Search

Background Therapeutic failure is a frequent issue in the management of post-operative peritonitis. Objectives A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients. Patients and methods Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses. Results Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17–3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05–8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03–1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36–11.49) and diabetes (OR 6.95; 95% CI 1.34–36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13–3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02–5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21–7.01). No specific risk factors were identified for microbiological failure. Conclusions Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type.

International audience; Ulipristal has recently been suspected to be hepatotoxic by the European Medicines Agency but the evidence base for hepatotoxicity is sparse. This is a brief formal report of a patient administered ulipristal for 6-8 weeks and who developed acute liver failure leading to liver transplantation. The explanted liver showed extensive hepatocyte necrosis and inflammation compatible with drug-induced liver injury and cirrhosis. The usual causes of acute hepatitis and cirrhosis were eliminated. There were no other potential causative drugs. This case suggests that ulipristal may cause acute hepatitis, with pre-existing cirrhosis probably contributing to the severity of liver injury observed in this case. Ulipristal prescribers must remain vigilant and monitor liver function in their patients.

International audience

Despite isolated reports of Brugada syndrome (BrS) in the inferior or lateral leads, the prevalence and prognostic value of ST elevation in the peripheral electrocardiographic (ECG) leads in patients with BrS remain poorly known.To study the prevalence, characteristics, and prognostic value of type 1 ST elevation and ST depression in the peripheral ECG leads in a large cohort of patients with BrS.ECGs from 323 patients with BrS (age 47 ± 13 years; 257 men) with spontaneous (n = 141) or drug-induced (n = 182) type 1 ECG were retrospectively reviewed. Two hundred twenty-five (70%) patients were asymptomatic, 72 (22%) patients presented with unexplained syncope, and 26 (8%) patients presented with sudden death (12 patients) or appropriated implantable cardioverter-defibrillator therapies (14 patients) at diagnosis or over a mean follow-up of 48 ± 34 months.Thirty (9%) patients presented with type 1 ST elevation in at least 1 peripheral lead (22 patients in the aVR leads, 2 in the inferior leads, 5 in both aVR and inferior leads, and 1 in the aVR and VL leads). Patients with type 1 ST elevation in the peripheral leads more often had mutations in the SCN5A gene, were more often inducible, had slower heart rate, and higher J-wave amplitude in the right precordial leads. Twenty-seven percent (8 of 30) of the patients with type 1 ST elevation in the peripheral leads experimented sudden death/appropriate implantable cardioverter-defibrillator therapy, whereas it occurred in only 6% (18 of 293) of other patients (P.0001). In multivariate analysis, type 1 ECG in the peripheral leads was independently associated with malignant arrhythmic events (odds ratio 4.58; 95% confidence interval 1.7-12.32; P = .0025).Type 1 ST elevation in the peripheral ECG leads can be seen in 10% of the patients with BrS and is an independent predictor for a malignant arrhythmic event.

Early repolarization pattern (ERP) has recently been associated with idiopathic ventricular fibrillation and with cardiovascular mortality in the general population. We aimed to identify electrocardiographic tools to differentiate the "malignant" form of ERP from benign ERP in a population-based study. We retrospectively assessed the prevalence of ERP by recording electrocardiograms in 1,161 southwestern French subjects 35 to 64 years old. ERP was defined by an elevation of the J point ≥1 mm in 2 consecutive leads excluding leads V(1) through V(3). We categorized ERP as notching or slurring pattern as located in inferior and/or lateral leads and measured the J-point elevation amplitude. ST segment after ERP was categorized as ascendant or horizontal/nonascendant and T waves as negative or positive. Association of ERP with all-cause and cardiovascular mortalities was assessed by adjusted Cox proportional hazard models. ERP was found in 157 subjects (13.3%). During a mean follow-up of 14.2 ± 2 years, 77 subjects died (6.6%), of whom 24 (2.1%) died from cardiovascular causes. Subjects with ERP had an increased hazard ratios for all-cause mortality (2.45, 95% confidence interval [CI] 1.44 to 4.15, p = 0.001) and cardiovascular mortality (5.60, 95% CI 2.27 to 11.8, p = 0.001). The highest risk was found for notching ERP and ERP with a nonascendant/horizontal ST segment, yielding when associated increased hazard ratios of 3.84 (95% CI 2.14 to 6.92, p = 0.001) and 8.75 (95% CI 3.48 to 22.0, p = 0.001) for all-cause and cardiovascular mortalities, respectively. Conversely, a slurring ERP or ascendant ST segment was not associated with increased mortality. ERP localization, J-point elevation amplitude, or T-wave morphology did not distinguish benign from malignant forms of ERP. In conclusion, ERP with notching pattern and horizontal/descendant ST segments was associated with the highest risk of all-cause and cardiovascular deaths. These electrocardiographic patterns may be used for risk stratification in subjects with ERP.

Background: T-wave alternans (TWA) is an accepted marker of risk for malignant ventricular arrhythmias, for which prognosis value has been established in different populations. Short QT syndrome (SQTS) is a very rare primary electrical disease carrying the risk of ventricular fibrillation. TWA in SQTS has not been evaluated yet. Methods: Thirteen patients with SQTS (QT = 308 ± 16 ms, QTc = 329 ± 10 ms, heart rate = 69 ± 8 beats/min) underwent microvolt TWA measurement using spectral analysis. TWA testing was performed using Heartwave II (Cambridge Heart™, Inc., Bedford, MA, USA) during bicycle exercice and classified as negative, positive, or indeterminate according to the published standards for clinical interpretation. Results: Twelve patients were male (mean age 23 ± 5 years). Five were asymptomatic, three presented with aborted sudden cardiac death, and five with unexplained syncope. Six patients belonged to two unrelated families, while familial cases of SQTS were present for two other patients. A familial history of sudden death (SD) was present for seven patients. Ventricular fibrillation was inducible in three patients. Four patients were implanted with an implantable cardioverter-defibrillator and one presented with polymorphic ventricular tachycardia during follow-up. TWA was negative in each but one patient (indeterminate). Maximal negative heart rate was 118 ± 12 beats/min. Patients with previous SD displayed significant shorter QT and higher resting heart rate compared to the remaining cases. Conclusions: TWA testing is negative in 12 of 13 SQTS patients, even in the symptomatic or inducible ones. Measurement of TWA using conventional protocol and criteria for risk stratification in SQTS seems therefore useless. (PACE 2012;35:1413–1419)

