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Summary Background High-level physical training induces cardiac structural and functional changes, including 12-lead electrocardiogram modifications. Objectives The purpose of this cross-sectional longitudinal study was to establish a quantitative electrocardiographic profile in highly trained football players. Initial and serial annual electrocardiogram monitoring over subsequent years allowed us to investigate the long-term effects of exercise on cardiac conduction and electrophysiological remodelling. Methods Between 2005 and 2015, serial evaluations, including 12-lead electrocardiograms, were performed in 2484 elite male football players from the French Professional Football League. A total of 6247 electrocardiograms were performed (mean 2.5 ± 1.8 electrocardiograms/player). Heart rate (beats/min), atrioventricular delay (PR, ms), intraventricular conduction delay (QRS, ms), corrected QT delay (QTc) and electrical left ventricular hypertrophy (LVH) (Sokolow-Lyon index, mm) were measured, and the fixed effect of time was evaluated using panel data analysis (β [95% confidence interval] change between two visits). Results According to European Society of Cardiology and Seattle criteria, 15% of the electrocardiogram intervals were considered abnormal. We observed 17% sinus bradycardia 200 ms (mean PR 170 ± 27 ms), 1.5% QRS > 120 ms (mean QRS 87 ± 19 ms) and 3% prolonged QT interval (mean QTc using Bazett's formula [QTcB] 395 ± 42 ms). Electrical LVH (mean Sokolow-Lyon index 34 ± 10 mm) was noted in 37% of players. Over time, electrocardiogram changes were noted, with a significant remodelling trend in terms of decreased heart rate (−0.41 [−0.55 to −0.26] beats/min), QRS duration (−2.4 [−2.7 to −2.1] ms) and QTcB delay (−1.2 [−1.9 to −0.5] ms) (all P Conclusions This study describes usual electrocardiographic training-induced changes in a large series of football players over the follow-up timeframe. The most frequent outliers were electrical LVH and sinus bradycardia. These results have important implications for optimizing electrocardiogram interval measurements in initial screening and during follow-up of football players, with potential cost-effective implications.

Summary Background Right ventricular (RV) dysfunction is an important predictor of impaired prognosis in idiopathic dilated cardiomyopathy. Aims To determine the prognostic role of RV dysfunction, independent of left ventricular (LV) dysfunction. Methods A total of 136 consecutive patients (73% men; mean age 59.0 ± 13.2 years) with idiopathic dilated cardiomyopathy (LV ejection fraction ≤ 45%) were enrolled retrospectively. Thirty-four patients (25%, group 1) presented with RV dysfunction, defined as tricuspid annular plane systolic excursion (TAPSE) ≤ 15 mm; 102 patients (group 2) had preserved RV function. Results Mean LV ejection fraction was 27.5 ± 8.7%. Mean TAPSE was 18.6 ± 5.4 mm (15–21.8 mm). Multivariable predictors of RV dysfunction were LV outflow tract time-velocity integral (odds ratio 0.8, 95% confidence interval [CI] 0.7–0.9; P = 0.003) and E-wave deceleration time ≤ 145 ms (odds ratio 4.1, 95% CI 1.3–12.8; P = 0.017). Major adverse cardiac event-free survival rates at 1 and 2 years were 64% and 55%, respectively, in group 1 and 87% and 79%, respectively, in group 2 ( P = 0.002). Both by multivariable analysis and after stratification using a propensity score, RV dysfunction emerged as an independent predictor for major adverse cardiac events (hazard ratio 3.2, 95% CI 1.3–7.6; P = 0.009), along with right atrium area and age. Conclusion In idiopathic dilated cardiomyopathy, RV dysfunction with TAPSE ≤ 15 mm offers additional prognostic information, independent of the extent of LV dysfunction.

