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Catheter ablation (CA) is a well-established treatment of atrial fibrillation (AF). Data-driven cluster analysis is able to better distinguish prognostically-relevant phenotype clusters among patients with AF. We performed a hierarchical cluster analysis in a cohort of AF patients undergoing a first CA and evaluate associations between identified clusters and recurrences of arrhythmia following ablation. The study included 209 AF patients treated with CA. A total of 3 clusters with distinct characteristics were identified. Recurrences at 1 year occurred in 27.2% in Cluster 1, 43.2% in Cluster 2 and 60.9% in Cluster 3 (P < 0.0001). Cluster classification was independently associated with arrhythmia recurrences (HR 1.58, 95% CI 1.01-2.49, P = 0.046) after adjustment for age, CHA2DS2-VASc score, left atrial volume, type of atrial fibrillation and ejection fraction. To concluded, cluster analysis identified 3 statistically-driven groups among AF patients treated with CA with different risks for arrhythmia recurrences. Catheter ablation (CA) is a well-established treatment of atrial fibrillation (AF). Data-driven cluster analysis is able to better distinguish prognostically-relevant phenotype clusters among patients with AF. We performed a hierarchical cluster analysis in a cohort of AF patients undergoing a first CA and evaluate associations between identified clusters and recurrences of arrhythmia following ablation. The study included 209 AF patients treated with CA. A total of 3 clusters with distinct characteristics were identified. Recurrences at 1 year occurred in 27.2% in Cluster 1, 43.2% in Cluster 2 and 60.9% in Cluster 3 (P < 0.0001). Cluster classification was independently associated with arrhythmia recurrences (HR 1.58, 95% CI 1.01-2.49, P = 0.046) after adjustment for age, CHA2DS2-VASc score, left atrial volume, type of atrial fibrillation and ejection fraction. To concluded, cluster analysis identified 3 statistically-driven groups among AF patients treated with CA with different risks for arrhythmia recurrences.

Despite a strong genetic background, Brugada syndrome (BrS) mainly affects middle-age patients. Data are scarce in the youngest and oldest age groups.The purpose of this study was to describe the clinical characteristics and variations in rhythmic risk in BrS patients according to age.Consecutive BrS patients diagnosed in 15 French tertiary centers in France were enrolled from 1993 to 2016 and followed up prospectively. All of the clinical and ECG data were double reviewed.Among the 1613 patients enrolled (age 45 ± 15 years; 69% male), 3 groups were defined according to age (52 patients17 years; 1285 between 17 and 59 years; and 27660 years). In the youngest patients, we identified more female gender (42%), diagnosis by familial screening (63%), previous sudden cardiac death (15%), SCN5A mutation (62%) sinus dysfunction (8%) and aVR sign (37%) (P.001). The oldest patients had the same clinical characteristics except for gender (40% women; P.001). During median follow-up of 5.5 [2.1, 10.0] years, 91 patients experienced an arrhythmic event, including 7 (13%) in the youngest patients, 80 (6%) in middle-age patients, and 4 (1%) in the oldest patients. Annual event rates were 2.1%, 1%, and 0.3%, respectively (P.01).Age on diagnosis changes the clinical presentation of BrS. Although children are identified more during familial screening, they present the highest risk of sudden cardiac death, which is an argument for early and extensive familial screening. The oldest patients present the lowest risk of SCD.

Left ventricular lead placement for cardiac resynchronization therapy may be challenging or even impossible. Left bundle area pacing has emerged as an interesting alternative method in case of failed implantation.

Background Cardiac resynchronization therapy (CRT) is an effective treatment of heart failure (HF), but is limited by a substantial proportion of nonresponders. We hypothesized that adding a second left ventricular (LV) lead to deliver a triple-site CRT (V3 CRT) may improve clinical status of CRT nonresponders. Objective We assessed the feasibility and safety of adding a second LV lead to CRT nonresponders and its clinical impact. Methods Eighty-four recipients of a CRT system and considered as nonresponders as per clinical composite score (CCS) were enrolled in this multicenter study. They were randomized to the V3 arm (implantation of an additional LV lead; n=43) or control arm (no change; n = 41). Implant success rate, incidence of severe adverse events, CCS, and secondary clinical and echocardiographic end points were evaluated at 12 and 24 months. Results Positioning of a second LV lead was successful at first (40 of 44 - 90.9%) or second (4 of 44 - 9.09%) attempt. The perioperative complication rate (infection, system explant, pneumothorax, and hematoma) was high (procedures or system-related complications for 9 patients- 20.4%). After 24 months, 35 systems (79.5%) were working properly. The multinomial logistic regression model showed that V3 treatment had no significant influence (P = .27) on the CCS, number of HF hospitalizations, time to first HF hospitalization, New York Heart Association class, and LV ejection fraction at 12 and 24 months. Conclusion Although addition of a second LV lead in CRT nonresponders is feasible with a high success rate, this approach is associated with a significant rate of severe adverse events and does not provide significant long-term clinical benefits (ClinicalTrials.gov Identifier No. NCT01059175).

Background Patients with kidney disease are more likely to develop atrial fibrillation (AF) than individuals with normal renal function, and more likely to suffer ischemic stroke (IS)/thromboembolism (TE). We investigated the relationship of kidney function evolution to IS/TE, mortality and bleeding in AF patients. Methods In a cohort of 8962 AF patients, 2653 had serum creatinine data, with 10894 patient-years of follow-up. Patients were stratified into quartiles of estimated glomerular filtration rate (eGFR) evolution (in mL/min per 1.73 m2/year). Results Rates of events (IS/TE, bleeding, mortality) increased with worsening eGFR by quartiles. The risk of events was particularly increased when patients in the 4th quartile were compared to others. Renal impairment per se was not an independent predictor of IS/TE but was an independent predictor of bleeding, whilst eGFR worsening was an independent predictor both for IS/TE (Hazard Ratio [HR] 1.573, 95%CI 1.160-2.134 for patients in the last quartile) and for bleeding events (HR 1.543, 95%CI 1.157-2.004). Worsening eGFR did not improve the predictive ability of the CHA2DS2VASc and HAS-BLED scores for identifying a higher risk of IS/TE or bleeding events, respectively. When the benefit of IS reduction was balanced against the increased risk of bleeding events, the net clinical benefit was positive in favor of OAC use (vs non-use) in patients with worsening eGFR. Conclusions Rates of IS/TE, mortality and bleeding increased with worsening eGFR >4.81 mL/min per 1.73 m2. Worsening eGFR was an independent predictor of IS/TE and of bleeding, and a better predictor of IS/TE than renal impairment in AF.

