Introduction
Assess the prevalence and predictors of left atrial tachycardia (LAT) after cryoballoon ablation of pulmonary veins.
Methods and results
Patients who underwent catheter ablation of ...pulmonary veins with a second‐generation cryoballoon for symptomatic paroxysmal (151 of 270, 56%) or persistent (119 of 270, 44%) atrial fibrillation were entered in a single‐center prospective registry. Patients who experienced postcryoballoon LAT (pcryo‐LAT) were selected on the basis of 12‐lead ECG characteristics. Left atrial origin was confirmed during conventional EP study and electroanatomical activation mapping, and patients were treated by RF catheter ablation.
Pcryo‐LAT was observed in 15 (5.6%) of 270 patients and was attributed to a reentrant mechanism in 11 patients (73%). The other four cases of pcryo‐LAT were due to focal atrial tachycardia associated with reconnection of one pulmonary vein. In comparison with patients who remained in sinus rhythm, LA area (HR = 1.09; CI 1.01, 1.2; P = 0.02), LVEF (HR = 0.94; CI 0.90, 0.97; P < 0.001), and LVEF <50% (HR = 8.5; CI 3.1, 23.6; P < 0.001) were predictors of pcryo‐LAT. After multivariate Cox analysis, only left ventricular ejection fraction < 50% remained predictive of pcryo‐LAT, (HR = 7.8, CI 2.3 26.7, P = 0.002). With a mean survival of 23 months, 73% of patients who experienced pcryo‐LAT were in sinus rhythm versus 78% of patients without pcryo‐LAT (log rank P = 0.85).
Conclusion
The prevalence of pcryo‐LAT in patients with atrial fibrillation is low. Left ventricular ejection fraction < 50% is associated with an increased risk of pcryo‐LAT. When treated by RF catheter ablation, the presence of pcryo‐LAT is not a predictive factor of subsequent recurrence of atrial fibrillation during follow‐up.
Aims
Acute cardiac tamponade (ACT) is the most common life‐threatening complication of interventional electrophysiology. Urgent drainage by percutaneous pericardiocentesis and anticoagulation ...reversal are required. Immediate direct transfusion of the blood volume aspirated from the pericardial space to the patient has been rarely described. This study was designed to assess the efficacy and safety of immediate direct autologous blood transfusion (AutoBT).
Methods
A retrospective case series of direct AutoBT performed for ACT was collected. Urgent drainage by percutaneous pericardiocentesis and immediate direct AutoBT were performed to achieve hemodynamic stabilization without a cell‐saver system.
Results
Twenty‐two electrophysiology centers were contacted to participate in the case series. Fourteen centers reported not to use direct AutoBT. Three centers reported using direct AutoBT with the cell‐saver system. Fourteen cases of immediate direct AutoBT without cell‐saver system were included from the five remaining centers. Electrophysiological procedures were performed for ventricular tachycardia (n = 5), atrial fibrillation (n = 5), atrial tachycardia (n = 2), left accessory pathway (n = 1), and premature ventricular contraction (n = 1) with transseptal (n = 9), retroaortic (n = 4), and/or epicardial access (n = 4). Pericardial drainage was performed by percutaneous pericardiocentesis for 13 patients and via the transseptal sheath for one patient. Surgical hemostasis was required for seven patients. The mean volume of autologous blood directly transfused was 1207 ± 963 mL. Direct AutoBT permitted to resume the procedure in four patients. No major complication related to the use of AutoBT occurred.
Conclusion
Direct AutoBT without a cell‐saver system is a feasible, safe, and useful technique for salvage therapy in ACT in interventional electrophysiology.
Objectives
The French left atrial appendage (LAA) closure registry (FLAAC) aimed to assess the safety and efficacy of LAA closure in daily practice.
Background
LAA closure has emerged as an ...alternative for preventing thromboembolic events (TE) in patients with non‐valvular atrial fibrillation (NVAF). Clinical data in this field remains limited and few investigator‐initiated, real‐world registries have been reported.
Methods
This nationwide, prospective study was performed in 36 French centers. The primary endpoint was the TE rate after successful LAA closure.
Results
The FLAAC registry included 816 patients with a mean age of 75.5 ± 0.3 years, mean follow‐up of 16.0 ± 0.3 months, high TE (CHA2DS2‐VASc score: 4.6 ± 0.1) and bleeding risks (HAS‐BLED score: 3.2 ± 0.05) and common contraindications to long‐term anticoagulation (95.7%). Procedure or device‐related serious adverse events occurred in 49 (6.0%) patients. The annual rate of ischemic stroke/systemic embolism was 3.3% (2.4–4.6). This suggests a relative 57% reduction compared to the risk of stroke in historical NVAF populations without antithrombotic therapy. By multivariate analysis, history of TE was the only factor associated with stroke/systemic embolism during follow‐up (HR, 3.3 1.58–6.89, p = 0.001). The annual mortality rate was 10.2% (8.4–12.3). Most of the deaths were due to comorbidities or underlying cardiovascular diseases and unrelated to the device or to TE.
