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[Display omitted] • Left bundle branch area pacing provided better 1-year outcome than HBP. • Significant improvement in LVEF and NHYA class observed with both techniques. • These data may clarify the role of HBP vs LBBAP in the "ablate and pace" strategy. Pacemaker implantation combined with atrioventricular node ablation (AVNA) is a well-established strategy for uncontrolled atrial arrhythmias. Limited data are available regarding His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) in this setting. To compare the outcomes of HBP and LBBAP in patients undergoing pacemaker implantation combined with AVN in routine clinical practice. We prospectively included all patients who underwent AVNA after successful conduction system pacing (CSP) in two hospitals between September 2017 and May 2023. The primary outcome was the 1-year composite of first episode of heart failure hospitalization, symptomatic atrioventricular node reconduction requiring a second AVNA procedure, lead revision or death from any cause. A total of 164 patients underwent AVNA following successful CSP (68 HBP and 96 LBBAP). Mean pacemaker implantation and AVNA procedure times were shorter in the LBBAP group than the HBP group (46 ± 18 vs 59 ± 23 min; P < 0.001 and 31 ± 12 v s 43 ± 22 min, respectively; P < 0.001). Complete atrioventricular block was more frequently obtained in the LBBAP group (88/96 patients [92%] vs 54/68 patients [79%]; P = 0.04). One-year freedom from the composite outcome was more frequent in the LBBAP group (89.7% vs 72.9%; hazard ratio 0.32, 95% confidence interval 0.14 − 0.72; P = 0.01). The strategy was similarly effective in both groups with a significant improvement in NYHA class and left ventricular ejection fraction. A secondary pacing threshold elevation >1 V occurred only in the HBP group (11%). In this prospective, comparative study, LBBAP provided better 1-year outcomes than HBP. [ABSTRACT FROM AUTHOR]

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

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. [ABSTRACT FROM AUTHOR]

Background: 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.Objectives: 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.Methods: 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.Results: 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.Conclusion: 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.Trial Registration: Clinicaltrials.gov identifier: NCT03837574. [ABSTRACT FROM AUTHOR]

• RVOT PVCs induce anatomical displacement during 3D electroanatomical mapping. • Target ablation site displacement occurs predominantly along a vertical axis. • RVOT PVC-induced displacement can mislead the operator about the site of origin. Catheter ablation is a first-line treatment for symptomatic right ventricular outflow tract (RVOT) premature ventricular complexes (PVCs). There is evidence of displacement of the ablation target site during PVCs relative to the location in sinus rhythm (SR). To analyse the extent of displacement induced by RVOT PVCs and its effect on the ablation sites and the mid-term efficacy of ablation. In this multicentre French study, we retrospectively included 18 consecutive adults referred for ablation of RVOT PVCs using a three-dimensional (3D) mapping system. PVC activation maps were performed conventionally (initial map), then each PVC activation point was manually reannotated considering the 3D location on a previous SR beat (corrected map). The ablation-site locations on the initial or the corrected area, including the 10 best activation points, were analysed. Mid-term efficacy was evaluated. The direction of map shift during PVCs relative to the map in SR occurred along a vertical axis in 16 of 18 patients. The mean activation-point displacement for each of the 18 mapped chambers was 5.6 ± 2.2 mm. Mid-term recurrence of RVOT PVCs occurred in 5 (28%) patients. In all patients with recurrences, no significant ablation lesion was located on the corrected (true) site of origin. RVOT PVCs induce a vertical anatomical shift that can mislead physicians about the true location of the arrhythmia's site of origin. Our study highlights the association between mid-term PVC recurrence and the absence of spatial overlap between ablation points and the corrected site of origin. [ABSTRACT FROM AUTHOR]