We present the case of a patient with incessant slow-fast atrio-ventricular (AV) node reentrant tachycardia induced by dual AV node conduction with aborted conduction to the ventricles. The unapparent conduction over the slow pathway was suspected here because of spontaneous nodal echoes without QRS complexes occurring during sinus rhythm, manifested as isolated premature atrial beats and which repetitively induced the tachycardia.

International audience; PURPOSES: Analysing ventricular fibrillation (VF) rate and regularity at different sites and at different times may help understanding some of the mechanisms underlying VF in humans. METHODS: Twelve episodes of VF (19.4 ± 5.6 s) were induced during electrophysiological study in eight men (63 ± 14 years old). Calculation of dominant frequency (DF) by fast Fourier transform, short-time Fourier transform, and analysis of the pitch frequency [VF cycle length duration (CL)] were performed. For each episode, we analysed the 12 lead-surface ECG, three unipolar, 10 near-field, and three far-field bipolar recordings by means of three quadripolar catheters positioned at the right ventricular apex (RV apex), right ventricular outflow tract, and at the coronary sinus (exploring the lateral left ventricular epicardium) (LV). RESULTS: Fast and regular discrete activation covered the whole duration of every intracardiac recording, whereas surface ECG consistently displayed chaotic and fibrillatory pattern. DF (5.25 ± 0.64 Hz) was very similar on surface ECG recordings and in various intracardiac recordings. Intracardiac activation was rather regular during VF despite the fibrillatory process with very low SD of the CL. There were some significant inverse correlations between VF rate and VF regularity. Intracardiac sites displaying the fastest and most regular activations were those including the RV apex. VF rate and stability slightly increased over time. Finally, the parameters exploring the VF rate were found to be well correlated together, as well as parameters of VF regularity CONCLUSIONS: Human VF induced during electrophysiological study has a clear DF of activation and appears quite regular in intracardiac recordings. There is some spatial heterogeneity, which needs to be more detailed in order to localize possible driving sources. Fastest VF are the most regular. Rate and stability tend to increase during the initial phases of VF.

Summary Background Differences in the duration of the excitable gap along the reentry circuit during typical atrial flutter are poorly known. Aim To prospectively evaluate and compare the duration and composition of the excitable gap during typical counterclockwise atrial flutter in different parts of the circuit all around the tricuspid annulus. Methods The excitable gap was determined by introducing a premature stimulus at various sites around the tricuspid annulus during typical counterclockwise atrial flutter in 34 patients. Excitable gap was calculated as the difference between the longest resetting coupling interval and the effective atrial refractory period. Results The duration of the excitable gap, the effective atrial refractory period and the resetting coupling interval differed significantly along the tricuspid annulus. Duration of excitable gap was significantly longer at the low lateral right atrium (79 ± 22 ms) than at the cavotricuspid isthmus (66 ± 23 ms; P = 0.002). The effective atrial refractory period was significantly longer at the cavotricuspid isthmus (160 ± 26 ms) than at the high lateral right atrium (149 ± 29 ms; P = 0.004). Other locations, such as coronary sinus ostium, right atrial septum and atrial roof displayed intermediate values. Conclusion The duration of the excitable gap differed significantly along the tricuspid annulus, with a larger excitable gap at the lateral right atrium and a shorter excitable gap at the cavotricuspid isthmus, because of longer refractory periods at the isthmus.

We report the first case of percutaneous radio-frequency (RF) ablation procedure in a patient implanted with a HeartMate II left ventricular assist device for refractory heart failure. This procedure was performed for poorly tolerated recurrent atrial arrhythmias. No harmful consequence happened during or after the procedure despite the potential electromagnetic interferences existing between the RF delivery and the functioning of the device.

We present the first form of laminopathy connected with a new mutation of the lamin A/C gene expressed by dilated cardiomyopathy and partial atrial standstill associated with Charcot-Marie-Tooth type 2 axonal neuropathy. The rapid development of the cardiac disease was controlled by medical treatment and resynchronization therapy associated with a defibrillator.

We report a new case of non-reentrant supraventricular tachycardia, associated with tachycardia-induced cardiomyopathy fully reversible after radiofrequency (RF) ablation, together with striking features of apparent concomitant Mobitz type 1 atrioventricular (AV) block in both AV node pathways. Further analysis of the conduction patterns during the incessant non-reentrant tachycardia raised unresolved hypothesis about the involved mechanisms and further interrogations on AV node physiology.

