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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.

Thirty-day readmission after surgery has been proposed as a quality-of-care indicator. We explored the effect of postoperative rehabilitation on readmission risk after groin hernia repair. We used the French National Discharge Database to identify all index hospitalizations for groin hernia repair in 2011. Readmissions within 30 days of discharge were clinically classified in terms of their relationship to the index stay. We used logistic regression to adjust the risk of readmission for patient, procedure and hospital factors. Among 122,952 index hospitalizations for inguinal hernia repair, 3,357 (2.7%) related 30-day readmissions were recorded. Reiterated analyses indicated that readmission risk was consistently associated with patient complexity: age (per year after 60 years, OR 1.03, 95% CI 1.02–1.03, P

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Summary Background Acute acidaemia is frequently observed during critical illness. Sodium bicarbonate infusion for the treatment of severe metabolic acidaemia is a possible treatment option but remains controversial, as no studies to date have examined its effect on clinical outcomes. Therefore, we aimed to evaluate whether sodium bicarbonate infusion would improve these outcomes in critically ill patients. Methods We did a multicentre, open-label, randomised controlled, phase 3 trial. Local investigators screened eligible patients from 26 intensive care units (ICUs) in France. We included adult patients (aged ≥18 years) who were admitted within 48 h to the ICU with severe acidaemia (pH ≤7·20, PaCO2 ≤45 mm Hg, and sodium bicarbonate concentration ≤20 mmol/L) and with a total Sequential Organ Failure Assessment score of 4 or more or an arterial lactate concentration of 2 mmol/L or more. We randomly assigned patients (1:1), by stratified randomisation with minimisation via a restricted web platform, to receive either no sodium bicarbonate (control group) or 4·2% of intravenous sodium bicarbonate infusion (bicarbonate group) to maintain the arterial pH above 7·30. Our protocol recommended that the volume of each infusion should be within the range of 125–250 mL in 30 min, with a maximum of 1000 mL within 24 h after inclusion. Randomisation criteria were stratified among three prespecified strata: age, sepsis status, and the Acute Kidney Injury Network (AKIN) score. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7. All analyses were done on data from the intention-to-treat population, which included all patients who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02476253. Findings Between May 5, 2015, and May 7, 2017, we enrolled 389 patients into the intention-to-treat analysis in the overall population (194 in the control group and 195 in the bicarbonate group). The primary outcome occurred in 138 (71%) of 194 patients in the control group and 128 (66%) of 195 in the bicarbonate group (absolute difference estimate −5·5%, 95% CI −15·2 to 4·2; p=0·24). The Kaplan-Meier method estimate of the probability of survival at day 28 between the control group and bicarbonate group was not significant (46% [95% CI 40–54] vs 55% [49–63]; p=0·09. In the prespecified AKIN stratum of patients with a score of 2 or 3, the Kaplan-Meier method estimate of survival by day 28 between the control group and bicarbonate group was significant (37% [95% CI 28–48] vs 54% [45–65]; p=0·0283). Metabolic alkalosis, hypernatraemia, and hypocalcaemia were observed more frequently in the bicarbonate group than in the control group, with no life-threatening complications reported. Interpretation In patients with severe metabolic acidaemia, sodium bicarbonate had no effect on the primary composite outcome. However, sodium bicarbonate decreased the primary composite outcome and day 28 mortality in the a-priori defined stratum of patients with acute kidney injury. Funding French Ministry of Health and the Societe Francaise d'Anesthesie Reanimation.

