditions ». La programmation spécifique de l'appareil en mode « IRM » et la surveillance des patients pendant l'examen restent obligatoires pour tous les patients porteurs de DECI. Une prise en charge standardisée s'appuyant sur un protocole institutionnel est recommandée dans chaque établissement effectuant de tels examens. Ce document conjoint du Groupe Rythmologie et Stimulation Cardiaque de la Société Française de Cardiologie et de la Société Française d'Imagerie Cardiaque et Vasculaire Diagnostique et Interventionnelle décrit les effets et les risques associés à l'IRM chez des porteurs de DECI. Nous proposons des recommandations pour la prise en charge de ces patients, leur surveillance, ainsi que la programmation des dispositifs qu'ils soient « IRM compatibles sous conditions », « IRM compatibles sous conditions hors garantie constructeur » ou « non-IRM compatibles ».

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

Electrocardiographic (ECG) screening prior to S-ICD implantation is unsuccessful in around 10% of cases. A personalized screening method, by slightly moving the electrodes, to obtain a better R/T ratio has been described to overcome traditional screening failure.

Prediction of outcomes remains an unmet need in LVAD candidates. Development of right heart failure portends an excess in mortality but imaging parameters of right ventricular systolic function have failed to demonstrate a prognostic role. By integrating pulmonary pressure, right ventriculoarterial coupling could fill this gap.

The introduction of a new technology always raises questions about its place compared with the reference technology. The use of an implantable cardioverter defibrillator to prevent sudden cardiac death is now a widely proven technique, with a clear statement of its indication in the guidelines. More recently, a subcutaneous implantable cardioverter defibrillator has been introduced, and appears to be an attractive technique as it removes the need to implant a lead inside the right ventricle to treat the patient, which should dramatically decrease the risk of complications over time. Currently, only one model of subcutaneous implantable cardioverter defibrillator is available on the market; its indications are the same as for transvenous implantable cardioverter defibrillators, except for patients who need stimulation because of conduction disorders or ventricular tachycardias that can potentially be treated effectively by antitachycardia pacing. The different technical characteristics of transvenous versus subcutaneous implantable cardioverter defibrillators therefore raise the question of which to choose in different clinical settings. The experts who participated in the preparation of this manuscript had three meetings, organized by the company Boston Scientific. Each expert prepared the draft of a section corresponding to a clinical situation. The choice between transvenous versus subcutaneous implantable cardioverter defibrillator was then voted on by all the experts. The results of the votes are presented in this manuscript, as it seemed important to us to show the disparities of opinion that can exist in certain situations. The votes were cast independently and anonymously.

Pacing and Clinical ElectrophysiologyVolume 19, Issue 1 p. 115-119 An Unusual Cause of Tachycardia-Induced Myopathy FREDERIC ANSELME, FREDERIC ANSELME Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, Massachusetts Supported by a grant from La Federation Francaise de Cardiologie.Search for more papers by this authorJOOST FREDERIKS, JOOST FREDERIKS Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsSearch for more papers by this authorNOEL G. BOYLE, NOEL G. BOYLE Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsSearch for more papers by this authorPANOS PAPAGEORGIOU, PANOS PAPAGEORGIOU Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsSearch for more papers by this authorMARK E. JOSEPHSON, Corresponding Author MARK E. JOSEPHSON Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsAddress for reprints: Mark E. Josephson, M.D., Harvard Thorndike Electrophysiologic Institute, Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215. Fax: [617] 667-4833.Search for more papers by this author FREDERIC ANSELME, FREDERIC ANSELME Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, Massachusetts Supported by a grant from La Federation Francaise de Cardiologie.Search for more papers by this authorJOOST FREDERIKS, JOOST FREDERIKS Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsSearch for more papers by this authorNOEL G. BOYLE, NOEL G. BOYLE Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsSearch for more papers by this authorPANOS PAPAGEORGIOU, PANOS PAPAGEORGIOU Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsSearch for more papers by this authorMARK E. JOSEPHSON, Corresponding Author MARK E. JOSEPHSON Harvard Thorndike Electrophysiologic: Institute, Beth Israel Hospital, Boston, MassachusettsAddress for reprints: Mark E. Josephson, M.D., Harvard Thorndike Electrophysiologic Institute, Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215. Fax: [617] 667-4833.Search for more papers by this author First published: January 1996 https://doi.org/10.1111/j.1540-8159.1996.tb04800.xCitations: 13 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume19, Issue1January 1996Pages 115-119 RelatedInformation

Catheter ablation of atrial fibrillation (AF) has been recently shown to have an impact on the outcome of patients with heart failure and reduced LV ejection fraction (LVEF). We aimed to assess patients with reduced LVEF referred to catheter ablation of AF, and the efficacy and safety of this procedure compared with healthier patients.2083 consecutive procedures of catheter ablation of AF in six centers were divided into two groups on the basis of LVEF (≤ vs >35%) and comparisons were performed regarding procedural safety and efficacy.Only 51 (2.4%) of patients had low LVEF. Complication rate was comparable: 8.0% vs 6.9% (P = .760). Low LVEF patients are more frequently in persistent AF at the time of the procedure, have a higher degree of left atrial dilation, and higher CHA2 DS2 VASc score. The rate of atrial arrhythmia relapse post-blanking period in the first 12 months was higher in the low LVEF group: 58.0% vs 37.6% (P < .001). During a median follow-up of 14 months (IQR 5-24), after adjusting for all baseline differences, AF duration, paroxysmal AF, CHA2 DS2 VASc score, BMI, and indexed LA volume were independent predictors of relapse. LVEF and LVEF ≤ 35% were not identified as predictors of relapse.Patients with reduced LVEF account for only a minority of patients undergoing catheter ablation of AF. However, ablation appears to be as safe as for the general population, and albeit the efficacy seems lower, this appears to be driven by other comorbidities or features, which are more frequent in this population.

In the current issue of the journal, Kautzner et al .[1] report a surprising and to date unrecognized high incidence (15%) of concomitant atrioventricular nodal reentrant tachycardia (AVNRT) in patients referred to the electrophysiology laboratory for catheter ablation of symptomatic right ventricular outflow tract tachycardia (RVOT VT). Although association of these two arrhythmias had not been clinically documented before ablation, they were beyond any doubt sequentially inducible in the same heart. Before concluding that this is mere chance, several potential common factors such as mechanisms, substrates, triggers, or sympathovagal status for initiation, which may contribute to the coexistence of these two different arrhythmias in the same patient, should be analysed. By definition, idiopathic VT refers to ventricular arrhythmias that originate in hearts without structural disease[2]. Although several magnetic resonance imaging studies have reported absence of structural ventricular defects in these patients, others have shown RVOT abnormalities including focal wall thinning and abnormal regional systolic wall motion. However, the causal relationship between the anatomic abnormalities and the site of tachycardia origin remains controversial[3,4]. Results of studies of right ventricular biopsy sample are heterogeneous. Pathological findings range from normal myocardium, interstitial fibrosis, myocardial cell hypertrophy to myocarditis[5,6]. Therefore, the implication of these histologic findings in the pathophysiology of RVOT VT remains unclear. Many studies have implied that the so-called fast and slow pathways involved in the genesis of AVNRT were anatomically distinct structures. However, …

Abstract Background Right ventricular pacing (RVP) induces ventricular asynchrony in patients with normal QRS and increases the risk of heart failure and atrial fibrillation in long term. His bundle pacing (HBP) is a physiological alternative to RVP, and could overcome its drawbacks. Recent studies assessed the feasibility and safety of HBP in expert centers with a vast experience of this technique. These results may not apply to less experienced centers. We aim to evaluate the feasibility and safety of permanent HBP performed by physicians who are new to this technique. Methods We included all patients who underwent pacemaker implantation with attempt of HBP in three hospitals between September 2017 and January 2020. Indication for HBP was left to operators' discretion. All the operators were new for HBP. His bundle (HB) electrical parameters were recorded at implant, 3‐ and 12‐month follow‐up. Results HBP was successful in 141 of 170 patients (82.9%); selective HBP was obtained in 96 patients and nonselective HBP in 45. The mean procedure and fluoroscopy durations were 67.0 ± 28.8 min, and 7.3 ± 8.1 min (3.1 ± 4.1 Gy·cm 2 ), respectively. The mean HB paced QRS duration was 106 ± 18 ms. The mean HB capture threshold was 1.29 ± 0.77 V and did not increase at 3‐ and 12‐month follow‐up. The ventricular lead revision was required in five patients. Our results showed a rapid technical learning allowing a high procedure success rate (89.8%) after 15 procedures. Conclusion HBP performed by operators new to this technique appeared feasible and safe. This should encourage HBP to be performed in patients expected to experience high RVP burden.

