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Raluca Şoşdean,1,2 Cristian Mornoş,1,2 Bogdan Enache,1,2 Răzvan I Macarie,2 Raluca Ianoş,2 Ana-Maria Ştefea,2 Sorin Pescariu1,2 1Department of Cardiology, “Victor Babeş” University of Medicine and Pharmacy, 2Cardiology Clinic, Institute of Cardiovascular Medicine, Timişoara, Romania Introduction: Cardiac resynchronization therapy (CRT) is known to have very important beneficial effects on heart failure patients. Unfortunately, biventricular implantable cardiac devices (CRT devices), through which this therapy is implemented, are very expensive and sometimes hard to achieve, especially in underdeveloped/developing economies, making this an important problem of public health. As a possible solution, CRT reuse is of great interest nowadays, but unlike simple devices, data in the literature are scarce about biventricular device reuse. Aim: To address safety concerns, we aimed to analyze infection burden in the general and elderly population and also early battery depletion and generator malfunction of resterilized biventricular devices compared to new devices. Methods: A cohort of 261 CRT patients (286 devices), who underwent implantation between 2000 and 2014, was retrospectively analyzed. The study group included 115 patients and 127 resterilized devices, that was divided into a subgroup of 69 elderly patients (≥60 years) and 74 devices and a subgroup of 47 younger patients (

Whether ultra-high density (UHD) contact mapping is useful in radiofrequency ablation of persistent atrial fibrillation (AF) is unknown. To sequentially map the left atrial (LA) activation during AF ablation (circumferential PVI and ablation of extra pulmonary vein drivers). Time reference was an LA appendage (LAA) electrogram (EGM). Points were acquired with respiratory gating if reference, cycle length (10 ms tolerance) and electrode location were stable. For fragmented EGM the timing of the surrounding area was used. In case of extremely low voltage (< 0.01 mV) or lack of local statistical coherence no colour-code was displayed (grey area). Circular propagation around single points was defined as organized rotating drivers (Fig. 1). All pts had PVI followed by remapping and ablation of the centre of rotational regions and at sites with focal type propagation. DC or chemical cardioversion were not performed in the first 48 h. Out of 41 patients (pts) undergoing first time ablation with the above described protocol, 30 (66 ± 8 y, mean current episode duration 8 months) were followed for a mean time of 14,7 months. At 48 hours post-procedure, 70% of pts were no longer in AF: 6 (20%) in sinus rhythm and 15 (50%) in atrial tachycardias. At 1 year after a single procedure, freedom from AF was 87% and freedom from AF and AT was 60% (Fig. 1). In persistent AF, sequential UHD activation mapping is useful in guiding and potentially improving long-term results of ablation of extra pulmonary vein drivers after PVI. [ABSTRACT FROM AUTHOR]

Epicardial portions of the circuit of endocardial re-entrant tachycardias are well established phenomena in the ventricles, but little is known about a similar phenomenon in post lesion atrial tachycardia (AT). Higher spatial and voltage mapping capabilities may help identify extra-endocardial bridging (EEB) during tachycardia. We retrospectively analysed our database of 119 pts with AT cases with ultra-high density mapping between March 2015 and March 2018. Epi-to-endo breakthrough sites were diagnosed when endocardial activation started at a discrete point before spreading radially in every available direction. PPI after transient entrainment at these sites confirmed local participation in AT. In 20 out of the 119 pts (mean age 70 ± 9 yrs, always with ≥ 1 prior procedures), 2 types of EEB were found. Type 1 is a "myocardial" EEB (n = 16). Subtype 1A (Fig. 1) with a visible antidromic wavefront back to a line of block (n = 10) whereas in subtype 1B activation starts immediately adjacent to a usually large line of block. Type 2 implied an extra-atrial "venous" bridging, either as a "shunt" over a line of block (subtype 2A, n = 6) or by using an epicardial vein as a major part of a circuit (subtype 2B, n = 1). In presence of EEB, AT termination was 17/22 (77%), significantly lower than our historical cohort of nonEEB AT (97%, P = 0.03). The most successful strategy was targeting epi-endo breakthrough site. Atrial EEB using either epicardial layers of the atrial wall, or extra-atrial venous structures is confirmed. Successful ablation at epi-to-endo breakthrough site proves the validity of the concept but results of ablation are inferior to nonEEB AT. [ABSTRACT FROM AUTHOR]