The CHA2DS2-VASc score may identify patients at higher risk of atrial fibrillation (AF) following ischemic stroke (IS) in patients without known AF. We compared gender-related differences in items from CHA2DS2-VASc score and their relation with AF occurrence after IS. This French cohort study was based on the database covering hospital care from 2009 to 2012 for the entire population. Of 336,291 patients with IS, 240,459 (71.5%) had no AF at baseline. Women were older, more frequently had hypertension, heart failure, and had a higher CHA2DS2-VASc score than men (4.63 vs 4.39, p

Summary Background Approximately one-third of patients do not respond favourably to cardiac resynchronization therapy (CRT). A longer distance between ventricular leads may improve response. Aim To study the impact of the true three-dimensional interlead distance (ILD) on outcomes. Methods Consecutive patients undergoing CRT device implantation were included prospectively. Interlead separation was measured from postprocedural anterior-posterior and lateral chest X-rays. The three-dimensional ILD was calculated using the Pythagorean theorem. Response to CRT was defined using a composite clinical score at 6 months. Results Forty-two patients were included (mean age 70 ± 9 years; QRS duration 154 ± 31 ms; left ventricular ejection fraction 26 ± 7%; 50% ischaemic). At 6 months, 71% of patients were considered to be responders. Responders had a significantly longer ILD (108 ± 17 vs. 87 ± 21 mm; P = 0.002). When the ILD was corrected for cardiac size, the optimal cut-off value was ≥ 0.53 for predicting response (sensitivity 83%, specificity 75%, area under the curve 0.84; P = 0.0002). Similar results were obtained in a historical retrospective cohort. The use of proximal electrodes on the left ventricular lead was associated with a longer ILD in 95% of patients, compared with more distal pacing configurations. In the total cohort of 74 patients (median follow-up, 420 days), those with an indexed ILD ≥ 0.53 had a 70% reduction in risk of hospitalization for heart failure (P = 0.004). Conclusion Longer three-dimensional ILD corrected for cardiac size measured on chest radiographs can accurately predict response to CRT and outcomes. This simple variable may be used to identify optimal lead placement and pacing configuration during CRT implantation.

International audience; Despite the increasingly high rate of implantation of pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We reviewed the data regarding the applicability, safety and effectiveness of conventional pacing, ICDs and cardiac resynchronization therapy (CRT) in elderly patients. Although periprocedural risk may be slightly higher in the elderly, the implantation procedure for PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, the general consensus is that DDD pacing with the programming of an algorithm to minimize ventricular pacing is preferred. In very old patients presenting with intermittent or suspected atrioventricular block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is similar in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantageous effect of the device on arrhythmic death may be attenuated by higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD implantation among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live more than 5-7years after implantation. Elderly patients usually experience significant functional improvement after CRT, similar to that observed in middle-aged patients. Management of CRT non-responders remains globally the same, while considering a less aggressive approach in terms of reinterventions (revision of left ventricular [LV] lead placement, addition of a right ventricular or LV lead, LV endocardial pacing configuration). Overall, physiological age, general status and comorbidities rather than chronological age per se should be the decisive factors in making a decision about device implantation selection for survival and well-being benefit in elderly patients.

Background It remains uncertain whether patients with atrial fibrillation (AF) and a single additional stroke risk factor (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or thromboembolism, vascular disease, age 65-74 years, and sex category [CHA 2 DS 2 -VASc] score = 1 in men, 2 in women) should be treated with oral anticoagulation (OAC). We investigated the risk of ischemic stroke, systemic embolism, and death in a community-based cohort of unselected patients with AF with zero to one stroke risk factor based on the CHA 2 DS 2 -VASc score. Methods Among 8,962 patients with AF seen between 2000 and 2010, 2,177 (24%) had zero or one additional stroke risk factor, of which 53% were prescribed OAC. Results Over a follow-up of 979 ± 1,158 days, 151 (7%) had a major adverse event (stroke/systemic thromboembolism/death). Prescription of OAC was not associated with a better prognosis for stroke/systemic thromboembolism/death for patients in the "low-risk" category (ie, CHA 2 DS 2 -VASc score = 0 for men or 1 for women; adjusted hazard ratio [HR], 0.68; 95% CI, 0.35-1.31; P = .25). OAC use was independently associated with a better prognosis in patients with AF with a single additional stroke risk factor (ie, CHA 2 DS 2 -VASc score = 1 in men, 2 in women; adjusted HR, 0.59; 95% CI, 0.40-0.86; P = .007). Conclusions Among patients with AF with a single additional stroke risk factor (CHA 2 DS 2 -VASc score = 1 in men, 2 in women), OAC use was associated with an improved prognosis for stroke/systemic thromboembolism/death.

Background Patients with chronic kidney disease (CKD) are more likely to develop atrial fibrillation (AF) and are more likely to suffer ischemic stroke (IS)/thromboembolism (TE). Recent findings suggest that this may also be true in AF patients with no CKD at baseline but with progressive worsening renal function during follow-up (FU). Purpose We investigated the relationship of estimated glomerular filtration rate (eGFR) evolution to IS/TE, mortality and bleeding and the predictors of eGFR evolution in AF patients. Methods Patients diagnosed with AF in a four-hospital institution between 2000 and 2010 were identified. Of them, 2622 had AF and serum creatinine data, with 10,894 patient-years of FU. Worsening renal function during FU was evaluated using eGFR evolution in mL/min/1.73 m2/year. Risk factors for worsening renal function were investigated with multiple regression analysis and risk of events were investigated with Cox regression models. Results In the whole population, mean eGFR evolution during FU was −1.91 mL/’/1.73 m2/year (median −1.26, interquartile range 6.30). Older age, heart failure, diabetes and use of diuretics were independent predictors of worsening renal function during FU. Rates of events (IS/TE, bleeding, mortality) increased with worsening eGFR by quartiles. Renal impairment per se was not an independent predictor of IS/TE but was an independent predictor of bleeding, whilst eGFR worsening was an independent predictor both for IS/TE (HR 1.59, 95% CI 1.17–2.16 for patients in the last quartile) and for bleeding events (HR 1.71, 95% CI 1.26–2.31). Conclusions Incidence rates of IS/TE, mortality and bleeding increased with worsening eGFR. Worsening eGFR was an independent predictor of IS/TE and bleeding, and a better predictor of IS/TE than renal impairment in AF. We were able to identify predictors of worsening renal function, which may help to tag patients needing regular FU for appropriate adaptation of antithrombotic therapy.