Women with congenital heart disease at high risk for sudden cardiac death have been poorly studied thus far.The aim of this study was to assess sex-related differences in patients with tetralogy of Fallot (TOF) and implantable cardioverter-defibrillators (ICDs).Data were analyzed from the DAI-T4F (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator) cohort study, which has prospectively enrolled all patients with TOF with ICDs in France since 2010. Clinical events were centrally adjudicated by a blinded committee.A total of 165 patients (mean age 42.2 ± 13.3 years) were enrolled from 40 centers, including 49 women (29.7%). Among the 9,692 patients with TOF recorded in the national database, the proportion of women with ICDs was estimated to be 1.1% (95% CI: 0.8%-1.5%) vs 2.2% (95% CI: 1.8%-2.6%) in men (P &lt; 0.001). The clinical profiles of patients at implantation, including the number of risk factors for ventricular arrhythmias, were similar between women and men. During a median follow-up period of 6.8 years (IQR: 2.5-11.4 years), 78 patients (47.3%) received at least 1 appropriate ICD therapy, without significant difference in annual incidences between women (12.1%) and men (9.9%) (HR: 1.22; 95% CI: 0.76-1.97; P = 0.40). The risk for overall ICD-related complications was similar in women and men (HR: 1.33; 95% CI: 0.81-2.19; P = 0.30), with 24 women (49.0%) experiencing at least 1 complication.Our findings suggest that women with TOF at high risk for sudden cardiac death have similar benefit/risk balance from ICD therapy compared with men. Whether ICD therapy is equally offered to at-risk women vs men warrants further evaluation in TOF as well as in other congenital heart disease populations. (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator [DAI-T4F]; NCT03837574).

Phrenic Nerve Isolation in Cardiac Resynchronization. Left phrenic nerve stimulation is a well‐known complication of cardiac resynchronization therapy (CRT). We report a case where electronic or anatomical repositioning of the left ventricular (LV) electrode (within the coronary sinus tributaries) was not feasible/effective. Surgical graft interpositioning was performed to successfully isolate the phrenic nerve from the previously implanted coronary sinus epicardial LV lead. (J Cardiovasc Electrophysiol, Vol. 23, pp. 778‐780, July 2012)

A new pacing mode was designed to combine the advantages of AAI mode with the safety of DDD for sick sinus syndrome patients (pts.). The objectives of this study were to assess the safety and efficacy of this new mode.

Different dual-chamber pacing modes are nowadays available to pace Sinus Node Dysfunction (SND) patients (pts.). Inappropriate ventricular pacing has been associated with adverse events as congestive heart failure and AF recurrences. The objective of this study was to assess the respective efficacy of different pacing modes, regarding preservation of spontaneous AV conduction.

Automatic beat-by-beat capture functions are designed to minimize the pacing energy delivered, while maintaining the highest safety by delivering an immediate back-up stimulus in case of loss of capture. The objective of this study was to estimate the lowering of ventricular pacing amplitude allowed by such a function, compared to amplitudes usually set manually in routine practice. An automatic ventricular pacing threshold test is launched every 6 hours to measure the automatic capture threshold (AT). From AT the function calculates: (1) the"capture amplitude"(V(c)) = AT + 0.5 V at a minimum output of 1 V and (2) the"safety amplitude" (V(s)) = twice AT at a minimum output of 2.5 V. The function preferentially uses V(c) and verifies capture after each paced beat. In case of loss of capture, a back-up spike is delivered and V(s) is implemented until the next threshold measurement. We estimated the ventricular amplitude delivered by the pacemaker from data stored in the pacemaker memory. We compared these values with the pacing amplitude typically programmed manually (MPA) by physicians at twice AT and a minimum of 2.5 V. Data from 57 recipients of Talent 3 DR pacemakers were analyzed. Complete data sets were available in 25 patients at 1 day, 28 at 1 month, and 39 between 1 day and 1 month. No loss of capture or ventricular pause was observed on 53 ambulatory electrocardiograms (ECG); and pulse amplitude automatically delivered by the device was significantly lower than the MPA at each of the three time points analyzed. This new beat-by-beat capture function allows a significant lowering of the pacing amplitude compared to manual settings, while preserving a 100% safety.

Frequency and distribution of left ventricular (LV) venous collaterals were studied in vivo to evaluate the ease and feasibility of implanting a new ultra-thin LV quadripolar microlead for cardiac resynchronization therapy (CRT).Methods and Results:Evaluable venograms were analyzed to define the prevalence of venous collaterals (>0.5 mm diameter) between: (1) different LV segments; and (2) different major LV veins in: unselected patients who underwent CRT from 2008 to 2012 at Rouen Hospital, France (retrospective); and CRT patients from the Axone Acute pilot study in 2018 (prospective). In prospective patients with evaluable venograms, LV microlead implantation was attempted. Thirty-six (21/65 retrospective, 15/20 prospective) patients had evaluable venograms with ≥1 visible venous collaterals. Collaterals were found between LV veins in all CRT patients with evaluable venograms. Regionally, prevalence was highest between: the apical inferior and apical lateral (42%); and mid inferior and mid inferolateral (42%) segments. Collateral connections were most prevalent between: the inferior interventricular vein (IIV) and lateral vein (64% [23/36]); and IIV and infero-lateral vein (36% [13/36]). Cross-vein microlead implantation was possible in 18 patients (90%), and single-vein implantation was conducted in the other 2 patients (10%).Venous collaterals were found in vivo between LV veins in all CRT patients with evaluable venograms, making this network an option for accessing multiple LV sites using a single LV microlead.

Left bundle branch pacing (LBBP) is a recent technique aiming at preservation of physiological ventricular electrical activation. Our goal was to assess mechanical synchrony parameters in relation to electrocardiographic features during LBBP performed in routine practice. From June 2020 to August 2021, all patients of our institution with permanent pacemaker implantation indication were eligible for LBBP. A “qR” pattern in V1 and a left ventricular activation time ≤ 80 ms in V5 defined a successful LBBP. Electrocardiogram and echocardiography were performed during spontaneous rhythm and LBBP: left ventricular mechanical asynchrony (LVMS) parameters using 2D Speckle tracking and interventricular mechanical delay (IVMD) were collected. LBBP was attempted with success in 134/163 patients (82.2%). During LBBP, the mean QRS width was 104 ± 12 ms. In patients with left bundle branch block (n = 47), LBBP provided a significant decrease of QRS width from 139 ± 16 ms to 105 ± 12 ms (P < 0.001) with reduction of LVMS (53 ± 21 ms vs. 90 ± 46 ms, P = 0.009) and IVMD (14 ± 13 ms vs. 49 ± 18 ms, P < 0.001) (example in Fig. 1). In patients with right bundle branch block (n = 38), LBBP led to a significant decrease of QRS width from 134 ± 14 ms to 106 ± 13 ms (P < 0.001) with no effect on LVMS and a reduction of IVMD (17 ± 14 vs. 50 ± 16 ms, P < 0.001). LBBP in routine practice preserved intra-ventricular mechanical synchrony in patients with narrow and RBBB QRS and improved asynchrony parameters in patients with LBBB.