Background Currently available antiarrhythmic drugs (AADs) for the prevention of atrial fibrillation (AF)/atrial flutter (AFL) suffer from incomplete efficacy and poor tolerability. Hypothesis Dronedarone could represent an effective and safe option in patients previously treated with AADs, especially class Ic AADs and sotalol. Methods Retrospective analysis of 2 double-blind, parallel-group trials (EURIDIS [European Trial in Atrial Fibrillation or Flutter Patients Receiving Dronedarone for the Maintenance of Sinus Rhythm] and ADONIS [American–Australian–African Trial With Dronedarone in Atrial Fibrillation or Flutter Patients for the Maintenance of Sinus Rhythm]) comparing the efficacy and safety of dronedarone with placebo over 12 months. The primary end point was AF/AFL recurrence in patients previously treated with another AAD that was discontinued for whatever reason prior to randomization. Results In patients previously treated with any AADs, dronedarone decreased the risk of AF recurrence by 30.4% vs placebo (hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.59-0.82; P < 0.001). In patients previously treated with a class Ic agent, dronedarone decreased the risk of recurrence by 31.4% (HR: 0.69; 95% CI: 0.53-0.89; P = 0.004), whereas in patients previously treated with sotalol, dronedarone showed a trend toward a decrease of risk of recurrence (HR: 0.86; 95% CI: 0.67-1.11; P = 0.244). Dronedarone was equally effective irrespective of whether class Ic or sotalol were stopped for lack of efficacy or adverse events (AEs). Discontinuation rates were similar in the 2 groups (55.9% vs 43.1%), as were incidence of AEs and serious AEs. Conclusions Dronedarone seems to be effective in preventing AF recurrences in patients without permanent AF previously treated with other AADs, even if those were discontinued for lack of efficacy. Dronedarone appears to be well tolerated even in patients who already had tolerability issues with AADs.

Introduction Left ventricular (LV) systolic dysfunction is the most frequent initial presentation of patient with LV noncompaction (NC). Our objectives were to evaluate myocardial contraction properties in patients with LVNC and the relationship of non-compacted segments with the degree of global and regional systolic deformation. Methods We included 50 LVNC with an echocardiography and speckle imaging calculation of peak longitudinal strain (PLS). Each of the 16 LV myocardial segments was defined as NC (ratio NC/compacted layer > 2), borderline (NC/C 0–2) and compacted (NC/C = 0). Basal, median and apical strain values were calculated as the average of segmental strain values. For comparison a group of 50 patients with dilated cardiomyopathy (DCM) underwent the same measurements. Results There was no statistical difference between the 2 groups for any conventional LV systolic parameters. A characteristic deformation pattern was observed in LVNC with higher strain values in the LV apical segments (− 12.8 ± 5.9 vs − 10.7 ± 5.7) and an apical–basal ratio (1.52 ± 0.73 vs 1.12 ± 0.42; p, Highlights • We observed a base–apex gradient with relatively preserved deformation values in the apical region in LVNC. • We find lower regional deformation values in compacted segments. • We illustrate the role of deformation echocardiography to evaluate the degree and extent of LV segmental dysfunction. • We define a new tool to help classification of patient with similar dilated cardiomyopathy phenotype. • We confirmed the concept that LVNC is a phenotypic marker of an underlying diffuse cardiomyopathy.

AIMS This French study was set up to collect perceptions of general practitioners (GPs), cardiologists and patients on anticoagulation therapy with vitamin K antagonists (VKA) in the management of thromboembolic risk in atrial fibrillation (AF). METHOD This is a prospective survey conducted in France, between July 1 and August 7 2011, on a sample defined to obtain a sufficient number of patient files of 133 physicians, divided into 65 cardiologists and 68 GPs. RESULTS Three hundred and ninety-four patients on VKA and 130 patients not receiving VKA were included in this study. For more than one in three patients, AF was diagnosed incidentally in a medical consultation for another reason. In addition, 15% and 23% of diagnoses of FA were performed after hospitalization for stroke or TIA by cardiologists and GPs, respectively. According to the patient, the doctor contacted first is a GP (52% for the GP vs. 35.5% for the cardiologist), but they state that the diagnosis was made mainly by a cardiologist (63% for the cardiologist vs. 27% for the GP). In 78% of cases, cardiologists are initial prescribers. A CHADS2 score of 0 was found in 23% of patients not receiving VKA and in 11% of patients on VKA. A CHADS2 score superior or equal to 2 is significantly more frequently found in patients with paroxysmal AF. Concerning the monitoring of the patient, GPs ensure mainly monitoring of INR. In terms of compliance, according to doctors, their patients systematically take their treatment in 91% of cases. However, by interviewing patients, 60% of non-compliant patients are considered compliant by their physician. CONCLUSION This study has achieved an overview of anticoagulation treatment in AF, in France. The initiation is mainly ensured by the cardiologist and the monitoring by the GP. Assessments between cardiologists and GPs are relatively similar, however, it appears that anticoagulation treatment is under-prescribed for the patients at risk.