International audience

Summary Background Avoidance of excessive sedation and subsequent prolonged mechanical ventilation in intensive care units (ICUs) is recommended, but no data are available for critically ill postoperative patients. We hypothesised that in such patients stopping sedation immediately after admission to the ICU could reduce unnecessary sedation and improve patient outcomes. Methods We did a randomised, parallel-group, clinical trial at three ICUs in France. Stratified randomisation with minimisation (1:1 via a restricted web platform) was used to assign eligible patients (aged ≥18 years, admitted to an ICU after abdominal surgery, and expected to require at least 12 h of mechanical ventilation because of a critical illness defined by a Sequential Organ Failure Assessment score >1 for any organ, but without severe acute respiratory distress syndrome or brain injury) to usual sedation care provided according to recommended practices (control group) or to immediate interruption of sedation (intervention group). The primary outcome was the time to successful extubation (defined as the time from randomisation to the time of extubation [or tracheotomy mask] for at least 48 h). All patients who underwent randomisation (except for those who were excluded after randomisation) were included in the intention-to-treat analysis. This study is registered with ClinicalTrials.gov, number NCT01486121. Findings Between Dec 2, 2011, and Feb 27, 2014, 137 patients were randomly assigned to the control (n=68) or intervention groups (n=69). In the intention-to-treat analysis, time to successful extubation was significantly lower in the intervention group than in the control group (median 8 h [IQR 4–36] vs 50 h [29–93], group difference −33·6 h [95% CI −44·9 to −22·4]; p Interpretation Immediate interruption of sedation in critically ill postoperative patients with organ dysfunction who were admitted to the ICU after abdominal surgery improved outcomes compared with usual sedation care. These findings support interruption of sedation in these patients following transfer from the operating room. Funding Delegation a la Recherche Clinique et a l'Innovation du Groupement de Cooperation Sanitaire de la Mission d'Enseignement, de Recherche, de Reference et d'Innovation (DRCI-GCS-MERRI) de Montpellier-Nimes.

High-flow nasal cannula oxygen (HFNC) has the potential to provide apnoeic oxygenation. We decided to assess in a proof-of-concept study whether the addition of HFNC to non-invasive ventilation (NIV) could reduce oxygen desaturation during intubation, compared with NIV alone for preoxygenation, in severely hypoxaemic intensive care unit (ICU) patients with respiratory failure. We conducted a randomised, controlled, single-centre trial with assessor-blinded outcome assessment in patients admitted to the ICU. Hypoxaemic patients requiring orotracheal intubation for respiratory failure were randomised to receive preoxygenation using HFNC [flow = 60 L/min, fraction of inspired oxygen (FiO2) = 100 %] combined with NIV (pressure support = 10 cmH2O, positive end-expiratory pressure = 5 cmH2O, FiO2 = 100 %) in the intervention group or NIV alone in the reference group prior to intubation. The primary outcome was the lowest oxygen saturation (SpO2) during the intubation procedure. Secondary outcomes were intubation-related complications and ICU mortality. Between July 2015 and February 2016, we randomly assigned 25 and 24 patients to the intervention and reference groups, respectively. In both groups the main reasons for respiratory failure were pneumonia and ARDS. During the intubation procedure, the lowest SpO2 values were significantly higher in the intervention group than in the reference group [100 (95–100) % vs. 96 (92–99) %, p = 0.029]. After exclusion of two patients from analysis for protocol violation, no (0 %) patients in the intervention group and five (21 %) patients in the reference group had SpO2 below 80 % (p = 0.050). We recorded no significant difference between the groups in intubation-related complications or ICU mortality. A novel strategy for preoxygenation in hypoxaemic patients, adding HFNC for apnoeic oxygenation to NIV prior to orotracheal intubation, may be more effective in reducing the severity of oxygen desaturation than the reference method using NIV alone.

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.

High-flow nasal cannula (HFNC) oxygen therapy is attracting increasing interest in acute medicine as an alternative to standard oxygen therapy; however, its use to prevent hypoxaemia after major abdominal surgery has not been evaluated. Our trial was designed to close this evidence gap. A multicentre randomised controlled trial was carried out at three university hospitals in France. Adult patients at moderate to high risk of postoperative pulmonary complications who had undergone major abdominal surgery using lung-protective ventilation were randomly assigned using a computer-generated sequence to receive either HFNC oxygen therapy or standard oxygen therapy (low-flow oxygen delivered via nasal prongs or facemask) directly after extubation. The primary endpoint was absolute risk reduction (ARR) for hypoxaemia at 1 h after extubation and after treatment discontinuation. Secondary outcomes included occurrence of postoperative pulmonary complications within 7 days after surgery, the duration of hospital stay, and in-hospital mortality. The analysis was performed on data from the modified intention-to-treat population. This trial was registered with ClinicalTrials.gov (NCT01887015). Between 6 November 2013 and 1 March 2015, 220 patients were randomly assigned to receive either HFNC (n = 108) or standard oxygen therapy (n = 112); all of these patients completed follow-up. The median duration of the allocated treatment was 16 h (interquartile range 14–18 h) with standard oxygen therapy and 15 h (interquartile range 12–18) with HFNC therapy. Twenty-three (21 %) of the 108 patients treated with HFNC 1 h after extubation and 29 (27 %) of the 108 patients after treatment discontinuation had postextubation hypoxaemia, compared with 27 (24 %) and 34 (30 %) of the 112 patients treated with standard oxygen (ARR 4, 95 % CI –8 to 15 %; p = 0.57; adjusted relative risk [RR] 0.87, 95 % CI 0.53–1.43; p = 0.58). Over the 7-day postoperative follow-up period, there was no statistically significant difference between the groups in the proportion of patients who remained free of any pulmonary complication (ARR 7, 95 % CI –6 to 20 %; p = 0.40). Other secondary outcomes also did not differ significantly between the two groups. Among patients undergoing major abdominal surgery, early preventive application of high-flow nasal cannula oxygen therapy after extubation did not result in improved pulmonary outcomes compared with standard oxygen therapy.