Background: Cryoballoon ablation (CBA) as a first-line rhythm control strategy is superior to antiarrhythmic drugs (AADs) for preventing atrial fibrillation (AF) recurrence; the impact of first-line CBA on quality of life (QoL) and symptoms has not been well characterized.Methods: Patients aged 18 to 75 with symptomatic paroxysmal AF naïve to rhythm control therapy were randomized (1:1) to CBA (Arctic Front Advance, Medtronic) or AAD (Class I or III). Symptoms and QoL were assessed at baseline, 1, 3, 6, 9, and 12 months using the EHRA classification and Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and SF-36v2 questionnaires. Symptomatic palpitations were evaluated via patient diary.Results: Overall, 107 patients were randomized to CBA and 111 to AAD; crossovers occurred in 9%. Larger improvements in the AFEQT summary, subscale and treatment satisfaction scores were observed at 12 months with CBA vs AAD (all P <0.05). At 12 months, the mean adjusted difference in the AFEQT summary score was 9.9 points higher in the CBA group (95% CI: 5.5 -14.2, P <0.001). Clinically important improvements in the SF-36 physical and mental component scores were observed at 12 months in both groups, with no significant between group differences at this timepoint. In the CBA vs AAD group, larger improvements in EHRA class were observed at 6, 9 and 12 months (P <0.05) and the incidence rate of symptomatic palpitations was lower (4.6 vs 15.2 days/year post-blanking; IRR: 0.30, P <0.001).Conclusions: In patients with symptomatic AF, first-line CBA was superior to AAD for improving AF-specific QoL and symptoms.Trial Registration: ClinicalTrials.gov number: NCT01803438. [ABSTRACT FROM AUTHOR]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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. [ABSTRACT FROM AUTHOR]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Conductive disturbances remain the most frequent complication after TAVI. Management of conduction disturbances is highly variable among centres and impact length of stay (LOS). Recently, an expert consensus has been proposed in order to reduce their impact on LOS. To evaluate the impact of the expert consensus for the management of conductive disturbances to reduce LOS after TAVI. We retrospectively included patients who underwent a TAVI between January 1st, 2017 and December 31st, 2018. Patients who had a pacemaker before TAVI were excluded. ECG before, immediately after and the first two days after TAVI were analysed. According to the expert consensus, patients were classified in 5 groups: group 1 (normal ECG and no modification after TAVI), group 2 (pre-implantation right bundle branch block without modification after TAVI), group 3 (PR or QRS enlargement > 20 ms in patients with pre-existing conductive disturbances), group 4 (new onset left bundle blanch block), group 5 (High degree atrioventricular block or complete heart block during procedure). We assessed the proportion of patients early discharged (within 72 hours) among these 5 groups. During the studied period, 348 patients were included. The median LOS was 2 [2–4] days and 245 (71%) patients were discharged early. LOS were longer in groups 2, 3, 4 and 5. Patients in groups 3, 4 and 5 were discharged early in 62%, 65%, and 63% of cases respectively. In contrast, group 1 patients were discharged early in 77% of cases. Patients identified as having a high risk of delayed conductive disturbances by the consensus had longer LOS (5 [2.5–6.5] days with a lower rate of early discharge (39%) (Table 1). This study confirm the impact of conductive disturbances on LOS. The consensus reduces their impact on LOS and allows early discharge in 71% of cases without other complications. [ABSTRACT FROM AUTHOR]

Background: Sudden cardiac death is frequent in patients with lamin A/C gene (LMNA) mutations and may be related to ventricular arrhythmias (VA). Objective: To evaluate a strategy of prophylactic implantable cardioverter-defibrillator (ICD) implantation in LMNA mutation carriers with significant cardiac conduction disorders. Methods: 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. Results: 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). Conclusions: 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. [Copyright &y& Elsevier]

Background Ablation of paroxysmal atrial fibrillation (PAF) using a cryo-balloon catheter is currently expanding. The success rate of ablation with the Arctic Front® cryoballoon has been found to be similar to what was observed with radiofrequency catheter.The recent use of the new catheter Arctic Front Advance® seems to improve this performances. We postulate that this new generation of catheter could decrease the rate of redo procedures and maintain more effectively the pulmonary vein (PV) isolation. Methods From January 2009 to April 2014, we prospectively collected data regarding all consecutive patients referred for PAF ablation with cryoballoon technology at our institution. Patients were assigned either to 1stCB group if the arctic front catheter was used (from January 2009 to June 2012) or to the 2ndCB group if the arctic front advance catheter was used (from jully 2012 to April 2014). We performed a follow up of one year in each group and we compared the number of redo procedures and their characteristics. Results We included 106 patients in borh groups.Characteristics of the population are described in table 1. The rate of redo procedures at one year was significantly lower in the 2ndCB group (9.4% vs 37%; p<0.01). When a redo procedure was performed, the average number of reconnected PV was 2.2 in the 2ndCB group and 2.8 in 1stCB group (p=0.14). In the 2ndCB group, PV reconnection occurred more frequently the inferior PVs (right inferior PV=90%, left inferior PV=63%, right superior PV 30% and left superior PV=15%). This difference of distribution is less pronounced in the 1stCB group (LIPV=90%, RIPV=65%, RSPV=58% and the LSPV=55%). Conclusion The new generation of cryoballoon significantly decreased the rate of redo procedures at one year. Using the second generation CB, pulmonary vein reconnection was more frequently observed with the inferior PV. This could probably be explained by the anatomical characteristics of these veins (figure next page). Abstract 0463 – Figure: Characteristics of the population [ABSTRACT FROM AUTHOR]