Optimal left ventricular (LV) lead implantation remains an important issue in the sphere of cardiac resynchronization therapy (CRT), mainly because of the complex anatomy of the coronary venous network. 1 Vernooy K. van Deursen C.J. Strik M. Prinzen F.W. Strategies to improve cardiac resynchronization therapy. Nat Rev Cardiol. 2014; 11: 481-493 Crossref PubMed Scopus (56) Google Scholar ,2 Thomas G. Kim J. Lerman B.B. Improving cardiac resynchronisation therapy. Arrhythm Electrophysiol Rev. 2019; 8: 220-227 Crossref PubMed Scopus (16) Google Scholar Unsuccessful LV lead implantation procedures still account for 3.6% of attempted CRT procedures and suboptimal LV lead placements for up to 7% of them. 3 Gamble J.H.P. Herring N. Ginks M. Rajappan K. Bashir Y. Betts T.R. Procedural success of left ventricular lead placement for cardiac resynchronization therapy: a meta-analysis. JACC Clin Electrophysiol. 2016; 2: 69-77 Crossref PubMed Scopus (52) Google Scholar A novel quadripolar microlead technology (Axone system, MicroPort CRM, Clamart, France) has been designed to overcome these limitations. 4 Anselme F. Albatat M. Marquié C. et al. Exploring a new systematic route for left ventricular pacing in cardiac resynchronization therapy. Circulation. 2021; 85: 283-290 Crossref Scopus (2) Google Scholar The microlead is a lumenless downsized wire structure (1.2 F) with 4 distant electrodes (IS4–LLLL). The microlead family offers different models of increased total length and interelectrode distance to address the variability of patient anatomy. The small size of its electrodes results in a high impedance value range. 5 Anselme F, Ziglio F, Shan N, Heckman LI, Kuiper M and Prinzen FW. Acute and chronic performance evaluation of a new ultra-thin left ventricular quadripolar pacing lead in a canine model. Poster presented at Heart Rhythm Society congress; May 6-9, 2020; San Diego, USA. Google Scholar

Although the first few months after acute myocardial infarction (MI) are associated with an increased risk of SCD, in particular when LVEF is ≤0.35, prophylactic ICDs are not recommended until LVEF has been reassessed after a period of 40 to 90 days following an acute MI. During this ‘waiting period’, wearable cardioverter defibrillators (WCD) may be used in patients considered at high-risk of SCD, but the prognostic significance of sustained VT/VF occurring under WCD protection is unknown. We sought to evaluate whether the occurrence of VT/VF, successfully treated by a WCD in the early post-MI phase, is associated with a poorer outcome with regard to death or VT/VF recurrences at one year. We recruited a series of patients with an acute MI and a resulting LVEF≤0.35 (evaluated 2-5 days after admission) who were prescribed a WCD upon hospital discharge (for a maximal expected duration of 3 months) and who were subsequently implanted with an ICD either because sustained VT/VF occurred while on WCD (Group A) or because LVEF remained ≤0.35 after the post-MI ‘waiting period’ (Group B). Informed consent was mandatory to participate in the study. Adjudication of arrhythmic events was based on the analysis of ICD/WCD recordings. Based on previous publications, eleven relevant clinical parameters (associated with a higher risk of SCD after MI) were assessed for statistical analysis in addition to the occurrence of VT/VF while on WCD. The study population consisted of 1032 consecutive patients (Group A: n=72, Group B: n=960) from 41 French centers. The median follow-up after ICD implantation was 2.6 years [interquartile range=1.5-3.9]. The clinical characteristics of the patients are shown in Table 1. At one year: 1) VT/VF requiring ICD treatment occurred in 22.2% vs 3.5% (p<0.0001) respectively in Group A and Group B patients and 2) death from any cause occurred in 11.1% vs 3.4% (p=0.001) respectively in Group A and Group B patients (Figure 1). Occurrence of VT/VF while on WCD was independently associated with the occurrence of VT/VF and all-cause death after ICD implantation. Our study suggests that the occurrence of VT/VF, while on WCD in the early post-MI period after an acute MI, is an independent marker of a poorer one-year prognosis in patients with a LVEF≤0.35. Further studies are needed to assess which therapeutic strategies might improve the short-term prognosis in these patients.Tabled 1Table 1: Patient characteristicsVariablesGroup A (n = 72)Group B (n = 960)p-valueGender (male, %)88.9%82.9 %0.25Age at ICD implantation (years, mean ± SD)61.5 ± 9.060.7 ± 10.50.52Current smoker (%)50.7 %47.9 %0.90Diabetes mellitus (%)30.6 %23.2 %0.20History of hypertension (%)47.9 %41.7 %0.32History of atrial fibrillation (%)8.3 %4.8 %0.17History of previous myocardial infarction (%)16.7 %18.8 %0.75Early (<24 hours) coronary revascularization for the index myocardial infarction (%)51.4 %66.3 %0.014Average heart rate during WCD (bpm, mean ± SD)73.2 ± 12.568.3 ± 9.6<0.0001NYHA III/IV class at ICD implantation (%)39.6%19.1%0.001Serum creatinine at ICD implantation [mg/L, median (Q1 - Q3)]10.8 (9.2 - 13.1)10.7 (8.9 - 13.2)0.42LVEF at ICD implantation (%, mean ± SD)29.1 ± 6.629.3 ± 6.20.78 Open table in a new tab

Abstract Background An accurate estimation of the risk of life-threatening (LT) ventricular tachyarrhythmia (VTA) in patients with LMNA mutations is crucial to select candidates for implantable cardioverter defibrillator (ICD) implantation. Methods We included 839 adult patients with LMNA mutations, including 660 from a French nationwide registry in the development sample, and 179 from other countries, referred to 5 tertiary centers for cardiomyopathies, in the validation sample. LTVTA was defined as a) sudden cardiac death or b) ICD-treated or hemodynamically unstable VTA. The prognostic model was derived using Fine-Gray's regression model. The net reclassification was compared with current clinical practice guidelines. The results are presented as means (standard deviation) or medians [interquartile range]. Results We included 444 patients 40.6 (14.1) years of age in the derivation sample and 145 patients 38.2 (15.0) years in the validation sample, of whom 86 (19.3%) and 34 (23.4%) suffered LTVTA over 3.6 [1.0–7.2] and 5.1 [2.0–9.3] years of follow-up, respectively. Predictors of LTVTA in the derivation sample were: male sex, non-missense LMNA mutation, 1st degree and higher atrioventricular block, non-sustained ventricular tachycardia, and left ventricular ejection fraction. In the derivation sample, C-index (95% CI) of the model was 0.776 (0.711–0.842). In the external validation sample, the C-index was 0.800 (0.642–0.959) and calibration slope 1.082 (95% CI, 0.643–1.522). A 5-year estimated risk threshold ≥7% predicted 96.2% of LTVTA and net reclassified 28.8% of patients with LTVTA compared with the guidelines-based approach. Conclusions Compared to the current standard of care, this risk prediction model for LTVTA in laminopathies facilitated significantly the choice of ICD candidates. Acknowledgement/Funding AFM Téléthon

Atrial fibrillation, atrioventricular conduction defects, heart failure and sudden death are common adverse events in patients with lamin A/C gene mutations. Since sudden death is often not prevented by permanent pacing, we hypothesized that it may be due to ventricular tachyarrhythmias (VA) and could be prevented by an implantable cardioverter defibrillator (ICD).