Aims Upper turn-around of the reentry circuit in typical atrial flutter (AF) is classically described to be located in front of the superior vena cava (SVC), but circuits posterior to the SVC as well as lower loop reentry (LLR) involving only the lower part of the right atrium have been described. However, true prevalence of such AF circuits remains unknown. Methods and results Fifty consecutive patients (46 men, 68 ± 9 years old) undergoing radiofrequency (RF) ablation of typical counter-clockwise AF were prospectively investigated. Prior to RF deliverance, AF was entrained by pacing 10 ms shorter than the AF cycle length (AFCL). Post-pacing interval (PPI) at the cavotricuspid isthmus (CTI) and at the atrial roof (AR)—between SVC and the high tricuspid annulus—were determined. AR was considered to be part of the AF circuit when local PPI–AFCL was ≤20 or 30 ms or, in case of long PPI at the CTI isthmus, if difference between AR-PPI and CT-PPI was ≤10 ms. In 47 patients, CTI-PPI–AFCL was ≤30 ms (94%). Among them, AR-PPI–AFCL was >30 ms in 12 cases (25%). In the remaining three patients, AR-PPI–AFCL did not exceed CTI-PPI–AFCL by more than 10 ms. In 42 patients, CTI-PPI–AFCL was ≤20 ms (84%). Among them, AR-PPI–AFCL was >20 ms in 16 cases (39%). In the remaining eight patients, AR-PPI–AFCL was more than 10 ms longer than CTI-PPI–AFCL in only one instance. Taken together, AR PPI was >20 or >30 ms longer than AFCL or >10 ms longer than CTI PPI when prolonged in 17 (34%) and 12 patients (24%), respectively. Conclusion In around a quarter to one-third of patients referred for RF ablation of typical AF, the atrial roof is not part of the circuit, thus they may present a ‘posterior’ variant of the typical counter-clockwise AF reentry circuit.

We describe a case presenting with ventricular tachycardia as the manifestation leading to the diagnosis of sarcoidosis. The ventricular tachyacardia's origin is correlated with granuloma localization on magnetic resonance imaging.

Objectives: Complete bidirectional cavo-tricuspid isthmus (CTI) block is mandatory for radio-frequency (RF) ablation of typical atrial flutter (AF). CTI block can be assessed by a simplified method using two catheters and the technique of differential pacing, but long-term results in large series are poorly known. Methods: CTI RF ablation was performed in 255 consecutive patients with typical AF, using one quadripolar catheter, and the ablation catheter, in association with the technique of differential pacing. Results: Procedural success, as defined by documentation of complete bidirectional CTI block using limited activation mapping, positive differential pacing together with termination of ongoing AF, was achieved in 80% of patients. AF recurred in 37 patients (14%) over a mean follow-up period of 15 ± 9 months. Two hundred and forty-one patients (94%) were finally cured, with 1.1 procedures/patient. The recurrence rate was related to the achievement of complete CTI bidirectional block (12% vs. 29%, p = 0.01). Conclusions: Long-term results of CTI ablation, employing a simplified method using the differential pacing technique, are similar to those for the standard methods using multipolar catheters. Therefore, this technique compares favorably to other established methods for such common RF procedures, especially due to its lower cost.

We report the case of a patient presenting with a previous inferior myocardial infarction complicated by incessant monomorphic ventricular tachycardia resistant to antiarrhythmic drugs. Because endocardial catheter ablation failed and because of focal endocardial activation arising from the left ventricular inferior wall, an epicardial location of the reentry circuit was suspected. Catheter mapping of the pericardial space through a surgical subxyphoid approach performed in the electrophysiological laboratory confirmed the epicardial location of the arrhythmogenic substrate and allowed us successfully to ablate and cure the patient. Surgical subxyphoid approach can be performed in the electrophysiological laboratory when epicardial ablation is needed in case of inadvisable, difficult, or failed non-surgical percutaneous access.

The authors report a case of paroxysmal, complete atrioventricular block during an anterior acute myocardial infarction, leading to asystolia. The different possible physiopathological mechanisms are discussed, suggesting a paroxysmal nodal conduction defect, secondary to transient parasympathetic stimulation, triggered by a Bezold-Jarish type of cardiac reflex. This reflex is frequently involved in various pathologic situations or diagnostic procedures, usual in cardiology. Although it is frequently observed in inferior myocardial infarction, it can occur during an anterior acute myocardial infarction.

A case of an electrical storm occurring in a patient implanted with a cardioverter-defibrillator for Brugada syndrome is reported. Recurrent ventricular fibrillation was initiated by short-coupled isolated monomorphic ventricular premature beats probably originating from the right ventricular outflow tract, associated with a manifest electrocardiographic pattern of Brugada syndrome. Infusion of atropine accelerated the heart rate but did not prevent ventricular fibrillation, however, low doses of isoprenaline quickly obviated any recurrence of ventricular fibrillation. This was associated with the disappearance of the short-coupled premature beats together with a normalization of the electrocardiographic pattern. Possible mechanisms are discussed according to the accepted pathophysiological hypothesis.

Background— The long-QT and Brugada syndromes are important substrates of malignant ventricular arrhythmia. The feasibility of mapping and ablation of ventricular arrhythmias in these conditions has not been reported. Methods and Results— Seven patients (4 men; age, 38±7 years; 4 with long-QT and 3 with Brugada syndrome) with episodes of ventricular fibrillation or polymorphic ventricular tachycardia and frequent isolated or repetitive premature beats were studied. These premature beats were observed to trigger ventricular arrhythmias and were localized by mapping the earliest endocardial activity. In 4 patients, premature beats originated from the peripheral right (1 Brugada) or left (3 long-QT) Purkinje conducting system and were associated with variable Purkinje-to-muscle conduction times (30 to 110 ms). In the remaining 3 patients, premature beats originated from the right ventricular outflow tract, being 25 to 40 ms ahead of the QRS. The accuracy of mapping was confirmed by acute elimination of premature beats after 12±6 minutes of radiofrequency applications. During a follow-up of 17±17 months using ambulatory monitoring and defibrillator memory interrogation, no patients had recurrence of symptomatic ventricular arrhythmia but 1 had persistent premature beats. Conclusion— Triggers from the Purkinje arborization or the right ventricular outflow tract have a crucial role in initiating ventricular fibrillation associated with the long-QT and Brugada syndromes. These can be eliminated by focal radiofrequency ablation.