SummaryAtrial fibrillation (AF) confers a substantial risk of stroke. Recent trials comparing vitamin K antagonists (VKAs) with non-vitamin K antagonist oral anticoagulants (NOACs) in AF were performed among patients with so-called “non-valvular” AF. The distinction between “valvular” and “non-valvular” AF remains a matter of debate. Currently, “valvular AF” refers to patients with mitral stenosis or artificial heart valves (and valve repair in North American guidelines only), and should be treated with VKAs. Valvular heart diseases, such as mitral regurgitation, aortic stenosis (AS) and aortic insufficiency, do not result in conditions of low flow in the left atrium, and do not apparently increase the risk of thromboembolism brought by AF. Post-hoc analyses suggest that these conditions probably do not make the thromboembolic risk less responsive to NOACs compared with most forms of “non-valvular” AF. The pathogenesis of thrombosis is probably different for blood coming into contact with a mechanical prosthetic valve compared with what occurs in most other forms of AF. This may explain the results of the only trial performed with a NOAC in patients with a mechanical prosthetic valve (only a few of whom had AF), where warfarin was more effective and safer than dabigatran. By contrast, AF in the presence of a bioprosthetic heart valve or after valve repair appears to have a risk of thromboembolism that is not markedly different from other forms of “non-valvular” AF. Obviously, we should no longer consider the classification of AF as “valvular” (or not) for the purpose of defining the aetiology of the arrhythmia, but for the determination of a different risk of thromboembolic events and the need for a specific antithrombotic strategy. As long as there is no better new term or widely accepted definition, “valvular AF” refers to patients with mitral stenosis or artificial heart valves. Patients with “non-valvular AF” may have other types of valvular heart disease. One should emphasize that “non-valvular AF” does not exclude patients with some types of valvular heart disease from therapy with NOACs.

BACKGROUND : Diabetes mellitus is recognized as a stroke risk factor in atrial fibrillation (AF). Patients with diabetes with retinopathy have an increased risk for systemic cardiovascular complications, and severe diabetic retinopathy predisposes to ocular bleeding. We hypothesized that patients with diabetes, retinopathy, and AF have increased stroke/thromboembolism (TE) and severe bleeding risks when compared with patients with diabetes and AF who do not have retinopathy or to patients with AF and without diabetes. METHODS : We tested our hypothesis in a large “real-world” cohort of individuals with AF from the Loire Valley Atrial Fibrillation project. RESULTS : Of 8,962 patients with AF in our dataset, 1,409 (16%) had documented diabetes mellitus. Of these, 163 (1.8% of the whole cohort) were patients with diabetic retinopathy. After a follow-up of 31 ± 36 months, when compared with patients without diabetes, the risk of stroke/TE in patients with diabetes with no retinopathy increased 1.3-fold (relative risk [RR], 1.30; 95% CI, 1.07-1.59; P =.01); in patients with diabetes with retinopathy, the risk of stroke/TE was increased 1.58-fold (RR, 1.58; 95% CI, 1.07-2.32; P =.02). There was no significant difference when patients with diabetes with no retinopathy were compared with patients with diabetes with retinopathy (RR, 1.21; 95% CI, 0.80-1.84; P =.37). A similar pattern was seen for mortality and severe bleeding. On multivariate analysis, the presence of diabetic retinopathy did not emerge as an independent predictor for stroke/TE or severe bleeding. CONCLUSIONS : Crude rates of stroke/TE increased in a stepwise fashion when patients without diabetes and with AF were compared with patients with diabetes with no retinopathy and patients with diabetes with retinopathy. However, we have shown for the first time, to our knowledge, that the presence of diabetic retinopathy did not emerge as an independent predictor for stroke/TE or severe bleeding on multivariate analysis.

Background Atrial fibrillation is the most common cardiac complication of hyperthyroidism. The association between history of hyperthyroidism and stroke remains unclear. We sought to determine whether history of thyroid dysfunction is a thromboembolic risk factor in patients with atrial fibrillation. Methods Patients with atrial fibrillation seen in an academic institution between 2000 and 2010 were identified and followed-up. Clinical events (stroke/systemic embolism, bleeding, all-cause death) were recorded and related to thyroid status and disorders. Associations were examined in time-dependent models with adjustment for relevant confounders. Results Among 8962 patients, 141 patients had a history of hyperthyroidism, 540 had a history of hypothyroidism, and 8271 had no thyroid dysfunction. Mean follow-up was 929 ± 1082 days. A total of 715 strokes/systemic embolism were recorded, with no significant difference in the rates of these events in patients with a history of thyroid dysfunction vs those without thyroid problems in either univariate or multivariable analysis (hazard ratio [HR] 0.85; 95% confidence interval [CI], 0.41-1.76 for hyperthyroidism; HR 0.98; 95% CI, 0.73-1.34 for hypothyroidism). There were 791 bleeding events; history of hypothyroidism was independently related to a higher rate of bleeding events (HR 1.35; 95% CI, 1.02-1.79). No significant difference among the 3 groups was observed for the incidence of death. Conclusions History of hyperthyroidism was not an independent risk factor for stroke/systemic embolism in atrial fibrillation, whereas hypothyroidism was associated with a higher risk of bleeding events. These data suggest no additional benefit from the inclusion of thyroid dysfunction in thromboembolic prediction models in atrial fibrillation.