Backgrounds Predictors of atrio-ventricular block (AVB) after transcatheter aortic valve implantation (TAVI) have been described as those leading to syncope or permanent pacemaker implantation (PPI), and thus have been assimilated to criterias used by the investigators for pacemaker implantation. Aims Evaluating the true predictors of AVB following TAVI, using clinical follow-up and devices’ memories. Methods Between 2011 and 2013, 213 patients without previous PPI underwent TAVI with an Edwards SAPIEN XT balloon-expandable valve using a femoral approach, in our institution. All patients had continuous cardiac rhythm monitoring ≥24 hours after TAVI. ECG was performed the following 2 days after TAVI, and 1 month later. Median follow-up for pacemaker interrogation was 8 months. Results Complete AVB occurred in 22 patients (10.3%), sudden death in 8 patients (3.8%). Pacemaker was implanted in 26 patients (12.2%). For 20 of them (77%), pacemaker memories showed complete AVB episodes or ≥2% ventricular pacing, despite the use of a minimizing ventricular pacing algorithm. Results of the multivariate analysis are shown below. Table No complete AVB or Sudden death (%) Complete AVB or Sudden death (%) Odds Ratio (95% CI) P Preexisting RBBB 15 (8) 13 (43) 6.62 (1.7 - 26.3) 0.007 New persistant LBBB 14 (8) 8 (33) 10.1 (2.5 – 41.7) 0.001 1 st degree AVB after TAVI 34 (27) 9 (56) 3.48 (1.1 – 11.2) 0.04 LBBB: left bundle branch block; RBBB: right bundle branch block Conclusions Our findings confirmed pre-existing RBBB and new persistent LBBB as predictors of AVB following TAVI. We also demonstrated here for the first time, first degree AVB is an independent predictive factor of severe conduction disorders after TAVI. [ABSTRACT FROM AUTHOR]

Background With the technical properties of the 2 nd generation (Arctic Front Advance, AFA) cryoballoon (CB), we postulated we could reduce complication rate without impairing efficacy in the treatment of paroxysmal atrial fibrillation if we stop the bonus application. Method Since January 2011, all patients referred to our institution for ablation of symptomatic drug refractory paroxysmal atrial fibrillation were included (n=129). Until June 2012, the ablation was performed with the Arctic Front cryoballoon (AF-CB) with application of 4mm bonus freeze after PVI (n=47). From July 2012 to December 2013, the ablation procedure was performed with the AFA-CB, without bonus freeze after PVI in 82 patients. All patients were seen at 4 to 6 month follow-up. They underwent at least 1 Holter monitoring in the post-operative period (2-4 month after ablation). Mid-term clinical success was defined by the association of sinus rhythm on ECG and Holter monitoring and lack of symptoms. Results Compared to the AFCB group, there was a significant reduction of the procedure time (131 min vs 95 min; p < 0.01), the X-ray exposure (27Gy/cm 2 vs 20 Gy/cm 2 ; p = 0.04) in the AFACB group. Isolation of the 4 PVs was obtained in 89 and 96% (p = 0.24) before performing a touch up with a Freezor Max catheter in the AFCB and AFACB group respectively. Using our definition for success, the mid-term success rate was higher in the AFA-CB group as compared with that of in the AF-CB group (78% vs 53% p = 0.01; CI [1,3 - 6,5]). Significant complications occurred in 9% in the AFA-CB group versus 13% in the AF-CB group (p = 0.44). There was no difference regarding the rate of phrenic nerve palsy (7% AF-CB group vs 5% AFA-CB group;p=0.24). Conclusion The lack of a bonus freeze application after PVI allows to significantly reducing the procedure time and the X-ray exposure. Even when using a reduced dosing strategy, our study shows the AFA-CB leads to a better outcome as compared to the AF-CB. [ABSTRACT FROM AUTHOR]