Occurrence of supraventricular tachycardia is a common cause of clinical impairment for patients implanted with CRT devices. We report the case of atrial activity oversensing by the left ventricular (LV) lead during typical flutter, which led to LV pacing inhibition. Temporary reprogramming of the LV detection from standard bipolar to extended bipolar and cavotricuspid isthmus ablation solved this problem.

Background Both type 1 myotonic dystrophy (MD1) and Brugada syndrome (BrS) may be complicated by conduction disturbances and sudden death. Spontaneous BrS has been observed in MD1 patients, but the prevalence of drug-induced BrS in MD1 is unknown. Objective The purpose of this study was to prospectively assess the prevalence of type 1 ST elevation as elicited during pharmacologic challenge with Class 1C drugs in a subgroup of MD1 patients and to further establish correlations with ECG and electrophysiologic variables and prognosis. Methods From a group of unselected 270 MD1 patients, ajmaline or flecainide drug challenge was performed in a subgroup of 44 patients (27 men, median age 43 years) with minor depolarization/repolarization abnormalities suggestive of possible BrS. The presence of type 1 ST elevation after drug challenge was correlated to clinical, ECG, and electrophysiologic variables. Results Eight of 44 patients (18%) presented with BrS after drug challenge. BrS was seen more often in men (26% vs 6%, P = .09) and was related to younger age (35 vs 48 years, P = .07). BrS was not correlated to symptoms, baseline ECG, HV interval, results of signal-averaged ECG, or abnormalities on ambulatory recordings. MD1 patients with BrS had longer corrected QT intervals, greater increase in PR interval after drug challenge, and higher rate of inducible ventricular arrhythmias (62% vs 21%, P = .03). Twelve patients were implanted with a pacemaker and 5 with an implantable cardioverter-defibrillator. Significant bradycardia did not occur in any patients, and malignant ventricular arrhythmia never occurred during median 7-year follow-up (except 1 hypokalemia-related ventricular fibrillation). Conclusion BrS is elicited by a Class 1 drug in 18% of MD1 patients presenting with minor depolarization/repolarization abnormalities at baseline, but the finding seems to be devoid of a prognostic role.

AIMS: Patients with well-tolerated sustained monomorphic ventricular tachycardia (SMVT) and left ventricular ejection fraction (LVEF) over 30% may benefit from a primary strategy of VT ablation without immediate need for a 'back-up' implantable cardioverter-defibrillator (ICD). METHODS AND RESULTS: One hundred and sixty-six patients with structural heart disease (SHD), LVEF over 30%, and well-tolerated SMVT (no syncope) underwent primary radiofrequency ablation without ICD implantation at eight European centres. There were 139 men (84%) with mean age 62 ± 15 years and mean LVEF of 50 ± 10%. Fifty-five percent had ischaemic heart disease, 19% non-ischaemic cardiomyopathy, and 12% arrhythmogenic right ventricular cardiomyopathy. Three hundred seventy-eight similar patients were implanted with an ICD during the same period and serve as a control group. All-cause mortality was 12% (20 patients) over a mean follow-up of 32 ± 27 months. Eight patients (40%) died from non-cardiovascular causes, 8 (40%) died from non-arrhythmic cardiovascular causes, and 4 (20%) died suddenly (SD) (2.4% of the population). All-cause mortality in the control group was 12%. Twenty-seven patients (16%) had a non-fatal recurrence at a median time of 5 months, while 20 patients (12%) required an ICD, of whom 4 died (20%). CONCLUSION: Patients with well-tolerated SMVT, SHD, and LVEF > 30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death and recurrences were generally non-fatal. These data would support a randomized clinical trial comparing this approach with others incorporating implantation of an ICD as a primary strategy.

Concealed left superior accessory pathways are very infrequent and can be difficult to diagnose and ablate. We describe here the case of a patient presenting with reciprocating tachycardia involving superior and inferior left accessory pathways. Left superior accessory pathway was suspected because of the simultaneous retrograde atrial activation at the distal coronary sinus (CS) and His bundle lead and could be successfully ablated using transseptal catheterization.

Concealed retrograde activation of bundle branch has been often proposed for explaining the persistence of functional rate-dependent bundle-branch block, but direct proof of such a mechanism in man has rarely been demonstrated. We report intracardiac recordings compatible with a reversal of activation of the left basal interventricular septum during intermittent left bundle-branch block. In our case, however, retrograde activation into the left bundle-branch cannot be recordable, probably due to the concealment within the muscular septal activation, even if this may explain the perpetuation of bundle-branch block according to the linking phenomenon.

IntroductionFrequent premature ventricular beats (PVB) may induce cardiomyopathy (CM). Characteristics and prognosis factor for recovery after RF ablation remain debated.Methods93 patients (74% men, 58±14 yo) with dilated CM associated with frequent isolated PVB were included. A group of 75 pts undergoing ablation for symptomatic PVB without significant cardiac disease serves as the control group.ResultsEF was 38±10% and left ventricular end diastolic diameter (LVEDD) was 63±8mm. One third have various associated cardiomyopathy.PVB burden was 27±12%. PVB arose from the left ventricle in 96 pts (LVOT 61, mitral 16, apex 7, septal 12) and from the right ventricle in 61 pts (RVOT 58) and multiple in 11. Epicardial ablation in the CS was needed in 25.In multivariate analysis, lack of palpitations (OR 9.09 [3.45-33.33]), VPB number > 20000 (OR 5.40 [1.98-14.70]), left ventricular origin (OR 4.12 [1.53-11.11]), epicardial location (OR 11.00 [1.92-62.50]), VPB right inferior axis (OR 2.31 [0.85-6.27]), baseline QRS width > 100ms (OR 3.66 [1.2810.43]), VPB coupling interval > 500ms (OR 3.11 [1.14-8.55]) and polymorphic VPB (OR 10.40 [1.05-103.05]) were independantly associated with CM compared to controls (p 80% reduction). In these, EF increased (36±9 to 51±12%, p 10% increase in EF. Only a VPB > 2mV (OR 19.2 [1.84-200.00], p=0.01) was independanlty associated with reversal of CM in multivariate analysis.ConclusionMechanisms leading to PVB-induced CM may involve lack of palpitations, a high VPB number, a left ventricular origin, an epicardial location, a VPB right inferior axis, a large baseline QRS duration, a long VPB coupling interval and polymorphic VPB. Reversal of CM after RF ablation may associate a high VPB amplitude and a shorter VPB coupling interval. This may help in selecting patients for RF ablation of suspected VPB-induced CM.