BackgroundMechanisms of maintenance of atrial fibrillation are known to include fibrosis. Galectin-3, as a biomarker of fibrosis, may be a valuable marker of atrial remodeling. We sought to find whether there was a link between clinical features and higher galectin-3 levels in patients with atrial fibrillation.MethodsSerum concentrations of Galectin-3 were determined in a consecutive series of patients addressed for ablation of atrial fibrillation.ResultsOne-hundred-and-eighty-seven patients were included, 56% having a paroxysmal type of atrial fibrillation. Mean Galectin-3 concentration was 14.5 ± 5.5 ng/mL. Age, persistent form of atrial fibrillation, underlying cardiac disease, heart failure, decreased left ventricular ejection fraction (LVEF), hypertension, diabetes, treatment with ACEI/ARB, enlarged left atrium and renal insufficiency were associated with higher Galectin-3 levels. Importantly, persistent form of atrial fibrillation, female sex, and LVEF < 45% were independent predictors (OR 13.9, p = 0.01, OR = 11.7, p = 0.03, and OR 54.2, p = 0.04, respectively) of higher Galectin-3 levels (≥ 15 ng/mL).ConclusionsPersistent type of atrial fibrillation is an independent predictor of higher Galectin-3 concentration. This biomarker of fibrosis may be implied in the mechanisms of atrial remodeling and maintenance of atrial fibrillation, and thus be helpful for the design of therapeutic strategy in patients with atrial fibrillation.

Patients with nonvalvular atrial fibrillation are often denied oral anticoagulation due to falls risk. The latter is variably defined, and existing studies have not compared the associated risk of bleeding with other cardiovascular events. There are no data about outcomes in individuals with nonvalvular atrial fibrillation with a prior history of (actual) falls, rather than being "at risk of falls." Our objective was to evaluate the risk of cardiovascular outcomes associated with prior history of falls in patients with atrial fibrillation in a contemporary "real world" cohort.Patients with nonvalvular atrial fibrillation in a 4-hospital institution between 2000 and 2010 were included. Stroke/thromboembolism event rates were calculated according to prior history of falls. Risk factors were investigated by Cox regression.Among 7156 atrial fibrillation patients, prior history of falls/trauma was uncommon (n = 76; 1.1%). Compared with patients without history of falls, those patients were older and less likely to be on oral anticoagulation; they also had higher risk scores for stroke/thromboembolism but not for bleeding. Compared with no prior history of falls, rates of stroke/thromboembolism (P = .01) and all-cause mortality (P.0001) were significantly higher in patients with previous falls. In multivariable analyses, prior history of falls was independently associated with stroke/thromboembolism (hazard ratio [HR] 5.19; 95% confidence interval [CI], 2.1-12.6; P.0001), major bleeding (HR 3.32 [1.23-8.91]; P = .02), and all-cause mortality (HR 3.69; 95% CI, 1.52-8.95; P = .04), but not hemorrhagic stroke (HR 4.20; 95% CI, 0.58-30.48; P = .16) in patients on oral anticoagulation.In this large "real world" atrial fibrillation cohort, prior history of falls was uncommon but independently increased risk of stroke/thromboembolism, bleeding, and mortality, but not hemorrhagic stroke in the presence of anticoagulation. Prior history of (actual) falls may be a more clinically useful risk prognosticator than "being at risk of falls."

Summary Defibrillator shocks, appropriate or not, are associated with significant morbidity, as they decrease quality of life, can be involved in depression and anxiety, and are known to be proarrhythmic. Most recent data have even shown an association between shocks and overall mortality. As opposed to other defibrillator-related complications, the rate of inappropriate and unnecessary shocks can (and should) be decreased with adequate programming. This review focuses on the different programming strategies and tips available to reduce the rate of shocks in primary prevention patients with left ventricular dysfunction implanted with a defibrillator, as well as some of the manufacturers’ device specificities.

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and are associated with an increased mortality. This study evaluated the prognosis of permanent and nonpermanent AF in patients with both AF and HF. All AF patients seen in our institution were identified and followed up. We included 1,906 patients suffering from AF and HF: 839 patients (44%) had preserved left ventricular ejection fraction (LVEF) and 1,067 patients (56%) had decreased LVEF; 1,056 patients (55%) had nonpermanent AF and 850 patients (45%) had permanent AF. During a median follow-up of 1.9 years (interquartile range 0.3 to 5.0), 377 patients died, 462 were readmitted for HF, and 200 had stroke or thromboembolic events. In patients with decreased LVEF, the rate of death was similar in patients with permanent or nonpermanent AF. In patients with preserved LVEF, permanent AF was associated with a higher risk of death and a higher risk of HF hospitalization. Stroke risk did not differ with permanent AF whatever the LVEF. NYHA functional class was an independent predictor of death (risk ratio [RR] = 1.33, 95% confidence interval [CI] 1.12 to 1.59, p = 0.001), as was permanent AF (RR = 1.79, 95%CI 1.32 to 2.42, p = 0.0002). Permanent AF (RR = 1.52, 95% CI 1.20 to 1.93, p = 0.0006) was also an independent predictor of readmission for HF. In conclusion, in patients with AF and HF, the risk of admission for HF and risk of death were higher when AF was permanent, particularly in patients with preserved LVEF. Stroke risk did not differ according to the pattern of AF, whatever the LVEF.