Bilateral internal mammary arteries (BIMA) remain widely underused in coronary artery bypass grafting (CABG). In this study, we aim to investigate the early and long-term outcomes of BIMA grafts in isolated CABGs.Single-centre retrospective observational study.University Hospital, Nancy.1000 consecutive patients undergoing elective, isolated, primary, multiple CABGs using BIMA grafts and supplemental venous grafts for multi-vessel coronary disease.In-hospital mortality and major morbidity, and long-term all-cause mortality.Mean age of the overall population was 60 ± 15 years. A left ventricular ejection fraction (LVEF) ≤ 45% was found in 28% of the patients and 27.1% of the patients were diabetics. Comorbidities were represented by chronic renal failure, chronic obstructive pulmonary disease and peripheral artery disease in 11, 11.7 and 27.3% of the cases, respectively. The in-hospital mortality rate was 2.8%. Early postoperative morbidity included myocardial infarction (2.2%), stroke (0.9%), mesenteric ischaemia (0.7%) and mediastinitis (2.2%). The Kaplan-Meier 8-year survival rates for patients less than 65 and between 65 and 74 years of age were 88% and 66%, respectively (p0.01). Multiple regression analysis showed that patients' age 65 years or greater at baseline (OR 2.3; 95% CI 1.3 to 4, p0.001), acute coronary syndrome (OR 1.9; 95% CI 1.1 to 3.4, p = 0.02), chronic renal failure (OR 2.7; 95% CI 1.4 to 5.2, p0.001), peripheral artery disease (OR 3.1; 95% CI 1.8 to 5.5, p0.001) and LVEF ≤ 45% (OR 2.6; 95% CI 1.4 to 4.5, p0.001) were independent predictors of long-term cardiovascular mortality.Our longitudinal analysis presents encouraging data concerning operative risk of BIMA grafting and provides excellent long-term survival in appropriately selected patients.

Stroke associated with left cardiac catheterization is a devastating complication, and its incidence has not changed over the decades. We investigated the incidence, in-hospital outcomes and the modifiable and non-modifiable risk factors for periprocedural ischemic stroke.Our retrospective cohort study included all patients experiencing periprocedural ischemic stroke among the 24,500 patients who underwent left cardiac catheterization between January 2003 and October 2010. The case group was compared with a group of control patients randomly selected among those who underwent the procedure during this period.Ischemic cerebrovascular events attested by brain imaging occurred in 37 patients (0.15% of procedures), transient ischemic attack occurred in 9 cases, and persistent neurological deficit occurred in 28 cases. Patients who developed strokes were more likely to be older and were more often female with a greater prevalence of comorbidities. Emergency and longer procedures were more frequent in patients in the case group who had more coronary complications. A multivariate analysis identified diabetes mellitus (adjusted odds ratio (OR) 4.2; 95% CI 1.8-9.9; P.001), chronic renal dysfunction (OR 2.4; 95% CI 1.1-5.4; P.001), known cerebrovascular disease (OR 5.1; 95% CI 2.3-11.5; P.001), emergency procedure (OR 3.1; 95% CI 1.4-9.2; P.01) and recent congestive heart failure (OR 6.1; 95% CI 2.9-13; P.001) as independent predictors for stroke. The independent modifiable predictive factors were represented by left ventricular angiography (OR 7.5; 95% CI 2.7-21; P.001), and low operator volume (OR 3.1; 95% CI 1.3-7.4; P.01).Limiting the performance of left cardiac catheterization to high volume operators and avoiding unnecessary left ventricular angiography may reduce periprocedural ischemic stroke.