Conclusions
Our study suggests that LAA closure can be an option in patients with NVAF. Long‐term follow‐up mortality was high, mostly due to comorbidities and underlying cardiovascular diseases, highlighting the importance of multidisciplinary management after LAA closure.
Registration
NCT02252861.
Cryoballoon pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) ablation is an increasingly used strategy. We aimed to determine the results and predictors of arrhythmia recurrence ...after a single procedure of cryoballoon PVI for patients with persistent and long-standing persistent AF. We included all consecutive patients who underwent cryoballoon PVI for the treatment of persistent symptomatic drug-refractory AF since 2012. All patients were prospectively followed to detect the recurrence of atrial tachyarrhythmia (ATa). Predictors of recurrence were assessed. Cryoballoon PVI was performed on 399 patients with persistent AF, among whom 52 (13%) had long-standing persistent AF. Patients with long-standing persistent AF had a significantly larger left atrium than those with persistent AF. A 28-mm cryoballoon was used for 322 patients (93%). In total, 359 patients (90%) completed the 12-month follow-up visit and the median follow-up was 24 months (interquartile range 43 to 13). The 2-year probability of freedom from ATa recurrence was 51% for persistent AF and 27% for long-standing persistent AF. Long-standing persistent AF and left atrial area/volume were independent predictors of ATa recurrence. Ten patients (2.5%) experienced phrenic nerve palsy, 1 tamponade (0.25%), 2 stroke (0.5%), 2 pericardial effusions (0.5%), and 5 vascular complications (1.25%). In conclusion, 2-year ATa-free survival rates were 51 and 27% for persistent and long-standing persistent AF patients, respectively. Complications were rare. Long-standing persistent AF and left-atrial area/volume were predictors of recurrence.
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•We report a detailed case of type 2 Timothy syndrome due to a p.(Gly402Ser) mutation in exon 8 of the CACNA1C gene.•Adding Mexiletine to Nadolol resulted in a reduction of the QTc and a slight ...decrease in the number of appropriate shocks during a long-term follow up of nine years.•Left cardiac sympathetic denervation also appears to have been effective.
We report a detailed case of type 2 TS due to a p.(Gly402Ser) mutation in exon 8 of the CACNA1C gene. The patient shows a marked prolongation of repolarization with a mean QTc of 540 ms. He shows no structural heart disease, syndactyly, or cranio-facial abnormalities. However, he shows developmental delays, without autism, and dental abnormalities. The cardiac phenotype is very severe, with a resuscitated cardiac arrest at 2.5 years of age, followed by 26 appropriate shocks during nine years of follow-up. Adding mexiletine to nadolol resulted in a reduction of the QTc and a slight decrease in the number of appropriate shocks.
Although the implantable cardioverter-defibrillator (ICD) remains the main therapy for Brugada syndrome (BrS), it does not reduce life-threatening ventricular arrhythmia. Based on pathophysiologic ...mechanisms, hydroquinidine (HQ) has been suggested for effective prevention of arrhythmia.
The purpose of this study was to provide evidence-based data supporting HQ use to prevent life-threatening ventricular arrhythmia in high-risk patients with BrS.
We performed a prospective multicenter randomized (HQ vs placebo) double-blind study with two 18-month crossover phases in patients with BrS and implanted with an ICD.
Among the 50 patients enrolled (mean age 47.0 ± 11.4 years, 42 84% male), 26 (52%) fully completed both phases. Thirty-four (68%) presented HQ-related side effects, mainly gastrointestinal, which led to discontinuation of the therapy in 13 (26%). HQ lengthened the QTc interval (409 ± 32 ms vs 433 ± 37 ms; P = .027) and increased repolarization dispersion as evaluated by Tpe max in precordial leads (89 ± 15 ms vs 108 ± 27 ms; P <.0001) with no significant changes in J-point elevation. During the 36-month follow-up, 1 appropriate ICD shock (0.97% event per year), 1 self-terminating ventricular fibrillation, and 1 inappropriate ICD shock occurred under placebo therapy. No arrhythmic events were reported under HQ therapy.
Although HQ seems to be effective in preventing life-threatening ventricular arrhythmia, it could not be an alternative for ICD implantation. Its frequent side effects greatly reduce its probable compliance and therefore do not reveal a significant effect. HQ increases repolarization dispersal with no changes in BrS pattern, which could indicate a more complex action of HQ than its I
blocking effect alone.