Background The atrial flutter of common type, with more frequent typical counterclockwise form, may occasionally present with clockwise form. The latter might be induced by clockwise functional block within cavotricuspid isthmus (CTI) of a premature atrial complex originating from the right atrium. Purpose As physiopathology might differ, we sought to compare long-term outcomes in patients who underwent CTI radiofrequency ablation for atrial flutter according to the electrical activation (clockwise or counterclockwise) at baseline. Methods All patients who underwent CTI radiofrequency ablation between 2000 and 2010 in the cardiology department of a four-hospital institution were included for analysis. Association with atrial fibrillation (supposed to be more frequently seen in case of left atrial origin of the arrhythmia), all-cause mortality, thromboembolic events, and atrial fibrillation occurrence were compared between patients with clockwise (group A) and counterclockwise (group B) CTI-dependant flutter. Results There was no significant difference at baseline (age, sex, heart failure, medication, hypertension, diabetes and stroke) between patients in group A (n = 41) and B (n = 831). Concomitant atrial fibrillation (AF) was present in 43% of patients in group A and 37% of patients in group B (P = 0.39). Deaths (n = 38), stroke/thromboembolic events (n = 30) and evolution to permanent AF (n = 53) were recorded after a follow-up of 826 ± 1024 days. There was no significant difference between both groups for occurrence of death of any cause (hazard ratio 1.31, 95%CI 0.53–3.23 in group A compared to group B, P = 0.55), stroke and thromboembolic events (hazard ratio 2.17, 95%CI 0.65–7.14, P = 0.20) and evolution to permanent AF (hazard ratio 2.27, 95%CI 0.78–6.25, P = 0.13). Conclusion Despite very different prevalence rates, clockwise and counterclockwise forms of CTI dependent atrial flutter occur in similar populations and seem associated with relatively similar outcomes.

Background Atrial fibrillation (AF) may commonly be associated with sinus node disease (SND) presenting as the so-called bray-tachy syndrome (BTS). BTS and AF are known to be at risk for ischemic stroke (IS). It remains unclear whether the risk of IS is similar in patients with isolated SND. Purpose Our objective was to compare the risk of IS in AF, SND and BTS patients and to identify risk factors of stroke in patients with SND. Methods This French longitudinal cohort study was based on the national hospitalization database, the Programme de medicalisation des systemes d’information (PMSI). We included all patients over 18 y.o. in France from January 2010 to December 2015 hospitalized with a main or related diagnosis of AF or SND. Baseline characteristics were pooled into a multivariate Cox model to identify significant predictors of IS. Results Of 1,732,412 patients included after exclusion of pacemaker or implantable cardiac defibrillator patients (PM/ICD), 1,601,435 (92.44%) had AF, 102,849 (5.94%) SND and 28,128 (1.62%) BTS. Compared to patients with AF or BTS, those with SND were younger, had a lower CHA2DS2-VASc score. Incidence of IS during follow-up was higher in AF than in BTS patients (yearly rate 4.90% vs. 2.73%, P Conclusion Patients with SND have a lower risk of thromboembolic events than those with AF or BTS. However, SND patients with a CHA2DS2-VASc score ≥ 2 had a markedly higher risk of IS during follow-up and may need specific considerations.

Background Kidney injury with renal tubular obstruction by red blood cell casts has been described in patients treated with vitamin K antagonist (VKA) and is known as anticoagulant-related nephropathy. Therefore, instable INR might play a role in favoring anticoagulant-related nephropathy. Purpose We investigated the relationship of VKA use and estimated glomerular filtration rate (eGFR) evolution in AF patients. Methods Patients diagnosed with AF in a four-hospital institution between 2000 and 2010 were identified. Renal function was evaluated using eGFR evolution in mL/min/1.73 m2/year. Risk factors for worsening renal function were investigated with multiple regression analysis. Results Two thousand six hundred and twenty-two patients had AF and serum creatinine data, with 10,894 patient-years of follow-up (FU). VKA was prescribed in 1580 (66%) patients, antiplatelet therapy for 473 (20%) and no antithrombotic treatment for 351 (14%). Non-VKA oral anticoagulants were not yet available. Mean eGFR evolution during follow-up was −1.91 mL/’/1.73 m2/year (median −1.26, interquartile range 6.30). Overall, patients with VKA use had similar eGFR evolution compared to non-users (−1.9 vs. −1.8 mL/’/1.73 m2/year, P = 0.77) and VKA use was not a predictor of eGFR evolution. Among patients with VKA use, those with labile INR (n = 60, 4%), had a similar eGFR evolution than those with no labile INR (−2.7 vs. −1.9 mL/’/1.73 m2/year, P = 0.49). Finally, patients with VKA use with SAMe-TT2R2 score > 2 (n = 293, 19%) had a similar eGFR evolution than those with SAMe-TT2R2 score ≤ 2 (−2.6 vs. −1.7 mL/’/1.73 m2/year, P = 0.20). Conclusions We found that AF patients with VKA use did not have a worse eGFR evolution during FU than those not treated with oral anticoagulation. Patients treated with VKA with labile INR or likely to have poor anticoagulation control neither had a worse eGFR evolution. These Results suggest that instable INR might not be the main determinant of anticoagulant-related nephropathy.

Background Atrial fibrillation (AF) may be related to acute, temporary causes such as alcohol use, myocardial ischemia, myocarditis, hyperthyroidism, etc. It remains unclear whether antithrombotic management should be different in this setting after resolution of the episode. Purpose Our objective was to describe the outcomes in patients with such a temporary cause of AF (TCAF), and to compare the specific subgroup of patients with TCAF associated with acute coronary syndrome (ACS) to other patients with TCAF with regard to antithrombotic management. Methods All patients with AF seen in our institution between 2000 and 2010 were identified in a database. The adverse outcomes were investigated during follow-up. Results Among 8962 patients with AF, 5467 patients with non-permanent AF of whom 920 (17%) had at least one possible temporary cause of AF. TCAF patients had higher CHA2DS2VASc score than other patients (3.6 ± 1.7 versus 3.0 ± 1.7, P Conclusion In patients with a possibly TCAF, use of oral anticoagulation was independently associated with a better prognosis. Antiplatelet therapy use was also independently associated with a better prognosis when patients with TCAF had ACS.