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.

Scheduled and/or thoracic, abdominal surgeries increase the risk of respiratory postoperative complications. In patients with chronic respiratory failure, preoperative evaluation should be performed to evaluate respiratory function in aim to optimize perioperative management. Preoperative gas exchange abnormalities (hypoxemia or hypercapnia) are associated with respiratory postoperative complications. Respiratory physiotherapy and prophylactic non-invasive ventilation should be integrated in a global rehabilitation management for cardiothoracic or abdominal surgery procedures, which are at high risk of postoperative respiratory dysfunction. Stopping tobacco consummation should be benefit, but decease risk of postoperative complications is relevant only after a period for 6 to 8 weeks of cessation. Bronchodilatator aerosol therapy (beta-agonists and atropinics) and inhaled corticotherapy allow a rapid preparation for 24 to 48 h. Systematic preoperative antibiotherapy should not be recommended.

Resume Objectif Decrire les causes de mortalite a trois mois apres une transplantation hepatique. Type d’etude Etude retrospective, observationnelle, monocentrique. Patients et methode De mars 1989 a juillet 2010, tous les patients decedes dans les suites d’une transplantation hepatique avant la fin du troisieme mois ont ete inclus. Les caracteristiques demographiques, les donnees pre- et peroperatoires des receveurs, des donneurs, les principales complications postoperatoires et les causes de mortalite ont ete recueillies. Resultats Sur les 788 transplantations hepatiques evaluees, 76 patients sont decedes en reanimation (11 %). Les principales indications de la transplantation hepatique etaient la cirrhose alcoolique (30 %), la cirrhose virale C (28 %), le carcinome hepatocellulaire (15 %), la cirrhose biliaire primitive ou secondaire (10 %) et l’hepatite fulminante (11 %). Un patient sur deux etait classe Child C. Les principales causes de mortalite etaient la non-fonction ou dysfonction du greffon sans indication de retransplantation (18 %) et le sepsis (18 %), les causes neurologiques (12 %), le choc hemorragique (13 %), la defaillance multiviscerale (5 %) et les causes cardiaques (6 %). Conclusion Dans notre serie, les principales causes de mortalite precoce apres transplantation hepatique sont infectieuses, neurologiques et hemorragiques. Ces resultats soulignent l’importance de la prevention et du diagnostic du sepsis, la prevention de l’hemorragie et l’optimisation du traitement immunosuppresseur.

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.

Resume L’intubation tracheale en reanimation est frequemment realisee chez un patient instable et est associee a un risque eleve de complications (20 a 50 %) menacant le pronostic vital. Alors que la preoxygenation chez les patients dont l’intubation est prevue difficile au bloc operatoire est largement utilisee, les indications et les techniques en soins intensifs sont moins connues. Dans cette revue, nous rappelons les concepts physiologiques de la preoxygenation et montrons son interet dans la securisation de la procedure d’intubation du patient critique. Nous rapportons egalement l’interet de la preoxygenation en ventilation non-invasive sur l’oxygenation et le risque d’hypoxie au decours immediat de l’intubation.

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.