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) [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: Radiofrequency (RF) catheter ablation has emerged as an effective treatment for patients with drug-refractory atrial fibrillation (AF). The objective of this study is to evaluate the efficacy and safety of pulmonary vein isolation (PVI) with a cryoballoon catheter (Arctic Front, Cryocath, Quebec, Canada). Methods: In 44 consecutive patients with symptomatic paroxysmal AF (28 males, age 57 +/− 11 years), circumferential PVI was performed using a cryoballoon catheter. Before discharge, all patients were subjected to 24-hour Holter electrocardiograms, echocardiography, and esophageal endoscopy. Magnetic resonance imaging was performed prior to and 3 months after ablation. At a mean follow up of 4.3 +/− 1.2 months after ablation, patients underwent clinical review and 24-hour Holter electrocardiograms. Clinical and demographic variables were analyzed via logistic regression to assess for predictors of recurrence. Results: Thirty-two of the 44 patients (73%) had complete isolation of all PVs. Out of 176 treated veins, 164 were completely isolated (93%). The number of balloon applications per vein was 2.3±0.8. The mean procedure and fluoroscopy times were 163.4±36.2 and 32.0±11.7min, respectively. Eight patients had evidence of mild pericardial effusions requiring no further treatment. Five patients (11.4%) experienced phrenic nerve palsy, 4 of which resolved immediately and one at 2 weeks. Follow up at 4.3 +/− 1.2 months showed freedom from AF in 28 patients (63.6%) and freedom from AF without antiarrhythmic drug therapy in 19 patients (43.2%). Of all clinical variables analyzed, only early recurrence of AF within 4 days post ablation was associated with long term AF recurrence (p=0.002; OR=0.11; CI=[0.018–0.524]). Conclusion: PVI can be safely achieved with the cryoballoon catheter with a moderate success rate at 4.3 months follow-up. Early recurrence of AF seems to be a clinical predictor for long term atrial fibrillation recurrence. [Copyright &y& Elsevier]

Background: Arrythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disease characterized by progressive fibrofatty replacement of the right ventricle (RV). The diagnosis of ARVC remains a challenge for clinicians. We hypothesized that 2D strain imaging helps to differentiate ARVC from normals. Material and Methods: 20 patients meeting both the Task Force and cardiac MRI criteria for ARVC were compared to 10 age-matched controls. From the apical-4 chamber view, we measured the end-diastolic RV area, the peak systolic S tissue velocity at the tricuspid level. A 2D strain region of interest including the RV free wall and the septum (occasionally diseased in ARVC) was manually traced, from which the averaged peak systolic 2D strain along 6 segments was calculated. Pulmonary systolic pressure as well as the systolic right atrial area were measured as surrogate for RV loading conditions. Overall, patients with ARVC had both larger right atrial and ventricular area (p<0.03 and p<0.02, respectively), compared to controls while pulmonary systolic pressure were similar in both groups (p=0.40). Peak systolic 2D strain was statistically deteriorated in ARCV patients (13±6 vs. 23±4% in normals, p<0.001) so as peak systolic S tissue velocity (8±3 vs. 12±4 in normals, p<0.005). From the ROC analysis, a peak systolic 2D strain of 19.7% had a sensitivity and specificity of 82% and 86% (AUC=90) while the peak systolic tissue velocity of 12 cm/s gave a sensitivity of 83% and a specificity of 71% (AUC=79). Conclusion: Peak systolic 2D strain is deteriorated in ARVC patients and may help to characterize arrythmogenic right ventricular cardiomyopathy. [ABSTRACT FROM AUTHOR]