Background: Multiple studies have shown that amiodarone is effective in treating atrial fibrillation (AF), but is associated with a relatively high incidence of side effects; however, due to amiodarone's long elimination half-life (20–100 days), physicians may hesitate to start other drugs until it has fully cleared. Hypothesis: A rapid switch from amiodarone to dronedarone is feasible. Methods: EURIDIS and ADONIS were double-blind, multinational, parallel-group trials comparing the efficacy and safety of dronedarone with placebo over 12 months. This retrospective subanalysis of EURIDIS/ADONIS compared the effects of dronedarone in patients discontinuing amiodarone within 2 days before randomization (“rapid switch”) with results in patients who had received no amiodarone during the 2 months preceding randomization. Results: In total, 1237 patients were enrolled (“rapid switch”, n = 154; “no amiodarone”, n = 1014). In both the “rapid switch” and the “no amiodarone” groups, dronedarone users had significantly lower AF recurrence than patients receiving placebo (HR = 0.64, 95% CI, 0.44–0.95; P = 0.0224 and HR = 0.79, 95% CI, 0.67–0.92; P = 0.0027, respectively). Dronedarone users had a higher incidence of bradyarrhythmic events than placebo-treated patients. A “rapid switch” from amiodarone to dronedarone was associated with a higher incidence of serious heart failure events and heart failure hospitalizations versus all other groups. Overall event rates were low and there was no significant difference in total adverse event rates or deaths between groups. Conclusion: In this patient population, a switch from amiodarone to dronedarone within a 2-day time frame might be feasible in certain patient categories, but further investigation is warranted. The ADONIS/EURIDIS studies and this post hoc analysis were funded by sanofi-aventis. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

International audience; We herein present the findings of the case of a 23-year-old man who was hospitalized for ventricular tachycardia (VT) with no previous history of cardiac disease or any family history of sudden death. Based on the clinical features as well as the echographic and MRI results, the patient was diagnosed with both acute viral myocarditis and arythmogenic right ventricular dysplasia (ARVD). The patient underwent implantation of an automatic cardioverter defibrillator. There was no recurrent VT during the 24 month follow-up. This case demonstrates the link between ARVD and myocarditis, and highlights the importance of conducting an RV assessment through a cardiac magnetic resonance (CMR) study in the context of arrhythmia and myocarditis.

The number of scar-related ventricular tachycardia (VT) ablation procedures is increasing worldwide. This is certainly due to the ever growing number of patients implanted with an implantable cardioverter defibrillator in whom an ablation procedure may be required to better control the ventricular arrhythmia burden, but is also likely related to our better understanding of the arrhythmias mechanisms as well as the improvement of the mapping techniques during the last 15 years. Most VTs, especially those arising after myocardial infarction, depend on a critical isthmus. Defining precisely the critical isthmus of postinfarct VT may be challenging, particularly when the arrhythmia is poorly tolerated. In the literature, there are extensive data concerning the value of conventional electrophysiological techniques, especially entrainment mapping in association with postpacing interval measurements, regarding the identification of postinfarct VT isthmuses. There are, however, other--sometimes emerging--approaches to image critical postinfarct VT channels. We have summarized these, reviewing data from the published literature as well as our own experience.

Aims Little is known about the optimal number of antitachycardia pacing (ATP) attempts to programme in the fast ventricular tachycardia (FVT) zone. We sought to analyse the long-term efficacy and safety of programming a high number of ATP attempts for FVTs. Methods and results All patients receiving an implantable cardioverter/defibrillator (ICD) for coronary artery disease or dilated cardiomyopathy for primary and secondary prevention between 2000 and 2009 were prospectively included. Implantable cardioverter/defibrillators were programmed to deliver 10 ATP attempts for FVT cycle lengths (CLs) of 250–300 ms (200–240 b.p.m.) before shock delivery (5 bursts, then 5 ramps; 8–10 extrastimuli at 81–88% FVT CL; minimal pacing CL 180 ms). Among 770 patients included and followed for 40.6 ± 25.6 months, 137 (17.8%) experienced a total of 1839 FVTs, 1713 of which were ATP-terminated (unadjusted efficacy = 93.1%, adjusted = 81.7%), 106 ATP-accelerated (5.8%), and 20 ATP-resistant (1.1%). The majority of FVT episodes were successfully treated by one or two attempts (98.3%). However, patient-based analysis showed that 17 (12.4%), 8 (5.8%), and 5 patients (2.1%) had at least one episode treated by three or more, four or more, and five or more ATP attempts. The benefit of this strategy was reduced after five attempts. The majority of FVT episodes was asymptomatic and diagnosed at device interrogation during follow-up: syncope and pre-syncope occurred in only 0.2 and 0.4% of episodes, respectively. Conclusion Programming a high number of ATP attempts (up to five ATP attempts) in the FVT zone is both safe and efficient and could prevent shocks in numerous ICD recipients.