Prevalence and prognostic value of conduction disturbances in patients with the Brugada syndrome (BrS) remains poorly known. Electrocardiograms (ECGs) from 325 patients with BrS (47 ± 13 years, 258 men) with spontaneous (n = 143) or drug-induced (n = 182) type 1 ECG were retrospectively reviewed. Two hundred twenty-six patients (70%) were asymptomatic, 73 patients (22%) presented with unexplained syncope, and 26 patients (8%) presented with sudden death or implantable cardioverter-defibrillator appropriated therapies at diagnosis or during a mean follow-up of 48 ± 34 months. P-wave duration of ≥120 ms was present in 129 patients (40%), first degree atrioventricular block (AVB) in 113 (35%), right bundle branch block (BBB) in 90 (28%), and fascicular block in 52 (16%). Increased P-wave duration, first degree AVB, and right BBB were more often present in patients after drug challenge than in patients with spontaneous type 1 ST elevation. Left BBB was present in 3 patients. SCN5A mutation carriers had longer P-wave duration and longer PR and HV intervals. In multivariate analysis, first degree AVB was independently associated with sudden death or implantable cardioverter-defibrillator appropriated therapies (odds ratio 2.41, 95% confidence interval 1.01 to 5.73, p = 0.046) together with the presence of syncope and spontaneous type 1 ST elevation. In conclusion, conduction disturbances are frequent and sometimes diffuse in patients with BrS. First degree AVB is independently linked to outcome and may be proposed to be used for individual risk stratification.

IntroductionAtrial fibrillation (AFib) progressively leads to electrical remodeling (ER) and anatomical-mechanical remodeling (AMR) whose relationships remain poorly known.MethodsER and AMR were compared in patients undergoing percutaneous RF ablation for AFib. ER was defined by right and left appendage activation rate (RAAAR and LAAAR) as a surrogate for atrial refractory periods. AMR was approached by left atrium (LA) diameters and area and left atrial appendage (LAA) area and contractile function (mean emptying flow velocity) (LAAFV) as determined during transoesophageal and transthoracic echocardiography performed during AFib the day before or immediately before RF ablation. Mean duration between successive LAA contractions was considered as LAA mechanical rate.Results40 pts with paroxysmal AFib (n=10), persistent AFib (n=25) or long-persistent AFib (n=5) were included (30 men, 64±9 yo, EF 39±14%). 63% were on amiodarone.Parameters exploring AMR were highly correlated to each other: LA area 27±7cm2; LAA area 5.5±2cm2; LA transv 48±14 mm; LA ant-post 58±13 mm; LAA velocity 28±13cm/sec (p

IntroductionFrequent premature ventricular beats (PVB) may induce cardiomyopathy (CM) whose characteristics and underlying mechanisms are poorly knownMethods38 patients (27 men, 57±16yo) with dilated CM associated with frequent isolated PVB suspected to be responsible the CM were ablated between 2005 and 2011. PVB were documented 5 years (n=10) before (unknown in 9). Ejection fraction (EF), left ventricular end-diastolic diameter (LVEDD) and NYHA class were compared before and after radio-frequency ablation. 16 pts with symptomatic PVB without CM serves as the control groupResultsBaseline EF was 39±1%, LVEDD was 61±7mm and mean NYHA class was 1.9±0.8. PVB arose from the RV in 10 pts (RVOT in 7) and from the LV in 28 pts (LVOTt in 10 and coronary cusps in 10)Compared to the control group, daily PVB number was not different in pts with suspected VPB-induced CM (22000±12000 vs 20000±14000, p=ns), as was the presence of PVB left bundle branch pattern (24/38 vs 13/16, p=ns) and gender or age. Pts with suspected PVB-induced CM had more often right axis VPB (31/37 vs 10/16, p=0.08). History of PVB was shorter in controls. Origin of the PVB did not differ between groupsRF ablation completely eliminated PVB in 26 pts (68%), partially in 4 and was inefficient in 8. During a follow up of 19±19 months, EF increased from 39±10 to 52±13% (p=0.003) while LVEDD decrease from 61±7 to 56±7mm (p=0.002) leading to a decrease in NYHA class (1.9±0.8 to 1.4±0.6, p=0.02). Parameters related to the failure of ablation were an older age, a higher NYHA class and a LVOT location of the focus. Parameters related to the lack of reversal of CM in successful ablations, were an older age, a lower baseline EF, but not the length of PVB history.ConclusionRF ablation of frequent PVB may lead to cure or significant improvement in 78% of pts with associated CM. Plausible mechanisms leading to a PVB-induced CM may associate a more longer history of PVB.