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020-FTI [Fast Track to Innovation] Pilot-2016 and MicroPort CRM Background Left ventricular (LV) lead positioning is an important contributor to cardiac resynchronization therapy (CRT) response. Multiple additional LV sites could be stimulated by passing a new ultra-thin (1.2 Fr, 0.4 mm) quadripolar microlead from one LV vein into another via venous collaterals. Purpose Study the acute and chronic stability and electrical pacing performance of a novel 1.2 Fr quadripolar microlead ("Axone 4LV"). Methods Seven healthy adult dogs underwent CRT defibrillator implantation, including a right ventricular lead and the microlead. The microlead was advanced into the coronary sinus network using a dedicated microguide catheter. The animals were followed up at 1, 15, 30 and 90 days post-implant to evaluate chronic stability and electrical pacing performance. Results Successful uncomplicated implantation was achieved in all cases. Despite the small diameter of the distal veins and collaterals, placement of the pacing electrodes in two different LV veins was feasible via available collateral passages. Lead position was stable in all cases and over the entire study period. Capture threshold and pacing impedance at 90 days post-implant were 1.7 ± 0.5 V with 1323 ± 245 Ω, respectively, at 0.5 ms pulse width. The mean pacing energy to get capture was 1.1 ± 0.5 µJ and less than 2 µJ in all cases (2 µJ ≈ 1.4 V @500 Ω, 0.5 ms). No phrenic nerve stimulation was observed during pacing. Conclusions The novel 1.2 Fr quadripolar microlead demonstrated adequate stability and good electrical performance allied to low energy consumption. This quadripolar microlead may extend pacing options while increasing device longevity in CRT. Changes in pacing parameters over time Post-implant Follow-up Pacing Threshold Pacing Impedance Pacing Energy 1 day 1.4 ± 0.7 V 1294 ± 270 Ω 0.8 ± 0.7 µJ 15 days 1.9 ± 0.9 V 1336 ± 274 Ω 1.8 ± 1.8 µJ 30 days 1.8 ± 0.7 V 1187 ± 303 Ω 1.5 ± 1.2 µJ 90 days 1.7 ± 0.5 V 1323 ± 245 Ω 1.1 ± 0.5 µJ

Brugada syndrome (BrS) is an inherited arrhythmia syndrome with increased risk of syncope and sudden death. Disease manifestation is clearly predominant in males and the studied population mainly consisted in men. The aim of this study is to describe the clinical characteristics of BrS in women. BrS women were recruited from 12 french tertiary centers. Clinical data, investigation of family history, 12-lead ECG and results for pharmacological challenge were collected. Average follow-up was 79±52 months. 202 women were recruited (mean age 46±16 years). Circumstances of diagnoses were: familial screening (n=94, 47%), systematic ECG (n= 61, 30%) and symptoms (n=47, 23%). 69 patients (34%) were symptomatic: resuscitated sudden cardiac death (SCD) in 11 women (5%), 42 syncope (21%), 8 supraventricular tachycardia (4%), 21 palpitations (10%), 24 lipothymia (12%) and 7 pain (3%). 20 women (10%) have a history of familial SCD. Implantable cardiac defibrillator (ICD) was implanted in 44/202 patients (22%). At baseline, mean HR was 71±12 bpm, PR 174±32 mm, QRS 99±17 mm and QTc 419±29 mm. 59 women (29%) have a spontaneous type- 1 ECG. Mean ST elevation were 3.3±1.1 mm. During follow-up, 7/202 patients (3.5%) have an arrhythmic event: resuscitated SCD (n=1), syncope (n=3), ventricular arrhythmia (n=1) and appropriate ICD shock (n=2). Among them, 5 women were symptomatic (syncope) and 2 were asymptomatic. Asymptomatic women don’t have a spontaneous type-1 ECG at baseline whereas 3/5 symptomatic women have a type-1 ECG at baseline. We compared our results to the men of the FINGER BrS Registry (n=745). The number of ICD implanted patients was higher in FINGER cohort (22 vs 47%). Men of the FINGER cohort presented more arrhythmic events than women of this study (5.7 vs 3.5%). Women seem to represent a lower-risk group than men. A spontaneous type-1 ECG at baseline doesn’t seem to be a risk factor for arrhythmic event in women.

Background: Tetralogy of Fallot (TOF) is the most frequent form of congenital heart disease managed by EP physicians for potential ICD. However, few studies have reported long-term outcomes of TOF patients with ICD. Methods: Between 2005 and 2014, all TOF patients with ICD in 17 French centers were enrolled in a specific evaluation aiming to determine characteristics at implantation as well as outcomes (overall mortality, appropriate ICD therapies, and device-related complications). Results: Overall 78 patients (45±13 years, 64% males) were enrolled. A majority of patients were implanted in the setting of secondary prevention (73%), whereas the remaining (27%) in primary prevention. Among the latest group, known risk factors for sudden cardiac death were: severe pulmonary regurgitation (30%,) prior palliative shunt (50%), syncope with unknown origin (25%), inducible ventricular tachycardia (45%), QRS duration ≥180ms (18%), non-sustained ventricular tachycardia (25%), and documented sustained supra ventricular tachycardia (45%).Overall, patients implanted in the setting of primary prevention presented with a mean of 3.1±1.4 risk factors. After a mean follow-up of 4.9±3.8 years, 35 patients (45%) experienced at least one appropriate therapy (25% in the primary prevention group compared to 53% in the secondary prevention group), giving annual-incidences of 6.9% (95%CI 0.14-13.7) and 21.3% (12.4-30.3) respectively (P=0,01). The mean time between ICD implantation and the first appropriate therapy was 2.2±3.2 years, without significant differences between primary and secondary prevention. Overall, ≥one ICD-related complication occurred in 30 patients (38%), including inappropriate shock (n=9), major pocket hematoma (n=1), lead dysfunction (n=12), infection (n=4), shoulder algodystrophia (n=2), device failure or dislodgement needing reintervention (n=2). Eventually, four patients were transplanted (5%), and six patients (8%) died during the course of follow-up. Conclusions: Considering relatively long-term follow-up, patients with TOF and ICDs experience high rates of appropriate ICD therapies, in both primary and secondary prevention. Major ICD-related complications remain, however, high.

The Advisa MRI™ SureScan® Pacing System is an MR conditional pacing system designed to safely undergo magnetic resonance image (MRI) scans. Its influence on image quality, particularly of cardiac MR (CMR) acquisitions, is not well known. The Advisa MRI Study evaluated the CMR image quality and

Placement of an LV lead is often constrained by phrenic nerve stimulation (PNS). To address the challenge, the Left Ventricular Lead Acute Clinical Study (LILAC) was conducted to evaluate the ability of a new investigational quadripolar LV lead to map the PNS occurrence and mitigate it with single lead insertion at implant using multipolar configurations. This non-randomized study was conducted at 9 international centers and enrolled 54 patients indicated for CRT implantation. The lead design tested was intended to provide electrode contact in two different LV zones simultaneously (mid-apex (MA) and mid-base (MB)). Two lead models with short (S) and long (L) electrode spacing were included to provide the implanter with the ability to select an electrode spacing that matched the patient's individual anatomy. After acquiring a venogram, the implanter tested 1 or 2 lead models by wedging the lead in a selected target vein and recorded the lead testing positions via fluoro images. Unipolar pacing thresholds (PT) and PNS thresholds at each electrode were collected. Fifty patients were tested successfully with additional 2 attempts and 2 intents. The PNS occurrence and threshold are summarized in Table 1. By basing lead selection on individual venograms (no repositioning of the lead), 90% of cases demonstrated that at least one electrode in either zone had a PT ≤ 2.5V without PNS. In addition, 70% of patients achieved dual zone stimulation with a PT of ≤ 2.5V without PNS in MB and MA zones simultaneously. Mean thresholds from the best electrodes in MB and MA zones were 1.7±1.4V vs. 1.6±1.6V (p=ns) accordingly. Of the 24 patients with PNS, electrode switching resulted in no PNS in 20 patients at a PT of ≤ 2.5V and in 23 patients at ≤ 3.5V with unipolar pacing configuration only.Tabled 1 The LILAC quadripolar mapping data suggests PNS mostly occur in MA region with low stimulation threshold compared to MB region. Using this family of quadripolar leads, implanters would be able to achieve low PT and PNS avoidance at either MA or MB zone without repositioning the lead at implant.