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important source for mortality and morbidity on a population level. Despite the clear association between AF and death, stroke, and other cardiovascular events, there is no evidence that rhythm control treatment improves outcome in AF patients. The poor outcome of rhythm control relates to the severity of the atrial substrate for AF not only due to the underlying atrial remodelling process but also due to the poor efficacy and adverse events of the currently available ion-channel antiarrhythmic drugs and ablation techniques. Data suggest, however, an association between sinus rhythm maintenance and improved survival. Hypothetically, sinus rhythm may also lead to a lower risk of stroke and heart failure. The presence of AF, thus, seems one of the modifiable factors associated with death and cardiovascular morbidity in AF patients. Patients with a short history of AF and the underlying heart disease have not been studied before. It is fair to assume that abolishment of AF in these patients is more successful and possibly also safer, which could translate into a prognostic benefit of early rhythm control therapy. Several trials are now investigating whether aggressive early rhythm control therapy can reduce cardiovascular morbidity and mortality and increase maintenance of sinus rhythm. In the present paper we describe the background of these studies and provide some information on their design.

Background: Radiofrequency ablation has became a validated therapeutic technique for symptomatic drug refractory atrial fibrillation (AF). Cardiac computed tomography (CT) is used to evaluate left atrial (LA) anatomy in order to improve AF ablation. The analysis of noncardiac structures during cardiac CT may identify clinically significant incidental findings (IFs). The objective of this study was to determine the prevalence of IF in patients undergoing AF catheter ablation. Methods: Between February 2008 and March 2010, all patients planned for a first procedure of AF or LA tachycardia (LAT) ablation underwent a cardiac CT scan and were retrospectively included in this study. Extracardiac IFs were considered to be present if an abnormality was identified without previous clinical suspicion or known disease. Results: Two hundred and fifty patients (55.2 ± 9.6 years of age, 82.4% men) were enrolled (133 paroxysmal, 43 persistent, 58 permanent AF, and 16 LAT). Fifty-eight patients (23.2%) had a total of 76 IFs. Patients with IF were significantly older (59.5 ± 8.2 vs 53.8 ± 9.7 years old, P < 0.001). No relationship existed between the type of arrhythmia and IF existence. The majority of IFs were pulmonary (50%), with 15.8% of pulmonary emphysema. Two cases of lung cancer and of pulmonary fibrosis, 15 mediastinal adenopathies, and three congenital coronary arteries anomalies were found. Conclusions: Cardiac CT scan is a useful tool to evaluate LA morphology before AF ablation. However, as a considerable prevalence of IF was found in our study, extracardiac structures should be routinely analyzed to detect unknown conditions, which could require specific management. (PACE 2011; 34:1665–1670)

Atrial fibrillation (AF) is the most common arrhythmia in clinical practise and its prevalence is increasing. Over the last 25 years, flecainide has been used extensively worldwide, and its capacity to reduce AF symptoms and provide long-term restoration of sinus rhythm (SR) has been well documented. The increased mortality seen in patients treated with flecainide in the Cardiac Arrhythmia Suppression Trial (CAST) study, published in 1991, still deters many clinicians from using flecainide, denying many new AF patients a valuable treatment option. There is now a body of evidence that clearly demonstrates that flecainide has a favourable safety profile in AF patients without significant left ventricular disease or coronary heart disease. As a result of this evidence, flecainide is now recommended as one of the first-line treatment options for restoring and maintaining SR in patients with AF under current treatment guidelines. The objective of this article is to review the literature pertaining to the pharmacological characteristics, safety and efficacy of flecainide, and to place this drug in the context of current therapeutic management strategies for AF.