International audience; AIMS: Inappropriate therapy delivered by implantable cardioverter defibrillators (ICDs) remains a challenge. The OPERA registry measured the times to, and studied the determinants of, first appropriate (FAT) and inappropriate (FIT) therapies delivered by single-, dual- and triple-chamber [cardiac resynchronization therapy defibrillator (CRT-D)] ICD. METHODS AND RESULTS: We entered 636 patients (mean age = 62.0 ± 13.5 years; 88% men) in the registry, of whom 251 received single-, 238 dual-, and 147 triple-chamber ICD, for primary (30.5%) or secondary (69.5%) indications. We measured times to FAT and FIT as a function of multiple clinical characteristics, examined the effects of various algorithm components on the likelihood of FAT and FIT delivery, and searched for predictors of FAT and FIT. Over 22.8 ± 8.8 months of observation, 184 patients (28.9%) received FAT and 70 (11.0%) received FIT. Ventricular tachycardia (VT) was the trigger of 88% of FAT, and supraventricular tachycardia was the trigger of 91% of FIT. The median times to FIT (90 days; range 49-258) and FAT (171 days; 50-363) were similar. The rate of FAT was higher (P

Introduction T wave alternans (TWA) is a reliable marker of risk for malignant ventricular arrhythmias whose prognosis value has been established in many populations. Short QT syndrome (SQTS) is a recently described and very rare channelopathy defined by a decrease in repolarisation duration and carrying a risk of ventricular fibrillation. TWA in SQTS has not been evaluated at yet. Methods 6 patients with SQTS (QT 310 ± 16 ms, QTc 329 ± 11 ms) underwent microvolt TWA measurement using spectral analysis. TWA testing was performed using Heartwave II (Cambridge HeartTM) during bicycle exercice and classified as negative, positive or indeterminate according to the published standards for clinical interpretation. Results there were 6 men (mean age 24 ± 2 yo): 4 asymptomatic, 1 with previous sudden cardiac death and 1 with unexplained syncope. 3 patients belonged from the same family. Familial history of SQTS was present in 4 (2 families) and history of unexplained sudden death was found in both families. Ventricular fibrillation was induced in 2 of 5 investigated patients. Two patients were implanted with an ICD without any appropriate therapy during follow-up. No patient was on any medical therapy. Genetic analysis was pending in each but without result at yet. TWA was negative in each patient except in one inducible asymptomatic patient (indeterminate due to too fast heart rate). Maximal negative heart rate was 113 ± 5 bpm. Conclusions Conversely to what is observed in other settings, TWA testing is negative in most SQTS patients even in the symptomatic or inducible ones. This may be explained by the longer diastolic interval according to the restitution curve theory. Measurement of TWA for risk stratification in SQTS is therefore useless.

BackgroundICD is an effective treatment to prevent SCD but very long term follow-up is poorly known.MethodsWe retrospectively studied the 67 patients implanted with an ICD at the University Hospital of Toulouse between 1989 and 1999.ResultsCharacteristics of the population are (number of patients): males: 56, ischemic heart disease (IHD): 42, mean EF 42%, secondary prevention: 62, abdominal implantation: 30, dual chamber devices: 57. Data were complete for 58 patients (mean follow-up: 100 months +/− 103), nine patients were lost to follow up (mean 52 +/− 40 months). Survival rate (of the 58 patients) is respectively 93%, 71% and 48% at 1, 5 and 10 years. Cause of death was cardiac for 10 patients (7 terminal cardiac failures, 2 sudden cardiac deaths and 1 endocarditis), extra cardiac for 7 patients and unknown for 13.Independent factors of global mortality are: age (p = 0.038), IHD (p = 0.035), NYHA>2 (p = 0.0058), EF

Introduction radio-frequency (RF) ablation of premature ventricular beats (PVB) has been only reported as isolated cases or in short series. Methods 34 successive pts (25 men, 53 ± 18 yo) underwent RF ablation of frequent or symptomatic isolated PVB at our institution from 2005 to 2009. Indication, technique and results were reported. Results 43 RF ablation of PVB was performed for post-ischemic electrical storm in 7 pts (6 men), for symptomatic PVB in 7 (3 men) and for suspected VPB-induced tachycardiomyopathy in 20 (16 men) with 1,2 procedure/pt. RF was performed in each case using pace mapping and activation mapping with conventional technique. RF ablation of PVB during intractable post-ischemic electrical storm was initially successful in each pt but fatal electrical storm recurred in 4 during the following days. PVB were targeted in the left septal Purkinje network. 10 procedures were performed in 7 pts for palpitations or syncope, leading to complete or partial clinical success in 6 (PVB reduction 9400 ± 12200 to 420 ± 610 /24h, NS). 25 procedures were performed for suspected VPB-induced tachycardiomyopathy in 20 pts leading to complete success in 9 pts and to significant decrease in VPB in 5 pts. Mean VPB/24h was 17800 ± 8600 before and 3410 ± 8150 after and 125 ± 230 at 11 ± 6 months follow-up (p=0,0005). EF increase from 41 ± 8 to 53 ± 7% (p Conclusions RF ablation of PVB may be indicated if highly symptomatic, for electrical storm or for suspected tachycardiomyopathy with good although imperfect success rate

IntroductionSustained ventricular tachycardia (VT) in structural heart disease (SHD) is usually an indication for ICD implantation. Whether successful RF ablation of VT in this setting could avoid the need of ICD implantation is unknown.MethodsWe report our initial experience of VT ablation in 27 successive non-implanted pts (22 men, 62±18 yo) presenting with sustained monomorphic VT and SHD. An ICD was not implanted either because of debilitating or end stage extra cardiac pathology, advanced age or because the VT was well tolerated and EF was preserved. Amiodarone failed to control VT in 33% and beta-blockers in 73%.Results33 procedures were performed (1.2/pt). Seventeen pts had ischemic heart disease, four had ARVD, 2 dilated cardiomyopathy, 1 congenital and three had non-categorized SHD. Mean EF was 44±13% (5 pts with EF < 0,35%). The end-point was elimination of post-systolic potentials by RF. VT was inducible in 71% with 1 to 4 different morphology (1.8±1). Acute success was defined by lack of any inducible monomorphic sustained VT and was achieved in 78%. The only complication was an arterial dissection managed with angioplasty. One patient died after 10 days due to intractable heart failure associated with relapse of electrical storm. Patients were discharged on beta-blockers and amiodarone was interrupted except when otherwise indicated. Mean follow-up was 13±9 months. Four patients died from non arrhythmic cardiac or non cardiac causes. There was one late sudden death in a patient with low EF (incomplete procedure due to ongoing vascular complication). VT recurred in 24% without compromise of the vital status. RF ablation was performed in again in 5 pts and VT further recurred in two. Final VT recurrence rate including redo precedures was 12%.ConclusionsRF ablation for VT occurring in pts with SHD without ICD appears relatively safe and efficient and may be considered in some cases when ICD therapy is not desired because of associated morbidity, advanced age or when VT is well tolerated and does not occur in the context of advanced heart disease.