Background: This multicenter, prospective, randomized, controlled, parallel trial compares the efficacy of biventricular (BIV) versus right ventricular (RV) antitachycardia pacing (ATP) in terminating all kinds of ventricular tachycardia (VT). Methods: Five hundred twenty-six patients implanted with a cardiac resynchronization therapy defibrillator (CRT-D) device were enrolled and randomized 1:1 to either BIV (266) or RV (260) ATP (single burst 8 pulse, 88% coupling interval) and were followed up for 12 months. Results: During 12 months'' follow-up, 1,077 ventricular episodes in 180 patients were detected and classified: 634 true VTs divided into 69 ventricular fibrillation (VF) (11%), 202 fast ventricular tachycardia (FVT) (32%), and 363 VT (57%). A comparable first ATP efficacy (BIV 65% vs RV 68%, P = .59) was observed in FVT + VT, in VT zone (BIV 62% vs RV 71%, P = .25), and in FVT zone (BIV 71% vs RV 61%, P = .34). A trend toward lower accelerations during ATP applied to FVT was observed in the BIV group (3.5% BIV vs 10.2% RV, P = .163). No syncope/presyncope occurred during ATP for FVT in the BIV group versus 4 events (3.2%) in the RV group (P = .016). biventricular ATP was more effective in treating FVT in coronary artery disease (CAD) patients (P = .032), whereas both modalities presented similar efficacy in patients with non-CAD etiology (P = .549). Conclusions: Antitachycardia pacing is effective in patients implanted with a CRT-D device. No significant differences in efficacy emerged between BIV- and RV-delivered ATP in the general population, whereas BIV ATP seems to present a safer profile in ischemic patients. [Copyright &y& Elsevier]

Background: Sudden cardiac death (SCD) is the predominant cause of mortality in patients with mild heart failure (HF). This 2-year follow-up, multicenter, cohort study aimed to assess the extent to which implantable cardioverter defibrillators (ICDs), by reducing SCD, lead to predominant progressive HF death in mildly symptomatic HF patients at baseline in daily medical practice. Methods: Between June 2001 and June 2003, 1,030 New York Heart Association II patients received an ICD in 22 French centers. Sudden cardiac death and progressive HF mortality rates were assessed using competing risk methodology, and predictors for progressive HF at baseline were tested in a multivariate regression model. Results: During a mean follow-up of 22 ± 6 months, 114 deaths occurred: 12 (10.5%) due to SCD and 52 (45.6%) due to progressive HF (24-month cause-specific mortality rates of 1.2% [95% CI 0.6-1.9] and 5.4% [95% CI 4.0-6.8], respectively). Diuretics use (hazard ratio [HR] 2.8, 95% CI 1.5-5.5, P = .002), history of atrial fibrillation (HR 2.09, 95% CI 1.2-3.65, P = .01), and low ejection fraction (HR 2.7, 95% CI 1.4-4.8, P = .0008) were independent predictors for progressive HF death, whereas β-blocker therapy was a protector (HR 0.6, 95% CI 0.3-0.9, P = .04). Half of the patients (48%) who died from progressive HF within 2 years of ICD implant initially presented with enlarged QRS (≥120 milliseconds). Conclusions: Because of ICD efficiency, progressive HF is the main cause of death within 2 years of implant, although these patients are only mildly symptomatic at implantation. In addition to optimal pharmacologic therapy, these results raise the question of systematically implanting ICDs with cardiac resynchronization therapy in patients with electrical asynchronism at baseline. [Copyright &y& Elsevier]

Background: Various types of gastro-intestinal complications have already been reported after atrial fibrillation (AF) radiofrequency ablation. The objective of this prospective study was to assess the incidence of esogastric injuries after pulmonary vein isolation (PVI) with the cryoballoon catheter (Arctic Front, Cryocath, Quebec, Canada). Methods: Between December 2007 and April 2009, 25 patients (15 males, mean age 55 years old) with symptomatic, drug refractory, paroxysmal (n= 24) or persistent (n= 1) AF underwent circumferential antral PVI using a cryoballoon catheter. Post-procedural upper gastro-intestinal endoscopy was systematically performed on the following day. Results: All procedures were performed in patients using a double lumen 23 or 28 mm cryoballoon catheter, with a mean maximal temperature of – 45.5±19.7°C. Out of the 100 veins treated by the cryoballoon technique, 93 were completely isolated (93%). The number of balloon applications per vein was 2.2±0.7 and the mean procedure time was 158.5±28.7 minutes. Endoscopy found gastroparesia in 4 patients (16%, 2 gastric bezoar and 2 severe gastric stasis) which were considered as likely related to the ablation and due to vagal injury. All patients were asymptomatic. In 13 cases (52%), endoscopic abnormalities were considered as fortuitous (peptic gastritis and esophagitis, n=8; gastric ulcer, n=1; hiatal hernia, n=5; esophageal lipoma, n=1). In one case, the endoscopy revealed a Mallory Weiss syndrome, presumably connected to pre-operative trans-esophageal echocardiography. Esograstric endoscopy was normal in only 8 cases (32%). Conclusion: Cryoballoon catheter ablation for AF is associated with an unusual high incidence of gastroparesia (16%) which could be related to procedural periesophageal vagal nerve damage. [Copyright &y& Elsevier]