Un secolo di storia mostra l’evoluzione dell’anestesia e dell’analgesia peridurali, tecniche ampiamente sviluppate con numerose indicazioni chirurgiche, ostetriche e analgesiche. Le tecniche, i materiali, i farmaci e le indicazioni subiscono tuttavia evoluzioni costanti, imponendo un regolare aggiornamento delle conoscenze in questo settore. Questo sviluppo, ampiamente suffragato dalle recenti raccomandazioni della Societe francaise d’anesthesie et de reanimation, mette in relazione queste evoluzioni con i dati farmacologici e con le tecniche recenti. Permette anche di rivalutare le indicazioni classiche e di precisare le condizioni di impiego nelle indicazioni piu recenti. Largamente conosciute, le tecniche peridurali restano tuttavia fonti potenziali di incidenti e di complicanze, di seguito menzionate in modo esauriente.

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.

Noninvasive positive-pressure ventilation (NPPV) with pressure support-ventilation and positive end-expiratory pressure are effective in providing oxygenation during intubation in hypoxemic patients. We hypothesized administration of oxygen (O2) using NPPV would more rapidly increase the end-tidal O2 concentration (ETO2) than preoxygenation using spontaneous ventilation (SV) in morbidly obese patients.Twenty-eight morbidly obese patients were enrolled in this prospective randomized study. Administration of O2 for 5 min was performed either with SV group or with NPPV (pressure support = 8 cm H2O, positive end-expiratory pressure = 6 cm H2O) (NPPV group). ETO2 was measured using the anesthesia breathing circuit, and is expressed as a fraction of atmospheric concentration. The primary end-point was the number of patients with an ETo(2)95% at the end of O2 administration. Secondary end-points included the time to reach the maximal ETO2 and the ETO2 at the conclusion of O2 administration.A larger proportion of patients achieved a 95% ETO2 at 5 min with NPPV than SV (13/14 vs 7/14, P = 0.01). The time to reach the maximal ETO2 was significantly less in the NPPV than in the SV group (185 +/- 46 vs 222 +/- 42 s, P = 0.02). The mean ETO2 at the conclusion of O2 administration was larger in the NPPV group than the SV group (96.9 +/- 1.3 vs 94.1 +/- 2.0%, P0.001). A modest, although significant, increase in gastric distension was observed in the NPPV group. No adverse effects were observed in either group.Administration of O2 via a facemask with NPPV in the operating room is safe, feasible, and efficient in morbidly obese patients. In this population NPPV provides a more rapid O2 administration, achieving a higher ETO2.

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.

An infant with a congenital auriculoventricular block (CAVB) of immunological origin was diagnosed prenatally. The mother had Gougerot-Sjögren disease with positive anti-Sjogren's Syndrome A (SSA) and Sjogren's Syndrome B (SSB) serologies. Cardiac pacing was necessary and the epicardial route was chosen. Considering the left ventricular (LV) dilatation, bi-ventricular (BiV) stimulation was preferred to the usual DDD mode, presumed to have a deleterious long-term effect. Echographic parameters were better with BiV stimulation: the asynchronism induced by mono-RV stimulation was corrected and the QRS complexes were narrower. BiV pacing of a CAVB with LV dilation looks clinically and echographically attractive but needs to be validated in the long term.

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.

Little is known about the physiologic and clinical effects of noninvasive positive pressure ventilation (NPPV) in patients who have acute respiratory failure (ARF) after abdominal surgery. We evaluated our clinical experience with the use of NPPV in the treatment of ARF after abdominal surgery.We prospectively evaluated NPPV use during a 2-year period in a medical-surgical ICU of a university hospital. We documented demographic and diagnostic data, gas exchange, and clinical outcomes. We compared patients who were not intubated to those who were intubated after a trial of NPPV.Of 72 patients with ARF after abdominal surgery who were treated with NPPV, 48 patients avoided intubation (67%). Patients in the intubated and nonintubated groups had similar demographic characteristics, and similar American Society of Anesthesiologists physical status and simplified acute physiology score II scores at admission. The intubated group had a significantly lower Pa(O2)/fraction of inspired oxygen (Fi(O2)) ratio (123 +/- 62 mm Hg vs 194 +/- 76 mm Hg, p0.01) and more extended bilateral alveolar infiltrates (67% vs 31%, p0.01) than the non-intubated group. Within the first NPPV observation period, the Pa(O2)/Fi(O2) increased (+ 36 +/- 29% [+/- SD], p = 0.04) and the respiratory rate decreased (28.2 +/- 3.4 breaths/min vs 23.1 +/- 3.8 breaths/min, p0.01) significantly only in the non-intubated group. The non-intubated group had significantly lower length of ICU stay (17.3 +/- 10.9 days vs 34.1 +/- 28.5 days, p0.01) and mortality rate (6% vs 29%, p0.01).NPPV may be an alternative to conventional ventilation in selected patients with ARF after abdominal surgery who require ventilatory support.