Journal of Cardiovascular ElectrophysiologyVolume 20, Issue 6 p. 699-701 An Unusual Cause of Syncope in a Patient with an Internal Cardioverter Defibrillator SLIM KACEM M.D., SLIM KACEM M.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this authorGIULIANO BECKER M.D., GIULIANO BECKER M.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this authorARNAUD SAVOURÉ M.D., ARNAUD SAVOURÉ M.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this authorFRÉDÉRIC ANSELME M.D., Ph.D., FRÉDÉRIC ANSELME M.D., Ph.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this author SLIM KACEM M.D., SLIM KACEM M.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this authorGIULIANO BECKER M.D., GIULIANO BECKER M.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this authorARNAUD SAVOURÉ M.D., ARNAUD SAVOURÉ M.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this authorFRÉDÉRIC ANSELME M.D., Ph.D., FRÉDÉRIC ANSELME M.D., Ph.D. Rouen University Hospital, Cardiology Department, Rouen, FranceSearch for more papers by this author First published: 01 June 2009 https://doi.org/10.1111/j.1540-8167.2008.01406.x Address for correspondence: Frédéric Anselme, M.D., Rouen University Hospital, Cardiology Department, 1 rue de Germont 76031, Rouen Cedex, France. Fax: +3-323-288-8327; E-mail: [email protected] Dr. Anselme reports receiving lecture fees from Boston Scientific. Section Editor: George J. Klein, M.D. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Volume20, Issue6June 2009Pages 699-701 RelatedInformation

Background: Esophageal motility abnormalities are often reported in patients with dysphagia undergoing esophageal manometry.Explaining patients symptoms based on esophageal manometry findings is challenging.Correlations between esophageal symptoms and manometry findings are underreported.Aim: To evaluate the correlation between esophageal symptoms, peristalsis and bolus transit using stationary impedance manometry.Methods: Patients presenting for esophageal manometry were asked to report severity and frequency of dysphagia during the last 2 weeks prior to testing (dysphagia score).Combined impedancemanometry was performed using a 9-channel catheter (5 pressure + 4 impedance located at 5, 10, 15 and 20 cm above the LES).During testing patients were asked, after each swallow, if they experienced dysphagia or not.Esophageal contractions were classified using previously published impedance-manometry criteria.Per-swallow analysis included correlation between dysphagia (yes/no), manometric (normal/ineffective/simultaneous) and impedance (complete/incomplete bolus transit).Per patient analysis included correlation between dysphagia score, % swallows reported as percieved, % manometric normal swallows and % swallows with complete bolus transit.Results: Data from manometries performed in 77 patients (45F; mean age 51, range 16-81 years) totalling 770 liquid and 749 solid swallows were analyzed.The per-swallow analysis for liquid swallows found manometric simultaneous and ineffective contractions more likely (p=0.01) to be associated with symptoms (10/35; 28.6% and 19/119; 16.0% respectively) compared to manometric normal contractions (72/606; 11%).Swallows with incomplete bolus transit were more likely (p= 0.02) to be associated with symptoms (21/104; 20.2%) than swallows with complete bolus transit (80/666; 12.0%).For solid swallows no such associations were found.The perpatient analysis found significant (p<0.01)but poor correlation between dysphagia score and % symptomatic swallows during testing (r=0.321liquid and r=0.344 solid swallows).Furthermore, dysphagia score did not correlate with neither % manometric abnormal contractions nor % swallows with incomplete bolus transit.The % symptomatic swallows per patient did not correlate with manometry or bolus transit.Conclusion: Manometric characteristics of esophageal contractions and bolus transit play a role in the perception of individual swallows.In addition to manometric and/or bolus transit abnormalities other factors determine the intensity of dysphagia reported by patients.

TOF is the most frequent congenital heart disease managed by cardiologists, at particularly high risk of sudden cardiac death (SCD). However, few studies have reported long-term outcomes of TOF with ICD. We aimed to report characteristics and outcomes from a large population of TOF with ICD. Between 2005 and 2016, all TOF implanted with an ICD in 22 centers were enrolled to determine characteristics at implantation and outcomes. Overall, 101 patients (43 ± 13 years, 69% males) were enrolled. A majority was implanted for secondary prevention (71%), whereas the remaining (29%) was for primary prevention. Among the latter, risk factors for SCD were: severe pulmonary regurgitation (25%), prior palliative shunt (43%), syncope (21%), inducible ventricular tachycardia (VT) (39%), non-sustained VT (29%), QRS duration ≥ 180 ms (19%), left ventricular significant dysfunction (29%, with ejection fraction ≤ 45%), and sustained supra-VT (46%). After a mean follow-up of 6.0 ± 4 years, 44 (43%) experienced ≥ one appropriate therapy (25% in the primary vs. 51% in the secondary prevention group), giving annual-incidences of 4.95% and 14.1%, respectively (P = 0.009). The median time between ICD implantation and the first appropriate therapy was 0.70 years (0.26–3.75), without significant differences between primary and secondary prevention (P = 0.27). Overall, ≥ 1 complication occurred in 40 patients (39%), including inappropriate shock (n = 26), major pocket hematoma (n = 1), lead dysfunction (n = 15), infection (n = 6), algodystrophia (n = 2), device failure needing reintervention (n = 3). Eventually, 6 patients received heart transplant (6%), and 9 (9%) died during the course of follow-up. TOF and ICDs experience high rates of appropriate therapies, especially in secondary prevention. ICD-related complications remain very high. Selection of candidates for primary prevention remains challenging and can be potentially improved.

Although cryoenergy safety profile is appropriate for the ablation of arrhythmogenic foci near the conduction system, mapping using the cryoablation catheter is of limited precision. Combining the safety of cryoenergy and the high precision of a 3D mapping system therefore appears the most appropriate set-up for ablation in the vicinity of the His bundle. A 29-year-old woman with a 3-year history of increasing shorteness of breath and palpitations refractory to medical treatment was sent to the EP laboratory for catheter ablation. Surface ECG showed sinus rhythm and frequent ectopic beats with narrow QRS complexes similar to those of the sinus beats. The left ventricular ejection fraction was impaired (38%) with no other etiology found, apart from frequent ectopies. Detailed intracardiac mapping, using a 3D electroanatomical system, revealed that the ectopy originated from the distal His bundle, which was indicated by both antegrade and reversed His bundle activation sequence during ectopy compared to that during sinus rhythm. Due to the proximity of the conduction system, cryoenergy rather than radiofrequency was chosen to target this Hisian ectopy. A special set-up was made in order to allow the cryoablation catheter to be visualized into the 3D mapping system. Cryoenergy delivered to the site of earliest Hisian ectopy activation completely abolished it (Fig. 1). Such a combined approach may help to improve therapeutic strategy for ablation procedures with a high-risk of injury to the conduction system. It could notably be extended to the ablation of para-Hisian ectopy or accessory pathways.

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

The French translations of the word "gap" include "hole, breach, opening". In the Anglo-saxon literature, the conduction gap or the gap phenomenon is defined as the period of the cardiac cycle during which a premature beat is blocked whereas more delayed or more premature beats are conducted. This rare phenomenon, observed mainly during extrasystolic stimulation, was previously called supernormal conduction. The underlying mechanism is distal block in the conduction system occurring when more premature beats lead to delay in the proximal conduction which gives the distal site time to become excitable again. The excitability gap is one of the main characteristics of reentrant arrhythmias. Its presence in a reentrant circuit ensures the regularity and stability of the arrhythmia. It also allows penetration of the circuit by external stimuli. This different extrasystolic stimulation technique (resetting) or rapid fixed rate pacing (entrainment) may be used diagnostically and therapeutically. It enables the identification of the arrhythmia circuit and a critical zone (protected isthmus, zone of slow conduction) which may constitute a target for ablation. It also offers a possibility for terminating the arrhythmia by external stimulation. Finally, the duration of the excitable gap may guide the choice of antiarrhythmic agent during pharmacological cardioversion of a reentrant tachycardia.