Purpose: Various gastro-intestinal complications have been reported after atrial fibrillation (Afib) radiofrequency (RF) ablation. The purpose of this study was to prospectively evaluate the incidence of esogastric injuries after Afib RF ablation. Methods: Between June 2007 and April 2009, all patients (pts) in whom Afib/left atrial flutter RF ablation was performed, underwent a systematic upper gastro-intestinal endoscopy 24 hours after the procedure. Endoscopic findings were classified as likely related to the procedure, potentially related or unrelated. Results: 100 ablation procedures were performed in 77 pts using a 4 mm irrigated-tip RF catheter with temperature set to 45°C. Ablation consisted in antral isolation of pulmonary veins (PVI) in 63 cases (63%; maximum power: 30W), associated with creation of roof and left isthmus lines in 14 (14%;35W), and additional left atrial fragmented electrograms ablation in 23 (23%;35W). Esogastric endoscopy found gastroparesia in 6 cases (6%), considered as likely related to the ablation and due to vagal injury. Among these cases, 4 had left atrial fragmented electrograms ablation (p<0.001). In 3 PVI cases (3%), localized esophagus erythema was also considered as likely related to the ablation procedure. In 5 cases with either Mallory Weiss-like syndrome (n=3) or circumferential esophagus erythema (n=2), RF induced lesions could not be fully ruled out. In 3 cases, esophageal lesions were likely due to pre-operative trans-esophageal echocardiography (2 hematomas and 1 proximal ulceration). In 45 cases (45%), endoscopic abnormalities were considered as unrelated to the ablation (gastritis, n=18; Barret''s esophagus, n=7; hiatal hernia, n=14). Endoscopy was normal in 43 cases (43%). Conclusions: In this prospective study, the incidence of asymptomatic esogastric injuries likely related to RF ablation was fairly high (9%). Gastroparesia was the main complication and was significantly associated with extensive left atrial ablation. [Copyright &y& Elsevier]

Background: Radiofrequency (RF) isolation of pulmonary veins (PVs) has emerged as an effective treatment for patients presenting drug refractory atrial fibrillation (AF). The objective of this study was to assess the feasibility, safety, and short-term outcome of pulmonary vein isolation (PVI) in paroxysmal and persistent AF patients with a new cryoballoon catheter technique (Arctic Front, Cryocath, Quebec, Canada). Methods: Between December 2007 and April 2009, 37 patients (25 males, mean age 56 years old) with symptomatic, drug refractory, paroxysmal (n= 36) or persistent (n= 1) AF underwent circumferential antral PVI using a double lumen 23 or 28 mm cryoballoon catheter. Before discharge, all patients were subjected to 24-hour Holter electrocardiograms, echocardiography, and esophageal endoscopy. In case of symptomatic recurrences, a second AF ablation aiming at PV isolation, was performed using RF catheter. Results: Out of 148 treated veins, 140 were completely isolated (94.6%). All PVs were completely isolated in 28/37 patients (75.6%). The number of balloon applications per vein was 2.18±0.69. The mean procedure and fluoroscopy time were 164.8±39.3 and 32.4±12.3 min respectively. Thirty-one patients were free of AF at hospital discharge (83.8%). No PV narrowing, atrio-esophageal fistula or thromboembolic event occurred. Three phrenic nerve palsy (8.1%) were observed after cryoapplication at the right superior PV. Two of them resolved immediately after cessation of cryoenergy, one resolved at 2 weeks. The most frequent complications were pericardial effusions (n=8) and groin hematoma (n= 3) or ecchymosis (n=6), all spontaneously reversible. Among the 15 patients seen at 4 months follow-up, all were AF free after one (n = 11) or two procedures (n= 4) without any antiarythmic drugs. Conclusion: Cryoballoon PVI appears as an effective and safe technique with a relatively high clinical success rate at short-term follow-up. [Copyright &y& Elsevier]