Active fixation leads for acute complete atrioventricular block (AVB 3) have recently been introduced in the last international guidelines for cardiac pacing. To describe the routine management of acute AVB 3 in France, with emphasis on the organisational aspects. From September 2019 to November 2019, a prospective national survey including 29 questions was electronically sent to 100 physicians (Google Form). The answers were collected from 93 physicians (response rate 93%). A temporary active fixation lead for AVB 3 has already been implanted by 50.5% of the operators. Eighty (86%) have already observed a dislocation of the temporary pacing lead (TPL), a cardiac perforation already occurred in 57 (61.3%), a groin hematoma in 35 (37.6%), and this technique was proscribed for 4.3% of the operators. Definitive pacemaker implantation during weekends and nights (after 8PM) is possible for 48.9% of the operators (< 5 times a year), for 15.2% (> 5 times a year), impossible for 35.9% of the operators. For AVB3 non-responsive to isoproterenol occurring during the night (Fig. 1), a TPL is implanted by: the on-site medical staff on-duty (27.2%), the on-call interventional cardiologist (20.7%), the on-call electrophysiologist (18.5%), a permanent pacemaker is implanted by the electrophysiologist (12%), the strategy is not standardised (15.2%). Our survey shows important disparities in terms of management of acute AVB3 among the different centres, and a high incidence of complications with temporary passive pacing leads. An active fixation lead with an external pacemaker was used by half of the centres. [ABSTRACT FROM AUTHOR]

The axillary route use for cardiac devices implantation has recently expanded either with fluoroscopy or ultrasounds guidance. Few studies included defibrillators (ICD), cardiac resynchronization therapy (CRT) and upgrade procedures for ultrasound-guided axillary vein puncture (UGVP). To assess the feasibility/safety of UGVP for complex cardiac devices implantation including CRT/ICD. Consecutive patients eligible for a pacemaker or ICD implantation were included. All procedures were performed by three operators (one experienced and two fellows). Guidewires insertion time (from lidocaïne administration), and complications were systematically studied. A group of patients implanted with alternative techniques was used for comparison (cephalic, subclavian). In 176 consecutive patients in whom UGVP was used, a total of 68 complex procedures were analyzed (74 ± 8 y, male 73%) with 138 leads implanted including 42 ICD, 48 CRT and 16 upgrade procedures. A majority (83%) was under anti-thrombotic therapy. UGAVP was successful in 96.8%. Mean insertion time for 2.02 guidewires per patient was 4.4 ± 4.4 min. Guidewires insertion time reached its plateau after 10 patients. One pocket hematoma (1.4%) was drained during a mean follow-up of 12 ± 5 months. The control group included 24 patients (8 subclavian, 16 cephalic; 15 ICD, 14 CRT, 4 upgrade procedures), with a mean insertion time of 10 ± 8 min, for 1.95 guidewires per patient (P < 0.0005). UGVP is feasible and safe even for complex device implantations including CRT/ICD and upgrade procedures. [ABSTRACT FROM AUTHOR]