Venice Chart International Consensus Document on Ventricular Tachycardia/Ventricular Fibrillation Ablation ANDREA NATALE, M.D.,∗ ANTONIO RAVIELE, M.D.,† AMIN AL-AHMAD, M.D.,‡ OTTAVIO ALFIERI, M.D.,¶ ETIENNE ALIOT, M.D.,∗∗ JESUS ALMENDRAL, M.D.,†† GUNTER BREITHARDT, M.D.,‡‡ JOSEP BRUGADA, M.D.,¶¶ HUGH CALKINS, M.D.,∗∗∗ DAVID CALLANS, M.D.,††† RICCARDO CAPPATO, M.D.,‡‡‡ JOHN A. CAMM, M.D.,¶¶¶ PAOLO DELLA BELLA, M.D.,∗∗∗∗ GERARD M. GUIRAUDON, M.D.,†††† MICHEL HAISSAGUERRE, M.D.,‡‡‡‡ GERHARD HINDRICKS, M.D.,¶¶¶¶ SIEW YEN HO, M.D.,∗∗∗∗∗ KARL H. KUCK, M.D.,††††† FRANCIS MARCHLINSKI, M.D.,‡‡‡‡‡ DOUGLAS L. PACKER, M.D.,¶¶¶¶¶ ERIC N. PRYSTOWSKY, M.D.,∗∗∗∗∗∗ VIVEK Y. REDDY, M.D.,†††††† JEREMY N. RUSKIN, M.D.,‡‡‡‡‡‡ MAURICIO SCANAVACCA, M.D.,¶¶¶¶¶¶ KALYANAM SHIVKUMAR, M.D.,∗∗∗∗∗∗∗ KYOKO SOEJIMA, M.D.,††††††† WILLIAM J. STEVENSON, M.D.,‡‡‡‡‡‡‡ SAKIS THEMISTOCLAKIS, M.D.,¶¶¶¶¶¶¶ ATUL VERMA, M.D.,∗∗∗∗∗∗∗∗ and DAVID WILBER, M.D.,†††††††† for the Venice Chart members From the ∗Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA; †Cardiovascular Department, Ospedale dell’Angelo, Mestre-Venice, Italy; ‡Cardiac Arrhythmia Service, Stanford University Medical School, Stanford, USA; ¶Department of Cardiac Surgery, Ospedale San Raffaele, Milan, Italy; ∗∗Department of Cardio-Vascular Diseases, CHU de Nancy, Hopital de Brabois, Vandoeuvre-les-Nancy, France; ††Division of Cardiology, Hospital General Gregorio Maranon, Madrid, Spain; ‡‡Department of Cardiology and Angiology, University Hospital of Munster, Munster, Germany; ¶¶Thorax Institute-Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; ∗∗∗Department of Cardiology, The Johns Hopkins Hospital, Baltimore, MD, USA; †††Department of Medicine, Section of Cardiovascular Disease, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; ‡‡‡Department of Electrophysiology, Policlinico San Donato, San Donato Milanese, Italy; ¶¶¶Cardiac and Vascular Sciences, St. George’s Hospital Medical School, London, UK; ∗∗∗∗Cardiology Division, Centro Cardiologico Monzino, Milan, Italy; ††††Cardiac Surgery, University of Western Ontario, London, Canada; ‡‡‡‡Hopital Cardiologique du Haut Leveque, Bordeaux, France; ¶¶¶¶Heart Center, Department of Cardiology, University of Leipzig, Leipzig, Germany; ∗∗∗∗∗Cardiac Morphology Unit, Royal Brompton Hospital, London and Imperial College, London, UK; †††††Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany; ‡‡‡‡‡Department of Medicine, Section of Cardiovascular Disease, University of Pennsylvania, Philadelphia, PA, USA; ¶¶¶¶¶Cardiac Translational and Electrophysiology Laboratory, Saint Mary’s Hospital Complex, Mayo Clinic Foundation, Rochester, NY, USA; ∗∗∗∗∗∗The Care Group, Indianapolis, IN, USA; ††††††Cardiac Arrhythmia Service, Miller School of Medicine, University of Miami, Miami, USA; ‡‡‡‡‡‡Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA; ¶¶¶¶¶¶Heart Institute, University of San Paulo Medical School, San Paulo, Brazil; ∗∗∗∗∗∗∗Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; †††††††Cardiovascular Division, University of Miami Hospital, Miami USA; ‡‡‡‡‡‡‡Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA; ¶¶¶¶¶¶¶Cardiovascular Department, Ospedale dell’Angelo, Mestre-Venice, Italy; ∗∗∗∗∗∗∗∗Cardiology, Southlake Regional Health Center, Toronto, Canada; and ††††††††Department of Cardiology, Loyola University Medical Center, Chicago, IL, USA