Connaître les principes de la technique d’ablation par radiofréquence de la Fibrillation Atriale (FA) paroxystique sur cœur sain. Connaître les autres alternatives thérapeutiques. Savoir identifier les variantes anatomiques veineuses pulmonaires pertinentes pour le traitement. Connaître les avantages et inconvénients respectifs de l’IRM et de la TDM. Connaître les complications possibles et savoir les identifier par l’imagerie. L’ablation par radiofréquence des foyers ectopiques de FA sur cœur sain est devenue le traitement de référence. La technique est aujourd’hui parfaitement protocolée avec un taux de complication très faible. L’IRM ou la TDM peuvent être utilisées, l’IRM présentant l’avantage de l’absence d’irradiation, la TDM de sa résolution et de la possibilité de visualiser l’œsophage.

Abstract Introduction Laminopathy (LMNA) is a group of rare disease caused by a mutation of lamin A/C genes. Heart transplantation (HT) is often required. Cardiac resynchronization therapy (CRT) may be an option to postpone HT. Purpose To describe characteristics and outcome of LMNA patients receiving CRT. Methods All consecutive LMNA patients implanted with a CRT device for conventional indications were included in the study. Clinical and echocardiographic (TTE) data were collected during the follow-up period. Results From 2002 to 2017, 68 LMNA patients had CRT implantation. Despite CRT, 30/68 patients (44%) had HT. Population divided into two groups according to response to CRT. Patients were considered without benefit (WHOB-CRT group) if they experienced severe events (inscription on heart transplantation list or death) within two years after CRT implantation. Other patients were in the WB-CRT group. TTE and clinical parameters are described in Table 1. Table 1 Parameters WB-CRT (n=33) WHOB-CRT (n=35) P-value At implantation Age (years) 52.3±9.7 50.6±9.5 0.27 Women 9 (27%) 13 (37%) 0.45 NYHA class 2.7±0.6 2.8±0.7 0.45 LVEF (%) 33.2±8.8 31.3±7 0.64 LVEDD (mm) 60±6.9 60±6.9 0.96 TAPSE (mm) 23±3.7 14±4.8 0.002 At last follow up NYHA class 2.2±0.6 2.9±0.7 &lt;0.001 LVEF (%) 36.4±11 27±9 &lt;0.001 LVEDD (mm) 59±5.5 59±7.7 0.98 TAPSE (mm) 19.9±5.5 12.3±3.3 0.003 Left ventricular ejection fraction (LVEF); Left ventricular end diastolic diameter (LVEDD); Tricuspid annular plane systolic excursion (TAPSE). Conclusion Cardiac resynchronization therapy is less efficient in LMNA patients. An impaired right ventricular stroke function seems to be the only predictive factor leading to poor response to CRT.

Abstract Introduction Right ventricular pacing (RVP) induces ventricular asynchrony in patients with normal QRS and increases the risk of heart failure and atrial fibrillation on long term. His bundle pacing (HBP) is a physiological alternative to RVP. Interest in HBP has been hampered in part by technical challenges and limited implantation tool set. Recent studies assessed feasibility and safety in expert centers with a vast experience of HBP. These results may not apply to less experienced centers. Purpose To evaluate feasibility and safety of permanent his bundle pacing in hospitals with limited technical training to this technique and to evaluate stability of his bundle capture thresholds at 3 months follow up. Methods We included all patients who underwent pacemaker implantation with attempt of HBP in three hospitals between September 2017 and December 2018. All the 5 operators were novice for HBP at the beginning of the study. Selective his bundle capture (HBC) was defined as concordance of QRS and T waves complexes with the native ECG (patients with underlying bundle branch block may normalize), presence of a delay between spike and QRS complex, absence of widening of the QRS at a low pacing output, and recordable his bundle electrogram. At 3 months follow-up, his bundle capture thresholds, R-wave amplitudes and pacing impedances were recorded. Results HPB was successful in 51 of 58 patients (87.9%); selective HBC was obtained in 40 patients while nonselective HBC occurred in 11 patients. Indication for pacemaker implantation was atrioventricular conduction disease in 31 patients (53%), sinus node dysfunction in 5 patients (9%) and AV nodal ablation for non-controlled atrial arrhythmias in 22 patients (38%). AV nodal ablation was performed during the same procedure in 14 patients. The mean procedure duration was 75±8 min, and mean fluoroscopy duration was 10±2 min. The mean HBP threshold was 1.47±0.27 V and did not increase after a 3 months follow-up (1.12±0.18 V). Only 7 patients (14%) had HBP threshold &gt;2V/0.5ms. The mean impedance was 477±37 Ω and slightly decreased at 3 months (364±24Ω). The mean R-wave amplitude was 4.1±1 mV at implantation and 3.2±0.6 mV at 3 months. Bundle branch block correction was achieved in 5 of 7 patients with underlying left bundle branch block. There was no pericardial effusion, no pneumothorax and no device infection. Ventricular lead revision was required at 3 months in one patient for sudden threshold increase, without obvious dislodgement. LBBB correction after HBP Conclusion His bundle pacing performed by novice operators to this technique appeared feasible and safe. The mean HBP threshold did not increase at 3 months follow-up.

His bundle pacing (HBP) is a physiological alternative to right ventricular pacing. Observational studies have demonstrated the feasibility of this technique. However, it is associated with longer procedure time and higher fluoroscopy exposure compared to standard pacemaker implantation. We evaluated the possibility to guide the His Bundle (HB) lead placement using HB unipolar mapping only, in an attempt to reduce radiation exposure. From October to November 2019, all consecutive patients candidates for HBP in our institution underwent pacemaker implantation using mainly unipolar mapping of the His bundle for lead placement. All procedures were performed by a single trained operator. His bundle electrogram was mapped with the pacing lead and directly recorded on both EP recording system and Medtronic pacing analyzer. Fourteen patients were implanted according to this new approach. Seven patients had a dual chamber pacemaker implantation. Indication for pacemaker implantation was sinus node dysfunction in 2 patients, AV nodal ablation for non-controlled atrial arrhythmias in 5 patients and atrioventricular conduction disease in 7 patients. HBP was successful in all patients. His Bundle signal was detected with the SelectSecure pacing lead during all procedures. Selective HBP was obtained in 9 patients (64%) while non selective HBP occurred in 5 patients. The mean procedure duration was 44 ± 8 min. The overall procedure fluoroscopy duration, including the atrial lead implantation, was 30 ± 13 sec. The mean radiation exposure was 0.22 ± 0.12 Gy.cm2. The baseline QRS duration was 102 ± 16ms and the paced QRS duration was 103 ± 14ms. The mean HBP threshold at implant was 1.31 ± 0.4 V. There was no pericardial effusion and no pneumothorax. His Bundle lead placement mainly using HB unipolar mapping was feasible and effective and was associated with very limited radiation exposure without compromising procedure duration.

Introduction: The Cryo-FIRST study (NCT01803438) demonstrated that pulmonary vein isolation (PVI) with cryoballoon catheter ablation (CA) is superior to antiarrhythmic drug (AAD) therapy as a first line treatment for the prevention of atrial arrhythmia recurrence in patients with paroxysmal atrial fibrillation (PAF). Earlier CA may also be beneficial for improving quality of life (QoL). Hypothesis: We hypothesized that PVI with cyroballoon CA is superior to AAD therapy for improving QoL in treatment naïve patients with PAF. Methods: Patients with symptomatic PAF free of heart disease who had not been administered AAD therapy for &gt;48 hours were enrolled at 18 sites in 9 countries. Patients were randomized (1:1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD therapy (Class IC or III). Subjects were followed at 1, 3, 6, 9, and 12 months. QoL was evaluated using the Atrial Fibrillation Effect on Quality of Life (AFEQT) and SF-36 v2 questionnaires. Health domains and component scores from the SF-36 were transformed to norm-based T scores. Mean adjusted differences between arms were compared at each follow-up. Results: Of the 218 patients randomized (age 52±13 years, 68% male) 86% completed the 12-month follow-up. Crossovers occurred in 9% of subjects (N=20, CA-to-AAD: N=1, AAD-to-CA: N=19). There were no group differences in baseline AFEQT or SF-36 scores. The mean AFEQT summary score was more favorable in the CA vs. AAD group at 12 months (88.9 vs. 78.1 points, respectively). The adjusted difference was 9.9 points (95%CI: 5.5-14.2; P &lt; .0001, Figure). A significant adjusted mean difference favoring CA was observed for the SF-36 physical component score at months 3 (1.8 points, p=0.031) and 9 (2.0 points, p=0.018). No other differences were observed in the physical or mental component scores between groups. Conclusions: Cryoballoon CA was superior to AAD therapy for improving AF-specific QoL in treatment naïve patients with symptomatic PAF.