The ECOST trial examined prospectively the long-term safety and effectiveness of home monitoring (HM) of implantable cardioverter defibrillators (ICD).
The trial's primary objective was to randomly ...compare the proportions of patients experiencing ≥ 1 major adverse event (MAE), including deaths from all causes, and cardiovascular, procedure-related, and device-related MAE associated with HM (active group) vs. ambulatory follow-ups (control group) in a sample of 433 patients. The 221 patients assigned to the active group were seen once a year, unless HM reported an ICD dysfunction or a clinical event requiring an ambulatory visit, while the 212 patients in the control group underwent ambulatory visits every 6 months. The characteristics of the study groups were similar. Over a follow-up of 24.2 months, 38.5% of patients in the active and 41.5% in the control group experienced ≥ 1 MAE (P < 0.05 for non-inferiority). The overall number of shocks delivered was significantly lower in the active (n = 193) than in the control (n = 657) group (P < 0.05) and the proportion of patients who received inappropriate shocks was 52% lower in the active (n = 11) than in the control (n = 22) group (P < 0.05). At the end of the follow-up, the battery longevity was longer in the active group because of a lower number of capacitor charges (499 vs. 2081).
Our observations indicate that long-term HM of ICD is at least as safe as standard ambulatory follow-ups with respect to a broad spectrum of MAE. It also lowered significantly the number of appropriate and inappropriate shocks delivered, and spared the device battery. Clinical trials registration NCT00989417.
Background
Various lead designs have been developed to accommodate different coronary sinus anatomies. Our objectives were to compare electrical parameters of straight and spiral left ventricular ...leads, to evaluate capture thresholds and impedances using different pacing vectors, and to study evolution of thresholds over time.
Methods
The RALLY‐X4 study enrolled patients implanted with a lead from the Acuity X4 family (straight, spiral short, or spiral long). Electrical parameters (including capture thresholds from all 17 vectors) were measured at baseline and follow‐up.
Results
Data from 795 patients who were successfully implanted were analyzed. Straight and spiral leads had similar proportions of patients with thresholds <2.5 V/0.4 ms using the distal electrode (61‐65% of patients) or from at least one of the proximal (E2‐E4) electrodes (81‐83% of patients). Unipolar vectors had significantly lower thresholds and impedances than bipolar vectors, with similar measurements compared to extended bipolar configurations. Capture thresholds increased with more proximal electrodes for all leads. Over a mean follow‐up of 1 year, a slight decrease in capture thresholds was observed.
Conclusion
Straight and spiral quadripolar leads allow to obtain clinically acceptable capture thresholds from at least one of the proximal electrodes in >80% of patients. Pacing vectors significantly affect electrical parameters, with higher thresholds in more proximal electrodes and lower thresholds with unipolar and extended bipolar configurations. Capture thresholds slightly decreased over a mean follow‐up of 1 year.
Background: Pulmonary vein cryoablation (PVC) is a new approach in the treatment of recurrent atrial fibrillation (AF). Computed tomography (CT) can be used to evaluate the left atrium anatomy and ...PVs dimensions to facilitate the procedure. In radiofrequency procedures, some anatomic variants such as common left (CLPV) or right (CRPV) PV were reported as factors associated with technical procedure difficulties and potential long‐term complications. We hypothesized that the absence of CLPV as determined by CT would predict better AF‐free survival after PVC.
Methods and results: We included 118 consecutive patients (mean age 56 ± 10 years; 77% males) with drug refractory paroxysmal (72%)/persistent (28%) AF, with more than 6 months follow‐up, who underwent PVC. On CT scanning images performed within 1 month prior to ablation, we evaluated PV anatomic patterns: presence of CLPV or CRPV. Each patient was evaluated by 24‐hour Holter monitoring within 1 and 3 months and all patients were periodically evaluated at 1, 3, and 6 months, and every 6 months thereafter. Patients were asked to record their 12‐lead electrocardiogram whenever they experienced symptoms suggestive of AF. Recurrence was defined as AF that lasted at least 30 seconds. CLPV was present in 30 (25%) patients and no patients with CRPV were identified. At the end of the 13 months follow‐up, patients with normal PVs had significantly better AF‐free survival compared to patients with CLPV (67% vs 50%, P = 0.02). The difference was present in patients with paroxysmal AF (P = 0.008) but not in patients with persistent AF (P = 0.92).
Conclusion: In patients undergoing cryoballoon PV isolation for AF, the presence of normal PVs pattern is associated with better AF‐free survival as compared to atypical PV anatomy with CLPV, particularly in patients with paroxysmal AF. (PACE 2011; 34:837–843)
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