Background Catheter ablation for atrial fibrillation (AF) is a validated therapy for patients with symptomatic AF to prevent recurrences. However, the influence of AF catheter ablation on ischemic stroke (IS) occurrence is unclear and debated. Purpose We aimed to compare the incidence of IS in patients after AF catheter ablation versus patients not treated with AF ablation. Methods This French longitudinal cohort study was based on the national hospitalization PMSI (Programme de Medicalisation des Systemes d’Information) database covering hospital care from the entire population. We included all patients, over 18 years old, with AF from January 2010 to December 2015. Items from the baselines characteristics were pooled into a Cox model to identify predictors of IS. Results Of 1,663,284 patients identified with AF, 28,018 patients were treated with AF ablation (28% female, mean age 60 ± 10 years old, mean follow-up 700 ± 603 days) and 1,635,266 patients did not have AF ablation (48% female, mean age 77 ± 12 years old, mean follow-up 463 ± 550 days). IS during follow-up was recorded in 48,766 patients (yearly rate 2.31%). Incidence of IS was lower in the AF ablation group (0.52% person per year versus 2.33% person per year; P Conclusion Ablation may be associated with lower incidence of IS in patients with AF, independently of CHA2DS2-VASc score. This beneficial finding was similar in patients with low or higher thromboembolic risk. This suggests that AF ablation may be an adjunctive therapy, in addition to oral anticoagulation therapy, for prevention of IS in AF patients.

Background In 2017, a new definition of ‘valvular/non-valvular’ atrial fibrillation (AF) has been proposed. Purpose We compared thromboembolic (TE) and bleeding risks in patients with AF according to the new ‘Evaluated Heartvalves, Rheumatic or Artificial’ (EHRA) valve classification. Methods Patients were divided into 3 categories: (i) EHRA type 1 corresponds to the previous ‘valvular’ AF patients, including those with either rheumatic mitral valve stenosis or mechanical prosthetic heart valves; (ii) EHRA type 2 includes AF patients with other valvular heart disease (VHD) and valve bioprosthesis or repair; and (iii) ‘non-VHD controls’ i.e. all AF patients with neither VHD nor post-surgical valve disease. Results Among 8962 AF patients seen between 2000 and 2010, 357 (4%) were EHRA type 1, 1754 (20%) were EHRA type 2 and 6851 (76%) non-VHD controls. Type 2 patients were older and had a higher CHA2DS2-VASc and HAS-BLED scores than either type 1 and non-VHD patients. After a mean follow-up of 1264 ± 1160 days (median 922, interquartile range 234–2083), 715 stroke/TE events and 274 major bleeding (≥ 3 in BARC definition) were recorded. The occurrence of TE events was significantly higher in EHRA type 2 than non-VHD patients [HR (95% CI): 1.30 1.09–1.54], P = 0.003; also, P = 0.31 for type 1 vs. 2, P = 0.68 for type 1 vs. non-VHD controls. The rate of major BARC bleeding events for AF patients was higher in either EHRA type 1 [HR (95% CI): 3.16(2.11–4.72), P Conclusion This systematic analysis in real life conditions shows that distinguishing AF patients according to the new EHRA valve classification could be relevant for creating more homogenous groups of patients in terms of TE and bleeding risk. This clearer classification than the previous one should be useful as in clinical research for harmonization of studies, as well as in clinical practice for targeted choices of OAC therapy.

Recent results from the Danish trial call into question the benefits of implantable cardioverter-defibrillator (ICD) in primary prevention for patients with nonischemic cardiomyopathy (NICM) and a reduced left ventricular ejection fraction (LVEF), considering that a majority of these well-treated

In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention with drug-eluting stent (DES) implantation, the available evidence from clinical trial data are inconclusive. We evaluated the safety and efficacy of the use of DESs versus bare-metal stents (BMSs) in a consecutive real-world cohort of patients with AF. Of 8,962 unselected patients with AF seen in our institution from 2000 through 2010, 833 (9%) had undergone percutaneous coronary intervention with stent implantation. BMSs were used for 678 patients (81%) and DESs for 155 (19%). During follow-up (median 688 days, interquartile range 1,114), all bleeding episodes, thromboembolism, and major adverse cardiac events (MACEs; i.e., death, acute myocardial infarction, target lesion revascularization) were recorded. Incidence of MACEs was similar in the 2 groups as was incidence of all-cause mortality. Results remained similar even after adjustment for age and other confounding factors. Factors independently associated with an increased risk of MACEs were older age (hazard ratio 1.024, 95% confidence interval 1.004 to 1.044, p = 0.02), implantation of stent during acute ST-segment elevation myocardial infarction (hazard ratio 1.81, 95% confidence interval 1.10 to 2.99, p = 0.02), and stent diameter (hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, p = 0.03). Implantation of DESs was not significantly associated with a higher risk of major bleeding and we observed a similar ratio of serious events at follow-up after DES compared to BMS implantation. In conclusion, in our cohort, systematic use of DESs does not seem to be justified in most patients with AF because it was not associated with any clear advantage compared to BMSs.

Myotonic dystrophy is the most frequent adult form of hereditary muscular dystrophy caused by a mutation on the DMPK gene. Myotonic dystrophy leads to multiple systemic complications related to weakness, respiratory failure, cardiac arrhythmias and cardiac conduction disturbances. Age of death is earlier in myotonic dystrophy patients than in general population with a high frequency of sudden death. Several mechanisms are involved in sudden death: atrio-ventricular block, severe ventricular arrhythmias or non-cardiac mechanism. The high degree of atrio-ventricular block is a well-recognized indication of pacemaker implantation but the prophylactic implantation of pacemaker should be considered to prevent sudden death in asymptomatic myotonic dystrophy patients. A careful clinical evaluation needs to be done for the identification of patients at high risk of sudden death. The resting ECG and SA ECG are non-invasive tools useful to select the patients who need an electrophysiologic study. In presence of prolonged HV interval more than or equal to 70 ms one can discuss the implantation of a prophylactic pacemaker. The choice of an implantable cardiac defibrillator is preferred in presence of spontaneous ventricular tachycardia or an alteration of the left ventricular ejection fraction.