Abstract Background Ventricular arrhythmias and sudden death are potential late complications in patients with tetralogy of Fallot. Data regarding the value of implantable cardioverter defibrillators (ICD) are scarce in this population. Purpose To assess long-term rates of appropriate ICD therapies and ICD-related complications in a large registry of ICD recipients with tetralogy of Fallot. Methods The DAI-T4F study is an ongoing national French registry including all patients with tetralogy of Fallot and ICD (NCT03837574). Information have been collected prospectively since 2010 with annual update. Baseline patient characteristics and clinical events during follow-up were analyzed with central adjudication. Cox proportional hazard models were used to identify factors associated with appropriate ICD therapies and complications. Results A total of 134 patients (median age 41.7 years, 70.7% males) were enrolled. The median (IQR) follow-up duration was 6.1 (2.7–10.2) years. ICDs were implanted for primary prevention in 47 (35.1%) patients and for secondary prevention in 87 (64.9%) patients. Overall, 14 (29.8%) and 45 (51.7%) patients received at least one appropriate ICD therapy in primary and secondary prevention, respectively, giving annual incidences of 5.5% and 7.1% (p=0.06). Patients with altered left ventricle ejection fraction (LVEF) at inclusion ≤35% experienced less appropriate ICD therapies (HR=0.31, 95% CI: 0.11–0.86, p=0.02), whereas a history of sustained or non-sustained ventricular arrhythmia (HR=2.7, 95% CI: 1.2–3.9, p=0.03) was positively associated with appropriate therapies. Fifty-seven (42.5%) patients had ICD-related complications, including 32 (24.2%) inappropriate ICD shocks, 22 (16.4%) significant lead dysfunction, 14 (10.4%) device infection, and 5 (3.7%) generator dysfunction/recall. History of supraventricular arrhythmias (HR=2.2, 95% CI: 1.2–3.7, p=0.01) and congestive heart failure (HR=2.0, 95% CI: 1.2–3.6, p=0.01) were both associated with a higher risk of complications. During follow-up, 7 (5.2%) patients underwent cardiac transplantation and 12 (9.0%) patients died, mainly from progressive heart failure (n=5). Only one sudden death due to electrical storm was recorded. Figure 1 Conclusions Appropriate therapies are frequent in patients with tetralogy of Fallot and ICDs, including in primary prevention. The relatively important proportion of ICD-related complication highlights the need for improving risk stratification in this population, considering associated conditions in the individual benefit-risk equation.

Les préexcitations ventriculaires représentent un groupe de pathologies cardiaques relativement rares mais pouvant dans certains cas mettre en jeu le pronostic vital des patients. Il s’agit d’anomalies congénitales responsables de connexions électriques anormales entre les oreillettes et les ventricules. L’expression clinique et le pronostic sont très variables selon le type de voie accessoire et ses caractéristiques électrophysiologiques. On retrouve principalement les voies accessoires auriculoventriculaires, mais il existe aussi plus rarement des voies accessoires nodoventriculaires, fasciculoventriculaires et atriohisiennes. L’objectif du clinicien est d’une part de faire le diagnostic de la préexcitation ventriculaire, et d’autre part d’évaluer l’importance des symptômes en rapport avec la voie accessoire et sa dangerosité potentielle afin d’adapter au mieux la prise en charge thérapeutique des patients. Atrioventricular preexcitation is a group of almost rare but, in some cases, life threatening cardiac diseases. These are inborn abnormalities responsible for abnormal electric conduction at the atrioventricular junction. The clinical presentation as well as the prognosis is widely variable, depending on the type of accessory pathway, and its electrophysiological properties. The most commonly involved accessory pathway is the atrioventricular connection, more rarely the nodoventricular, fasciculo-ventricular, and the atrio-Hisian connections. For the physician, the goal is to diagnose the ventricular preexcitation and also to assess the importance of symptoms with respect to the accessory pathway, in addition to the assessment of the potential related risk in order to adapt the therapeutic strategy.

Right ventricular pacing (RVP) induces ventricular asynchrony in patients with normal QRS and increases the risk of heart failure and atrial fibrillation on long term. His bundle pacing (HBP) is a physiological alternative to RVP. Observational studies have demonstrated the feasibility of this technique. However, it is associated with longer procedure time and higher fluoroscopy exposure compared to standard pacemaker implantation. We evaluated the possibility to guide the His Bundle (HB) lead placement using HB unipolar mapping only, in an attempt to reduce radiation exposure. From October 2019 to January 2020, all consecutive patients candidates for HBP in our institution underwent pacemaker implantation using mainly unipolar mapping of the His bundle for lead placement. The pacing lead was delivered through a fixed curve sheath. His bundle electrogram was mapped with the pacing lead and directly recorded on both EP recording system and Medtronic pacing analyser. Thirty-nine patients were implanted according to this new approach. Sixteen patients (41%) had a dual chamber pacemaker implantation. HBP was successful in all patients. Selective HBP was obtained in 25 patients (64%) while non-selective HBP occurred in 14 patients (36%). His Bundle signal was successfully detected with the pacing lead during all procedures. The overall procedure fluoroscopy duration, including the atrial lead implantation, was 48 ± 54 sec and the mean radiation exposure was 0.34 ± 0.57 Gy.cm2. The mean procedure duration was 48.4 ± 15.6 min. The mean His Bundle capture threshold at implant was 1.36 ± [email protected] There was no pericardial effusion, no pneumothorax and no early lead dislodgment (Fig. 1). His Bundle lead placement mainly using HB unipolar mapping was feasible and effective and was associated with very limited radiation exposure without compromising procedure duration.

Journal of Cardiovascular ElectrophysiologyVolume 32, Issue 5 p. 1521-1521 RESPONSE TO LETTER TO EDITOR Response to letter to the editor: Very late recurrences after ablation of AVNRT Corentin Chaumont MD, Department of Cardiology, Rouen University Hospital, Rouen, France INSERM U1096, FHU REMOD-VHF, UNIROUEN, FranceSearch for more papers by this authorFrédéric Anselme MD, PhD, Corresponding Author Frederic.anselme@chu-rouen.fr orcid.org/0000-0002-2130-9790 Department of Cardiology, Rouen University Hospital, Rouen, France INSERM U1096, FHU REMOD-VHF, UNIROUEN, France CorrespondenceFrédéric Anselme, MD, Cardiology Department, CHU - Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen Cedex, France. Email: Frederic.anselme@chu-rouen.frSearch for more papers by this author Corentin Chaumont MD, Department of Cardiology, Rouen University Hospital, Rouen, France INSERM U1096, FHU REMOD-VHF, UNIROUEN, FranceSearch for more papers by this authorFrédéric Anselme MD, PhD, Corresponding Author Frederic.anselme@chu-rouen.fr orcid.org/0000-0002-2130-9790 Department of Cardiology, Rouen University Hospital, Rouen, France INSERM U1096, FHU REMOD-VHF, UNIROUEN, France CorrespondenceFrédéric Anselme, MD, Cardiology Department, CHU - Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen Cedex, France. Email: Frederic.anselme@chu-rouen.frSearch for more papers by this author First published: 24 March 2021 https://doi.org/10.1111/jce.14996 Disclosure: Frédéric Anselme is a consultant for and has received lecture fees from Boston Scientific, Medtronic, Microport CRM. Other author: No disclosures. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume32, Issue5May 2021Pages 1521-1521 RelatedInformation