Etienne M. Aliot, MD, FESC, FHRS1, William G. Stevenson, MD, FHRS2, Jesus Ma Almendral-Garrote, MD, PhD3, Frank Bogun, MD4, C. Hugh Calkins, MD, FHRS5, Etienne Delacretaz, MD, FESC6, Paolo Della Bella, MD, PhD, FESC7, Gerhard Hindricks, MD, PhD8, Pierre Jais, MD, PhD9, Mark E. Josephson, MD10, Josef Kautzner, MD, PhD11, G. Neal Kay, MD12, Karl-Heinz Kuck, MD, PhD, FESC, FHRS13, Bruce B. Lerman, MD, FHRS14, Francis Marchlinski, MD, FHRS15, Vivek Reddy, MD16, Martin-Jan Schalij, MD, PhD17, Richard Schilling, MD18, Kyoko Soejima, MD19, and David Wilber, MD20

The purpose of this Consensus Statement is to provide a state-of-the-art review of the field of catheter ablation of ventricular tachycardia (VT), and to report the findings of a Task Force, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS) that was charged with defining the indications, techniques, and outcomes of this procedure. This statement summarizes the opinion of the Task Force members based on their own experience in treating patients, as well as a review of the literature. It is directed to all healthcare professionals who treat patients who are considered for catheter ablation of VT. This statement is not intended to recommend or promote catheter ablation of VT. Rather, the ultimate judgement regarding care of a particular patient must be made by the healthcare provider and the patient with consideration of the individual patient characteristics that impact on risks and benefits of the therapy. In writing a ‘consensus’ document, it is recognized that consensus does not mean that there was complete agreement among all Task Force members. We identified those aspects of VT ablation for which a true ‘consensus’ could be identified. Surveys of the entire Task Force were used to identify these areas of consensus. For the purposes of this Consensus Document, we defined a consensus as 70% or greater agreement by the members of this task force. One objective of this document is to improve patient care by summarizing the foundation of knowledge for those involved with catheter ablation of VT. All members of the Task Force, as well as peer reviewers of the document, were asked to provide disclosure statements of all relationships that might be perceived as real or potential conflicts of interest. Disclosures for the members of the task force are given in the Appendix section. Catheter ablation …

The survival of patients with idiopathic dilated cardiomyopathy (IDCM) at III and IV stages of New York Heart Association (NYHA) is decreased in those with a bundle branch block (BBB) compared to those without BBB. Less is known on the prognosis of patients at earlier stages of NYHA and who had a left BBB (LBBB) or right BBB (RBBB). We sought to evaluate the prevalence and the clinical significance of LBBB or RBBB in patients with IDCM and classes I and II of NYHA.Clinical data, noninvasive, and invasive studies were consecutively collected in 310 patients, with IDCM, followed up to 4.8+/-3.7 years.Seventy-six patients (25%) had LBBB, 21 (7%) had RBBB, and 212 had no BBB. Patients with BBB were older than other patients (P0.009). Left ventricular ejection fraction (LVEF) was lower in LBBB than in RBBB and other patients (P0.05). Syncope was more frequent in BBB than in absence (P0.05). Incidence of spontaneous ventricular tachycardia (VT) and atrial fibrillation, VT induction, total cardiac events, and sudden death were similar in the presence or absence of BBB. Deaths by heart failure and heart transplantations tended to be more frequent in BBB than in absence.LBBB was present in 25% of patients with IDCM; RBBB was rare. Patients with BBB were older and had more frequent syncope than patients without BBB; LVEF was lower in LBBB than in RBBB or in absence of BBB. BBB did not increase the risk of spontaneous VT, VT induction, or sudden death, and tended to increase deaths by heart failure and the indications of heart transplantation.