In atrial fibrillation (AF), the absence of a clear benefit of a rhythm-control strategy over a rate-control strategy seen in recent trials may be due to the fact that many of the usual antiarrhythmic strategy have significant weaknesses. Besides research efforts to improve the efficacy and safety of conventional antiarrhythmic agents, therapies directed 'upstream'of the electrical aspects of AF, towards the underlying anatomical substrate and atrial remodelling, have been proposed as new pharmacological therapeutic approaches. Potential upstream therapies for AF comprise a variety of agents such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), statins, N-3 polyunsaturated fatty acids and steroids. On the basis of experimental data, clinical studies have provided information on the potential of upstream therapy for the prevention of AF across a broad spectrum of cardiovascular patient groups. In patients with heart failure or hypertension, data are sufficient to support the use of ACEI or ARB as treatment that may decrease the risk of AF beyond their other beneficial effects. Similarly, it is highly possible that the use of statin in patients with a recognized indication may be associated with a benefit against AF. However, in most clinical settings, the evidence appears to be insufficient to drive changes in therapy management per se, and large-scale, randomized controlled trials with adequately defined endpoints are still needed. The results from these trials may help to understand the complex mechanisms that lead to AF, and may clarify the benefit-to-risk ratio of these new therapeutic approaches.

Background Atrial fibrillation (AF) may commonly be associated with sinus node disease (SND) presenting as the so-called brady-tachy syndrome. Such patients are known to be at risk for embolic stroke. It remains unclear whether the risk of stroke is higher in this setting, and if antithrombotic management should be different, particularly in patients with a low CHA2DS2-VASc score. Purpose We aimed to describe and compare the risk of stroke in AF patients with and with no SND. Methods All patients with AF seen in our institution between 2000 and 2010 were identified in a database. Outcomes were investigated during follow-up. Results Among 8962 patients with AF, 548 (6%) had SND among whom 237 (43%) where treated with a pacemaker. Patients with SND were older than patients with no SND (73.8 ± 11.9 versus 70.6 ± 14.7, P Conclusion AF patients with SND had a similar risk of stroke/TE than other AF patients. SND was not an independent risk factor for stroke when using a contemporary risk stratification scheme with the CHA2DS2-VASc score. Use of OAC was overall associated with a better prognosis in these patients.

Background CHA2DS2-VASc score is a tool estimating the risk of stroke in patients with atrial fibrillation (AF). This score is also able to identify patients at higher risk of AF following ischemic strokes (IS) among patients without known AF. Purpose We compared gender-related differences in items from CHA2DS2-VASc score and their relationship with possible AF occurrence dissimilarities in men and women after IS. Methods This French longitudinal cohort study was based on the national database covering hospital care from 2009 to 2012 for the entire population. Results Of 336,291 patients with IS from 2009 to 2012, 240,459 (71.5%) did not have AF at baseline. A total of 14,095 (5.9%) of these patients were diagnosed as having AF during a follow-up of 7.9 ± 11.5 months (incidence rate 8.9 per 100 person-years, 50.3% female, 49.7% male). The total incidence of AF was superior in women (9.8%) than in men (8.2%). In patients with IS without pre-existing AF at baseline, increasing CHA2DS2-VASc score was associated with a risk of new onset (or previously undiagnosed) AF during follow-up (overall HR 1.43 CI 1.41–1.45, HR 1.48 CI 1.45–1.50 in men and HR 1.46 CI 1.44–1.49 in women). In the total population, predictors of incident AF were older age, hypertension, heart failure, non-cerebral systemic embolism and vascular/coronary artery disease with similar results in men and women except for peripheral/vascular disease (NS) and non-cerebral systemic embolism (NS) in men. Diagnostic values of the CHA2DS2-VASc score for identifying patients at higher risk of incident AF were similar between men (C statistics 0.720, 95% CI 0.717–0.722) and women (C statistics 0.702, 95% CI 0.699–0.704). Conclusion A strategy using CHA2DS2-VASc score for identifying a higher risk of incident (or previously unknown) AF after IS might be similarly proposed in both genders because most results were similar in both groups and because sex-ratio of new AF after stroke was close to 1.

Background Atrial Fibrillation (AF) is associated with a substantial part of ischemic strokes (IS). CHA2DS2-VASc score is able to identify patients at higher risk of AF following IS among patients without known AF. Purpose We aimed to find other independent predictive factors related to AF occurrence after IS. Methods This French longitudinal cohort study was based on the national database covering hospital care from 2009 to 2012 for the entire population. Results Of 336,291 patients with IS from 2009 to 2012, 240,459 (71.5%) did not have AF at baseline. A total of 14,095 (5.9%) of these patients were diagnosed as having AF during a follow-up of 7.9 ± 11.5 months (incidence rate 8.9 per 100 person-years). Beyond CHA2DS2-VASc score, newly found independent predictors of subsequent diagnosis of AF were coronary artery disease (HR 1.22, 95% CI 1.15–1.28), abnormal renal function (HR 1.12, 95% CI 1.07–1.17), anaemia (HR 1.10, 95% CI 1.06–1.15), lung disease (HR 1.14, 95% CI 1.09–1.18), PM-ICD implantation (HR 1.56, 95% CI 1.48–1.64) and valvular disease (HR 1.44, 95% CI 1.37–1.51). From these results, we developed a new score with better predictive ability (C statistics 0.756 95%CI 0.754–0.757) for identifying patients at higher risk of incident AF following IS than CHA2DS2-VASc score (0.703 95%CI 0.701–0.704, p Conclusion New risk factors, particularly a history of coronary artery disease, pacemaker/ICD implantation, valvular disease and kidney disease, anaemia or chronic lung disease were associated with AF onset after IS. These finding helped us to build a new risk score identifying patients at higher risk of incident (or previously unknown) AF following IS with better predictive ability than previously described scores.