Right ventricular pacing (RVP) induces ventricular asynchrony in patients with normal QRS and increases the risk of heart failure and atrial fibrillation in long-term. His bundle pacing (HBP) is a physiological alternative to RVP, and could overcome its drawbacks. Recent studies assessed the feasibility and safety of HBP in expert centers with a vast experience of this technique. These results may not apply to less experienced centers. We aim to evaluate the feasibility and safety of permanent HBP performed by physicians who are new to this technique. We included all patients who underwent pacemaker implantation with attempt of HBP in three hospitals between September 2017 and January 2020. Indication for HBP was left to operators’ discretion. All the operators were new for HBP. His bundle (HB) electrical parameters were recorded at implant, 3- and 12-month follow-up. HBP was successful in 141 of 170 patients (82.9%); selective HBP was obtained in 96 patients and nonselective HBP in 45. The mean procedure and fluoroscopy durations were 67.0 ± 28.8 min, and 7.3 ± 8.1 min (3.1 ± 4.1 Gy·cm 2 ), respectively. The mean HB paced QRS duration was 106 ± 18 ms. The mean HB capture threshold was 1.29 ± 0.77 V and did not increase at 3- and 12-month follow-up. The ventricular lead revision was required in five patients. Our results showed a rapid technical learning allowing a high procedure success rate (89.8%) after 15 procedures ( Fig. 1 ). HBP performed by operators new to this technique appeared feasible and safe. This should encourage HBP to be performed in patients expected to experience high RVP burden.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. We aimed to describe long-term follow-up of TOF patients implanted with ICD through a nationwide French registry. Nationwide French Registry including all TOF patients with an ICD initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event endpoint was the time from ICD implantation to first appropriate ICD therapy. Clinical events were centrally adjudicated by a blinded committee. A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (IQR) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least one appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively, P = 0.03). Overall, 71 (43.0%) patients presented with at least one ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) primary prevention patients, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with respectively no, one, two, or ≥ three guideline-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (HR 3.47, 95% CI 1.19–10.11), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 (P = 0.006) (Fig. 1). Patients with TOF and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification.

Grâce au developpement des techniques de cartographie et d'imagerie, le circuit du flutter auriculaire typique a ete parfaitement determine, ce qui a contribue a l'essor de son traitement curatif par ablation. Dans ce travail, nous avons tente de repondre a certaines questions d'ordre physiopathologiques, technique, et clinique concernant cette arythmie et son traitement. Ainsi, nous avons montre 1 ) que la localisation du bloc de conduction unidirectionnel necessaire a l'induction d'une reentree et du flutter, se situe au niveau de l'isthme cavo-tricuspidien, siege egalement de la zone de conduction lente; 2) l'absence de benefice a utiliser une electrode de 8 mm a simple thermocouple par rapport a une electrode standard de 4 mm dans l'ablation du flutter auriculaire typique; 3) que l'ablation du flutter realisee au niveau de la partie posterieure de l'isthme est aussi efficace que celle effectuee au niveau de la partie anterieure de l'isthme, mais est associee a un risque de troubles conductifs auricolo-ventriculaires; 4) que l'obtention d'un bloc isthmique complet bidirectionnel, documente par la cartographie d'activaton, est un critere predictif de succes de l'ablation a tres long terme, qui se traduit par une amelioration durable de l'etat fonctionnel et de la qualite de vie. Les palpitations presentees par les patients aprse ablation sont dues a la survenue d'acces de fibrilation auriculaire; 5) que la technique d'analyse des potentiels auriculaires sur la ligne d'ablation est capable de determiner la presence d'un bloc isthmique complet bidirectionnel, mais est plus difficile d'utilisation que la technique classique de cartographie d'activation. L'utilisation concomitante de ces 2 techniques, couplee a la stimulation positionelle en presence d'un aspect de bloc isthmique horaire incomplet, est preconisee dans l'evaluation des proprietes de conduction de l'isthme cavo-tricuspiden au cours de l'ablation du flutter auriculaire typique.

Journal of Cardiovascular ElectrophysiologyVolume 10, Issue 12 p. 1692-1692 Reply to the Editor Frédéric Anselme M.D., Frédéric Anselme M.D. Rouen University Hospital Rouen, FranceSearch for more papers by this authorMark E. Josephson M.D., Mark E. Josephson M.D. Rouen University Hospital Rouen, FranceSearch for more papers by this authorNadir Saoudi M.D., Nadir Saoudi M.D. Rouen University Hospital Rouen, FranceSearch for more papers by this author Frédéric Anselme M.D., Frédéric Anselme M.D. Rouen University Hospital Rouen, FranceSearch for more papers by this authorMark E. Josephson M.D., Mark E. Josephson M.D. Rouen University Hospital Rouen, FranceSearch for more papers by this authorNadir Saoudi M.D., Nadir Saoudi M.D. Rouen University Hospital Rouen, FranceSearch for more papers by this author First published: 20 April 2007 https://doi.org/10.1111/j.1540-8167.1999.tb00236.xCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1 Anselme F, Poty H, Cribier A, et al: Entrainment of typical AV nodal reentrant tachycardia using para-hisian pacing: Evidence for a lower common pathway within the AV node. J Cardiovasc Electrophysiol 1999; 10: 655– 661. 2 Alboni P, Scarfo S, Baggioni GF, et al: Relationship between the most proximal His bundle and the morphology of intracavitary pressure curves. Eur Heart J 1989; 10: 887– 891. 3 Billette J, Shrier A: Atrioventricular nodal activation and functional properties. In DP Zipes, J Jalife, eds: Cardiac Electrophysiology: From Cell to Bedside. Second Edition. WB Saunders. Philadelphia . 1995, p. 216. 4 Zipes DP: Genesis of cardiac arrhythmias: Electrophysiological considerations. In E Braunwald, ed; Heart Disease: A Textbook of Cardiovascular Medicine. Fourth Edition. WB Saunders, Philadelphia . 1992, p. 588. Citing Literature Volume10, Issue12December 1999Pages 1692-1692 ReferencesRelatedInformation

In contrast with aortic valve replacement, the treatment of choice for severe aortic stenosis because of the better long-term results, percutaneous aortic valvuloplasty, has only limited indications, mainly because of the high rate of restenosis. However, in very elderly patients, the surgical risk is high, sometimes prohibitive. For this reason, the authors report their latest results with this technique in a series of octogenarians. Between January 1989 and December 1990, 70 aortic valvuloplasties were performed in octogenarians (average age 85 +/- 3 years). The indications were advanced age > or = 85 years (46%), poor left ventricular ejection fraction < 40% (20%), secere associated coronary artery disease (3%), associated extracardiac pathology (11%), poor general condition (11%) or refusal of surgery (4%). The great majority of these patients (83%) were very symptomatic: 70.5% had Grade III-IV dyspnoea, 20% had Grade III-IV angina and 20% had syncopal attacks. Valvuloplasty reduced the mean transvalvular pressure gradients from 61 +/- 23 to 30 +/- 11 mmHg (p < 0.01) and increased aortic valve surface area from 0.53 +/- 0.19 to 0.94 +/- 0.12 cm2 (p < 0.001). There were two deaths (2.9%) in the catheterization laboratory and 4 (5.7%) complications during the hospital period (myocardial infarction: 1, cerebrovascular accident: 1, severe aortic regurgitation: 1 and complete atrio-ventricular block: 1). There were no serious vascular complications. The average duration of the hospital period was 6 +/- 5 days. Clinical follow-up of 17 +/- 7 months was obtained in 97% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)