Introduction T wave alternans (TWA) has been demonstrated as a strong predictor of mortality and ventricular arrhythmias. ICD-stored intracardiac electrograms (IEGM) present a unique opportunity for detecting temporal relationship between the occurrence of TWA and spontaneous arrhythmia. The aim of the ETWAS study was to assess the feasibility of detection of TWA preceding the onset of VT/VF in IEGM. Methods 56 implanted patients with St Jude medical ICDs (44 men, 63 ± 12 yo, mean EF 34 ± 15%) were prospectively enrolled and monitored for one year. Thirteen different T wave parameters were extracted from IEGM (T amplitude, T peak time, Bazett and Hodges corrected T peak time, T end time, T duration between baseline crossing and between points of maximal slopes, T peak to T end, maximal ascending and descending slopes, timing of points of maximal slopes and T wave area). Successive beat by beat differences in each parameter in recordings prior to VT/VF were compared to control recordings in the same pts. TWA was considered if beat by beat variations for at least one parameter was significantly higher than baseline with a p value Results 22 VT/VF episodes (24 ± 13 beats, 71 ± 17 bpm) and 13 baseline (25 ± 9 beats, 72 ± 18) (ns) were analyzed in 12 pts (1,8 episode/ pt). TWA was present before VT/VF onset in 13 episodes (7 pts) with 1 to 9 differing parameters (3 ± 2). Significant beat by beat differences before VT/VF onset were observed in amplitude, timing, slopes, area and duration of the T wave. Amplitude of the beat by beat variations was 3 to10 larger in episodes than in baseline. Paired and unpaired comparisons of the averaged values of beat by beat variations however did not reveal significant difference between baseline and episodes, except for T wave amplitude (0,07 +/– 0,006 vs 0,14 +/– 0,03 mV, p=0.03 paired and 0,04 unpaired). Conclusions Detection of TWA prior to VT/VF might be useful in predicting imminent arrhythmia occurrence. TWA can be detected before VT/VF onset in more than half of episodes using a simple time-domain technique and multiple T wave measurements. T wave amplitude seems the most discriminant parameter.

We report the case of a patient presenting with incessant monomorphic ventricular tachycardia resistant to antiarrhythmic drugs, and in whom usual percutaneous vascular or pericardial access to the left ventricle was hindered by mechanical aortic and mitral prosthetic valves. Because an epicardial location was suspected by electrocardiogram features and because access to the target area through the coronary sinus was not possible, we decided to perform a surgically based radiofrequency (RF) ablation. Catheter mapping of the epicardial surface through surgical left lateral thoracotomy in the operating room confirmed the epicardial location of the arrhythmogenic substrate and allowed successful RF ablation of the clinically incessant tachycardia. Combined surgical and electrophysiological approach should therefore be performed when RF ablation is needed in case of unadvisable, difficult, or failed nonsurgical percutaneous access.

We report the histological evaluation of both endocardial and epicardial radiofrequency (RF) ablation lesions in the explanted heart of a patient presenting with nonischemic dilated cardiomyopathy complicated by recurrent electrical storms. In this case, chronic RF lesions were almost transmural at the endocardial side, while remaining only superficial at the epicardial aspect, possibly because of the insulating interposed epicardial fat layer.

RF ablation of frequent premature ventricular contractions (PVC) has recently been shown to improve left ventricular (LV) systolic function and dimensions in a few patients, however mainly when they originated from the right ventricular outflow tract.RF ablation was performed at various ventricular locations in six consecutive patients with frequent, isolated PVC associated with idiopathic dilated cardiomyopathy (DCM). Baseline clinical status, PVC counts, LV ejection fraction (EF) and end-diastolic diameter (EDD) were recorded at baseline and at 6 months of follow-up.PVC ablation was performed in the right ventricle in four patients, the left ventricle in two patients. Before RF ablation, five patients were in New York Heart Association (NYHA) functional class I, and one patient was in class II. After RF ablation, the mean PVC count/24 h decreased from 17,717 +/- 7,100 to 268 +/- 366 (p = 0.006) while LVEF increased from 42 +/- 2.5% to 57 +/- 3% (p = 0.0001) and LVEDD decreased from 60.0 +/- 3.5 to 54.0 +/- 3.7 mm (p = 0.0009). The clinical status normalized with regression of palpitations and NYHA class.Elimination of frequent isolated PVC in patients with DCM with RF can normalize the clinical status and LV systolic function and dimensions, regardless of the morphology or origin of the PVC.

Introductionearly repolarization (ER) in Brugada or short QT syndrome is common and has been associated with a less favourable outcome. Even if apparently paradoxical, ER can also be seen in long QT (LQT) but prevalence and correlations to other variables are unknown.MethodsECG of 105 LQT patients (44 men, 36±21 yo) and 269 age and gender matched controls (135 men, 36±18 yo) were reviewed. LQT was diagnosed by a positive genetic testing (n=71) or by showing abnormal T wave and long QT interval spontaneously or during epinephrin infusion in pts without discovered genetic mutation (n=34). ER was defined by > 1mm J point elevation in the inferior or lateral leads with notch or slurring pattern.ResultsQT in lead II was 433±68 msec in LQT patients and 338±41 in controls (p

Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation of a cardiac resynchronization therapy device. We report the case of an ectopic drainage of the CS in the left atrium. A left ventricular lead was implanted by the transseptal route.