Background Whether ultra-high density (UHD) contact mapping (Rhythmia) may be used to map activation of atrial fibrillation (AF) is unknown. Purpose We sequentially mapped the left atrial (LA) activation during AF ablation (circumferential pulmonary vein isolation–CPVI, followed by defragmentation). Methods Time reference was an LA appendage (LAA) electrogram (EGM). Points were acquired with respiratory gating if reference, mapped EGM (10 ms tolerance) and electrode location were stable. For fragmented EGM the timing of the surrounding area was used. In case of extremely low voltage (< 0.01 mV) or lack of local statistical coherence no colour-code was displayed (grey area). Circular propagation around single points were defined as organized rotating drivers (see Fig. 1 ). Results AF was mapped in 17 patients (patients; 9 men, 68 ± 5 y). LA maps (162 ± 49 ml, 30947 ± 14061 EGM, 95 ± 26 cm 2 ) were acquired in 15.7 ± 6.5 minutes. In 70% of the cases, stable rotating drivers (mean 1.9, 1 to 5) with continuous activation in the centre were visualized. All patients had CPVI followed by ablation of the centre of rotational regions and at sites with fragmented bipolar EGM. After CPVI, LAA CL increased from 171 ± 10 to 199 ± 14 ms ( P = 0.02). Termination of AF without electrical cardioversion was obtained in 62%. Conclusion Sequential UHD activation mapping of AF allows visualisation of areas of rotational activation that are always around a fragmented EGM and seem to be an appropriate target for ablation. [ABSTRACT FROM AUTHOR]

Background Sequential low-resolution contact mapping to guide radiofrequency (RF) atrial fibrillation (AF) ablation is used but controversial. Whether ultra-high density (UHD) mapping can produce maps useful for ablation is unknown. Purpose To sequentially map left atrial (LA) activation during ablation with Rhythmia (circumferential pulmonary vein isolation, CPVI, followed by defragmentation). Methods Using an LA appendage (LAA) electrogram (EGM) as reference, and the Orion catheter for signals acquisition, beats were automatically selected based on cycle length (CL) stability, electrode location stability and respiratory gating. In case of extremely low voltage or lack of statistical coherence between neighbouring points, grey is displayed. Regions with uniform colour (meaning predominantly simultaneous activation) were defined as organized. Results Seventeen patients (patients; 68 ± 5 years) underwent repeated AF mapping at baseline and after each ablation step. Initial LA maps (162 ± 49 ml, 30947 ± 14061 EGM, 95 ± 26 cm 2 ) were acquired in 15.7 ± 6.5 min. All patients had CPVI followed by ablation of sites with fragmented bipolar EGM. After CPVI, LAA CL rose from 171 ± 10 to 199 ± 14 ms ( P = 0.02). Surface of organized areas increased from 16 ± 3% of total LA before to 29 ± 5% after CPVI ( P = 0.01; Fig. 1 ), increasing the accuracy of appropriate fragmented site identification for ablation. AF termination with RF was obtained in 62%. Only 2 AF recurrences occurred within 6 months. Conclusion Sequential AF UHD contact activation mapping visualized increasing organization with ablation, unmasking optimal residual ablation targets. [ABSTRACT FROM AUTHOR]

Background: A standard technique regarding venous approach for implantation of biventricular cardiac electrical devices used for cardiac resynchronization therapy implementation has not yet been established. We analyzed the safety and efficiency of implanting these devices using a double venous approach (cephalic and subclavian) by comparing it with the simple approaches, in order to overcome some of their inconvenients. Materials and methods: We retrospectively analyzed all 228 resynchronization patients implanted at the Timisoara Institute of Cardiovascular Medicine between January 1st, 2000 and January 1st, 2013. The 204 patients successfully implanted with biventricular pacemakers or defibrillators were divided according to the implantation techniques, and compared by complication rates and values of acute stimulation-detection thresholds. Group A featured a subclavian approach (48 patients), group B a cephalic approach (81 patients) and group C a double venous approach (76 patients). Results: Adjusting for age, sex and device type there is no evidence in the data that complication rates are significantly different when using the different techniques: 6 complications (12.5%) in group A, 8 (9.87%) in group B and 5 (6.75%) in group C (p = 0.51). A slight downward trend was observed by using double venous approach. Values of acute stimulation-detection thresholds had no statistically significant differences neither (p = 0.36). Cephalic vein was of high quality in 59.8% of cases. Conclusions: Subclavian and cephalic double venous approach implantation technique for biventricular devices proved to be feasible and at least as safe as single venous approach using subclavian or cephalic vein alone, and it can be used as a first resort technique. [ABSTRACT FROM AUTHOR]