Background: Patients with nonischemic dilated cardiomyopathy (DCM) may be at lower risk for ventricular arrhythmias compared with those with ischemic cardiomyopathy (ICM). In addition, DCM has been identified as a predictor of positive response to cardiac resynchronization therapy (CRT).Objectives: The aim of this study was to investigate the impact of an additional implantable cardioverter-defibrillator over CRT, according to underlying heart disease, in a large study group of primary prevention patients with heart failure.Methods: This was an observational, multicenter, European cohort study of 5,307 consecutive patients with DCM or ICM, no history of sustained ventricular arrhythmias, who underwent CRT implantation with (n = 4,037) or without (n = 1,270) a defibrillator. Propensity-score and cause-of-death analyses were used to compare outcomes.Results: After a mean follow-up period of 41.4 ± 29.0 months, patients with ICM had better survival when receiving CRT with a defibrillator compared with those who received CRT without a defibrillator (hazard ratio for mortality adjusted on propensity score and all mortality predictors: 0.76; 95% confidence interval [CI]: 0.62 to 0.92; p = 0.005), whereas in patients with DCM, no such difference was observed (hazard ratio: 0.92; 95% CI: 0.73 to 1.16; p = 0.49). Compared with recipients of defibrillators, the excess mortality in patients who did not receive defibrillators was related to sudden cardiac death in 8.0% among those with ICM but in only 0.4% of those with DCM.Conclusions: Among patients with heart failure with indications for CRT, those with DCM may not benefit from additional primary prevention implantable cardioverter-defibrillator therapy, as opposed to those with ICM. [ABSTRACT FROM AUTHOR]

Abstract: Background: Using standardized scales, we assessed the point prevalence, the severity of anxiety and depressive disorders, and the quality of life (QOL) in implantable cardioverter defibrillator (ICD) recipients who received a device shock. Methods: Forty research subjects with device shocks (Group 1) and 25 without shocks (Group 2) were interviewed after ICD implantation using the Mini International Neuropsychiatric Interview (MINI), the Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Results: The point prevalence of anxiety disorders was higher in Group 1 (37.5%) than in Group 2 (8%) (P=.009). Depressive symptoms scores were higher in Group 1 (4.75) than in Group 2 (2.24) (P=.04)), but the prevalence of depressive disorders or the anxiety scores were not significantly different. A positive correlation was found between the number of shocks and the depressive symptoms scores (P=.05, r=0.24); there was a negative correlation between the mental health subscore of the SF-36 and the number of shocks (r=−0.36, P=.003). The point prevalence of depressive disorders was higher in the group with congenital cardiac diseases (50%) than in the valvular (8%) and ischemic groups (23%) (P=.04), and the mental health composite summary score of the SF-36 was lower in this group (46.34) than in those with valvular and ischemic disease (56.09 and 52.61, respectively) (P=.03). Conclusion: Exposure to shocks may lead to an increased risk of anxiety and depressive symptoms. Research subjects receiving a high number of shocks and research subjects with congenital cardiovascular diseases were at higher risk of depressive symptoms or at higher risk of poorer psychological aspects of QOL. [Copyright &y& Elsevier]

: ObjectivesWe hypothesized that pacemaker (PM) implantation in patients with myotonic dystrophy (MD) with a prolonged HV interval, even asymptomatic, may protect them against sudden death related to atrioventricular (AV) block. We sought to prospectively document the true incidence of AV block episodes in this high-risk population and accurately trace, in the long term, by the PM, the occurrence of arrhythmias that may remain undetected during conventional follow-up.: BackgroundMyotonic dystrophy is associated with a high risk of sudden death, commonly attributed to AV block or ventricular arrhythmias, but cardiac pacing is only recommended as a secondary prevention.: MethodsPatients with MD with an HV interval ≥70 ms, even in the absence of related symptoms, prospectively received a cardiac PM, including an algorithm capable of diagnosing episodes of bradycardia and tachyarrhythmias.: ResultsThe population consisted of 49 patients (45.5 ± 8.9 years old) followed for 53.5 ± 27.2 months. Paroxysmal arrhythmias were recorded in 41 patients (83.7%), consisting of complete AV block (n = 21), sino-atrial block (n = 4), or atrial (n = 25) or ventricular (n = 13) tachyarrhythmias. No patient died of AV block during follow-up, but 10 deaths occurred, 4 of them sudden. An arrhythmic cause could be excluded by postmortem PM interrogation in two cases of typical sudden death.: ConclusionsArrhythmias are common in patients with MD with infrahisian conduction abnormalities. The prophylactic implantation of a pacing system when the HV interval is ≥70 ms seems appropriate. The PM protects the patient against the clinical consequences of paroxysmal profound bradycardia and facilitates the diagnosis and management of frequent paroxysmal tachyarrhythmias. [Copyright &y& Elsevier]