55-year-old man was admitted to the inten-sive care unit for shock. He had a history ofsevere coronary artery disease and arterialhypertension, and had undergone heterotopic car-diac transplantation 14 years ago for refractive con-gestive heart failure. Persistent ventricular arrhyth-mia attributed to native heart dysfunction wasinitially treated medically. A cardioverter defibril-lator was implanted after recurrence of syncopalventricular tachycardia 2 years ago. On admission,severe hypotension was noted (73/53 mm Hg).Physical examination at the time of admissionshowed no cardiac murmur or abnormal heartsounds. The patient’s heart rate was 90 beats/minand temperature was 38.6°C. Mechanical ventilation(controlled mode, tidal volume 9 mL/kg, respiratoryrate 20 breaths/min, F

Background Current ESC guidelines require anticoagulation with VKA in patients with “valvular atrial fibrillation (AF)”, which includes all types of prosthetic valve. We evaluated the value of the CHA2DS2 -VASc score for thromboembolism risk assessment in AF patients with biological valve replacement. Methods and results Among 8962 patients with AF seen between 2000 and 2010, 8053 (90%) had "non-valvular AF” and 909 (10%) had valvular AF. Patients with valvular AF had a biological prosthesis in 59% (n=549), among which 77% (n=426) had a single aortic prosthesis and 64% (n=309) received a VKA. Patients with aortic bioprosthesis were older and had a higher CHA2DS2-VASc score than those with a mitral prosthesis or a double valve replacement. During a follow up of 876±1048 days, 681 stroke/thromboembolic events were recorded. The occurrence of events were similar in patients with bioprosthesis compared to the patients without prosthesis: (hazard ratio HR 1.10, 95% CI 0.83-1.45, p=0.52). Patients with aortic bioprosthesis tended to have a higher risk of embolic events vs other AF patients with bioprosthesis (HR 1.73, 95% CI 0.87-3.45), p=0.12). In multivariate analysis, older age and higher CHA2DS2-VASC score were the only predictors of embolic events whilst the presence of a bioprosthesis was not an independent predictor of events. The CHA2DS2-VASC score predicted the embolism risk in AF patients with a bioprosthesis (c-statistic 0.55 95% CI 0.47-0.63) but was less efficient than in “non-valvular” AF patient (c-statistic 0.66, 95% CI 0.64-0.67). Conclusion This “real world” results support the use of oral anticoagulation in AF patients who have bioprosthetic heart valves. It also supports the use of CHA2DS2-VASc scoring for the risk evaluation of AF patients with bioprostheses, albeit with reduced reliability. Patients with aortic bioprosthesis had a non significant higher risk of embolic events. A higher CHA2DS2-VASc score in these patients is likely to explain these results.

ObjectivesThe purpose of this study was to evaluate the ventricular arrhythmias (VA) frequency in patients with unexplained syncope, ischemic or non-ischemic cardiac disease and left ventricular dysfunction (LVEF) and negative electrophysiological study (EP), implanted with cardioverter-defibrillator (ICD).BackgroundAccording to the current guidelines, EP is performed to evaluate syncope in patients with significant altered LVEF, mainly to guide treatment by ICD. Limited data concerning incidence of ventricular events in patients with no inducible arrhythmias is available.MethodsWe evaluated 58 consecutive patients with unexplained syncope who underwent EP. All patients had a depressed LVEF (< 45%). Sustained VA was only inducible in 28 patients (VF n = 8, SMVT n = 20). All patients were treated with ICD. We compared primary endpoint of severe VA in patients with negative and positive EP.ResultsBaseline characteristic were similar in the both groups. In the population (97% men), mean age was 67 ± 10 years, 67% had ischemic cardiopathy; mean LVEF was 30 ± 7% in non inducible group, 32 ± 9% in inducible group (p=0.16). During the follow-up (25 ± 22 months), 22 severe VA occurred; Kaplan-Meier analysis of time to first appropriate ICD therapy for non-inducible and inducible VA showed overlapping curves (p = 0.9), with 11 (37%) and 11 (39%) events in each group. Sub-group analysis according to LVEF and etiology of cardiopathy did not show significant difference.ConclusionsIn patients with unexplained syncope, ischemic or non-ischemic cardiopathy and left ventricular dysfunction, severe VA occurs in the follow-up at same rate whatever the result of EP. This study suggests that these patients should be treated with ICD without doing electrophysiological testing.

b s m s A 66-year-old man with a history of surgical removal of a left atrial myxoma was admitted to our department for radiofrequency ablation of a symptomatic atrial flutter. Baseline ECG showed atrial flutter with variable atrioventricular conduction and narrow QRS complexes (Figure 1). Atrial activity showed an aspect of intraatrial conduction delay. Echocardiography showed normal left ventricular function and no atrial dilation. Electrophysiologic study demonstrated a constant atrial cycle length of 420 ms, with clockwise activation within the right atrium. Entrainment maneuvers confirmed a macroreentrant mechanism involving the right atrium. However, right atrial activation time covered only 70% of the total cycle length, and, surprisingly, coronary sinus activation was distal to proximal. An electroanatomic map of both the right and left atria through a transseptal approach was performed using the

Smoking is incorporated in a simple score (SAMe-TT2R2) that can predict poor INR control in patients with atrial fibrillation (AF) treated with vitamin K antagonists (VKA). Moreover, the clinical benefit of clopidogrel in reducing myocardial infarction and stroke in randomized clinical trials of antiplatelet drugs (APD) was seen primarily in smokers, with little benefit in nonsmokers. We made the hypothesis that active smoking may differently influence 1) the risk of stroke and 2) the risk of bleeding in AF patients treated with VKA or with APD. Methods We examined the clinical course of 7.948 consecutive patients with AF and/or atrial flutter seen between 2000-2010. The outcomes in patients with active smoking were compared with those in other patients. Results Among 7.948 patients with AF (age 71±15 years), 1034 (13%) had active smoking. APD was prescribed on an individual basis for 2761 patients (35%) and VKA for 4534 (57%). During a follow-up of 929±1082 days, 631 strokes/thromboembolic events, 707 severe bleedings and 248 major BARC bleedings were recorded. Smoking was not independently associated with a higher risk of stroke in these AF patients (relative risk=0.94, 95% CI 0.75-1.18, p=0.62). By contrast, after adjustment on age, CHADS2 score, HASBLED bleeding risk score, VKA use and APD use, smoking was independently associated with a worse prognosis for the risk of severe bleeding (relative risk=1.23, 95% CI 1,02- 1,50, p=0.03) and for the risk of major BARC bleeding (relative risk=1.40, 95% CI 1.03-1.91, p=0.03). Smoking was independently associated with a higher risk of bleeding in patients treated with VKA (relative risk= 1.32, 95% CI 1.04-1.66. p=0.02) whilst this association did not reach significance in patients treated with APD (relative risk=1.31, 95% CI 0.97-1.76. p=0.07). Conclusion In AF, there was a higher risk of bleeding in smokers, mainly in those treated with VKA