Introduction T wave morphological changes before onset of ventricular arrhythmia are poorly known. ICD-stored intracardiac electrograms (EGM) present a unique opportunity for detecting temporal changes in repolarisation before initiation of VT/VF. Methods 57 implanted patients with St Jude Medical ICDs (45 men, 64 ± 12 yo, mean EF 34 ± 15%) were prospectively enrolled. Eleven different T wave parameters were extracted from EGM (T amplitude, T peak time, T end time, T duration between baseline crossing and between points of maximal slopes, T peak to T end, maximal ascending and descending slopes, timing of points of maximal slopes and T wave area). Values of each parameter in recordings prior to VT/VF were compared to control recordings sharing comparable QRS and T wave morphology and similar heart rate in the same pts. Results 23 VT/VF episodes (24 ± 13 beats) and 13 baseline (25 ± 9 beats) (ns) were analyzed in 12 pts (1,9 episode/pt). Mean heart rate was 71 ± 17 bpm for episodes and 66 ± 16 bpm for baseline recordings (ns). Significant differences were found in T wave amplitude, T wave maximal slopes, T peak time and timing of the T wave maximal ascending slope (although ns when corrected by the heart rate). Conclusions T wave amplitude is higher, T wave slopes are steeper and initial parts of the T wave are earlier before ventricular arrhythmia compared to baseline. Detection of T wave changes prior to VT/VF might be useful in predicting imminent arrhythmia occurrence. Download : Download full-size image Example of T wave changes before VT

Background The mechanisms of action of cardiac resynchronisation therapy (CRT) and the predictive factors to CRT's effect are not well known. The mechanical left intra-ventricular dysynchrony (LIVD) has a important physiopathological role in severe left ventricular dysfunction with wide QRS. Several studies compared LIVD before and just after CRT implant but few data are available about LIVD in the mid to long term. Methods and Results We included prospectively the 42 consecutive patients (younger than 75 yo) implanted in the University Hospital of Toulouse with ACC/AHA/ESC indications for CRT. Characteristics of the population were: male sex 88%, ischemic cardiomyopathy 45%, mean LVEF 22%, mean QRS duration 160 ms, CRT-D 98%. The echocardiographic (Pulsed Doppler and Tissue Doppler Imaging) parameters of cardiac dysynchrony were obtained at baseline and six month (or more) after CRT implant. We defined the responder group as an improvement in 1 NYHA class and no hospitalisation for heart failure (HF) during the follow up (mean duration 15 month). 62% (n = 26) were clinical responders. The echocardiographic assessment was done at 11 (6 to 20) month. There was no statistically significant difference between the “residual” mechanical dysynchrony of the responders versus the non-responders. Considering only the responders, there is no reduction of LIVD at six month after CRT. A baseline aortic pre-ejection delay > 140 ms, a non ischemic cardiomyopathy and the left ventricular activation time measured before implantation with a method described recently by Sweeney et al are the only factors of response to CRT. Conclusions The clinical response to CRT is not well correlate with the “residual” mechanical LIVD such as we measured by echocardiography (DTI and PD).

IntroductionMonomorphic sustained ventricular tachycardia (MSVT) in structural heart disease (SHD) carries poor prognosis and usually needs ICD implantation. Whether successful RF ablation of VT in this setting could avoid the need of ICD implantation is largely unknown.Methods105 successive with SHD (88 men, age 64±16) were followed after RF ablation of MSVT. An ICD was not implanted either because of end stage extra cardiac pathology, advanced age or well-tolerated MSVT and preserved EF. 33% were on amiodarone and 51% on beta-blockers.Results128 procedures were performed (1,2/pt) in 4 centers. Coronary artery disease was present in 54%, right ventricular dysplasia in 10%, dilated cardiomyopathy in 10% and various SHD in 26%. Mean EF was 48±12% (14% with EF

Background The success rate of left ventricular (LV) lead implantation for cardiac resynchronization therapy (CRT) is high. Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation. Method and result A 64-year-old male with standard indication for CRT was referred to our institution for a CRT-D implantation. Unfortunately, intubation of the CS was not possible. TEE showed a congenital CS anomaly with complete drainage of the CS into the left atrium. Because of contra-indication for general anaesthesia and thus for surgical epicardial implantation, we proposed to implant the LV lead by a transseptal approach. After the patient had given his consent, a transseptal puncture was performed via the right femoral vein. A conventional screw-in lead was implanted at the laterobasal segment of the LV using a deflectable catheter guide introduced via the left subclavian vein through the transseptal puncture. Post-implantation parameters of the LV lead were acceptable: pacing threshold 0.7 V-0.4 ms, impedance 435 ohms, R wave amplitude 5 mvolts. Right ventricular and right atrium leads were then implanted (fig 1) A post-implant CT scan confirmed the ectopic location of the CS ostium without persistent superior vena cava (fig 2). Download : Download full-size image Figure 1 Download : Download full-size image Figure 2 The patient was discharged on anticoagulation with a targeted international normalized ratio between 3 and 4. At the one- and three-month follow-up, no complication had occurred. He was in class 2 of the NYHA and had not been hospitalised. Electrical parameters remained steady. Conclusion Complete drainage of the CS in the left atrium without persistent vena cava is a rare congenital abnormality. When cardiac resynchronization therapy is needed, transseptal implantation could be a feasible alternative.