To compare volume support ventilation (VSV) in which the pressure support level is continuously adjusted to deliver a preset tidal volume, with pressure support ventilation (PSV), in terms of patient behavior and ventilator response when ventilatory demand was increased by addition of dead space to the circuit.Randomized cross-over study in an intensive care unit university hospital.We assessed in ten patients being weaned off mechanical ventilation the effect of increasing the ventilatory demand by adding a heat-and-moisture exchanger to augment the dead space with a fixed level of PSV and VSV.Arterial blood gases, breathing pattern, and respiratory effort parameters at the end of each of the four steps. Adding dead space significantly increased minute ventilation and PaCO2 values with both PSV and VSV. Indexes of respiratory effort (pressure-time index of respiratory muscles and work of breathing) increased with both ventilatory modes after dead-space augmentation. This increase was 2.5-4 times with VSV than with PSV and induced overt respiratory distress in two patients. The assistance delivered during VSV decreased significantly after dead-space augmentation, from 15.0+/-6.5 to 9.1+/-4.8 cmH2O, whereas no change occurred with PSV.With a fixed level of VSV, but not of PSV, an increase in ventilatory demand results in a decrease in the pressure support provided by the ventilator, opposite to the desired response. VSV may conceivably result in respiratory distress in clinical settings.

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.

Resume Objectifs. – Connaitre l’incidence de l’utilisation postoperatoire de la ventilation non invasive (VNI) en pression positive dans les unites de reanimation, et sa mise en place pratique. Type d’etude. – Enquete telephonique realisee en septembre 2001, 60 services de reanimation du sud de la France tires au sort a partir d’un annuaire national (public : 47, prive : 13 ; medicales : 11, chirurgicales : 20, polyvalentes : 29). Resultats. – La VNI etait utilisee frequemment dans 55 % et occasionnellement dans 35 % des unites. Les 10 % qui n’utilisaient jamais la VNI etaient chirurgicales dans 83 % des cas et avaient un nombre de lits moins important (7 ± 3 vs 12 ± 5). Le systeme d’humidification utilise etait un echangeur de chaleur et d’humidite (ECH) (52 %), un humidificateur chauffant (HC) (24 %), l’un ou l’autre (4 %). Les services n’utilisant pas d’humidification (19 %) ne disposaient de ventilateurs portables que dans 30 % des cas. Au cours de la VNI, 80 % des reanimations disposaient d’un respirateur lourd de reanimation, et 89 % d’un masque facial. La VNI etait pratiquee exclusivement par les medecins dans 15 %, en collaboration apres sa mise en place dans 71 % des cas. Soixante-neuf pour cent des reanimateurs avaient recours a la VNI en premiere intention pour la prise en charge d’une insuffisance respiratoire aigue postoperatoire, et 54 % face a une atelectasie. Conclusion. – L’ECH etait le systeme d’humidification le plus utilise malgre l’espace mort additionnel. Les pratiques de la VNI etaient variables d’un service a l’autre. Cette enquete montre le developpement croissant de la VNI, largement utilisee aujourd’hui en reanimation chirurgicale bien que son indication reste a mieux definir.

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.

International audience; Aims: To assess the impact of a simple computer-based decision-support system (computer help) on the quality of nutrition support orders and patients' outcome in Intensive-Care Unit (ICU).Methods: This quality-improvement study was carried out in a 16-bed medical-surgical ICU in a French university hospital. All consecutive patients who stayed in ICU more than 10 days with non-oral feeding for more than 5 days were retrospectively included during two 12-month periods. Prescriptions of nutrition support were collected and compared to French national guidelines as a quality-improvement process. A computer help was constructed using a simple Excel-sheet (MicrosoftTM) to guide physicians' prescriptions according to guidelines. This computer help was displayed in computers previously used for medical orders. Physicians were informed but no systematic protocol was implemented. Patients included during the first (control group) and second period (computer help group) were compared for achievement of nutrition goals and ICU outcomes.Results: The control and computer help groups respectively included 71 and 95 patients. Patients' characteristics were not significantly different between groups. In the computer help group, prescriptions achieved significantly more often 80% of nutrition goals for calorie (45% vs. 79% p

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.