Catheter ablation is increasingly widely used to treat atrial fibrillation (AF) and constantly evolving techniques and protocols have led to improved success rates and lower risks of complications in a broad range of patients. However, long-term clinical trial data are still limited and as a result many questions remain unanswered. Particularly in patients with symptomatic paroxysmal AF, high success rates in restoring sinus rhythm (SR) with a low risk of complications are reported by experienced centres. Nevertheless, the continued suppression of AF over time, particularly with regard to the recurrence of asymptomatic episodes of AF which could influence stroke risk, is not yet adequately documented and therefore the safety of discontinuing oral anticoagulation remains unclear. The risk of silent or subclinical complications associated with ablation procedures, the likelihood of autonomic modulation and the long-term impact of ablation on left atrial mechanical function have not yet been fully determined. Limited clinical trial data suggest that catheter ablation may be particularly beneficial for patients suffering from heart failure (HF) secondary to AF, indicating improved left ventricular function and quality of life with the restoration of SR. However, the processes underlying HF and the co-existing morbidities vary from one patient to another and the factors predicting a successful outcome of ablation have not yet been fully defined. Similarly, the consistently higher rates of AF suppression achieved with catheter ablation vs. antiarrhythmic drug therapy shown in comparative clinical trials encourage consideration of this treatment as a potential first-line treatment in certain patients, but whether this is currently justifiable and if so, in which patient subsets, are open questions. This article reviews current approaches to catheter ablation and attempts to address some of the controversies regarding its use.

Atrial fibrillation (AF) is associated with impaired functional capacity and quality of life and significant morbidity and mortality. The current management approach fails to maintain stable sinus rhythm (SR) in the majority of patients. For many years, guidelines have recommended antiarrhythmic treatment of a first AF episode only if the AF is poorly tolerated, a position that has been reinforced by studies showing no mortality or morbidity advantage of rhythm control over rate control. During the last decade, research has shown mechanisms of self-perpetuation of AF based on electrophysiological and structural remodelling induced by AF itself. There is mounting evidence that 'lone' AF is because of a host of factors, some of which may be easily treatable, such as hypertension, sleep apnoea, and obesity, thus allowing secondary prevention at the time of the first episode of AF. According to these concepts, lack of early intervention could be one of the reasons for long-term failure of maintenance of SR. In this position paper, we propose testing the working hypothesis that if an SR maintenance strategy is selected, treatment of AF should commence at the first-detected episode and should be based on a double strategy of SR restoration and aggressive treatment of associated conditions that promote atrial remodelling.

The morbidity and mortality associated with atrial fibrillation (AF), the most frequent cardiac arrhythmia, remain substantial. The efficacy and safety of current antiarrhythmic drugs continue to be less than optimal. The development of newer antiarrhythmic drugs has recently been made possible through a greater understanding of the pathophysiology of AF and knowledge of atrial electrophysiology relative to the properties of the congeners of known antiarrhythmic agents. Highly specific atrially acting drugs are currently being explored, their major merit concerning safety. In contrast, their role may be somewhat limited in view of the electrophysiological complexity of AF as an arrhythmia. The data suggest that complex antiarrhythmic agents with a multiplicity of actions may be preferable, although currently there are few data on the precise effectiveness of atrial-specific agents in maintaining sinus rhythm in AF. It is of interest that combining antiarrhythmic and non-antiarrhythmic agents, such as anti-inflammatory or antioxidant drugs, may increase the effectiveness of antifibrillatory actions in patients with AF, although these data have been obtained in uncontrolled, small or retrospective studies. Thus, at present, it is not certain whether it is preferable to target single antiarrhythmic drugs with antiadrenergic properties or to combine ‘purely’ antiarrhythmic drugs with other drugs devoid of anti-adrenergic effects. Controlled clinical trials are required to precisely define the effectiveness of single agents vs. various combinations of agents in maintaining sinus rhythm in patients with AF.

Background: Long-term prognosis of coronary artery disease (CAD) patients is worsened when stress ischemia persists on treatment, but the relationship with adverse cardiac remodelling had never been investigated. Aim: To analyze changes in blood markers of fibrosis in patients with chronic CAD exhibiting exercise ischaemia. Methods: Circulating markers of collagen: (i) turnover (amino-terminal propeptide of collagen-III [PIIINP]) and (ii) degradation (matrix metalloproteinase 1 [MMP-1]), were obtained in 139 CAD patients referred for exercise 201Tl-SPECT. Results: In the 57 patients who had SPECT-ischaemia, PIIINP was higher (4.3±2.9 μg L−1 vs. 3.1±1.5 μg L−1, p=0.002) and MMP-1 lower (3.8±2.1 μg L−1 vs. 4.7±2.8 μg L−1, p=0.04) than in the 82 patients without SPECT-ischaemia. PIIINP was independently related to LV volume, SPECT-ischaemia and age, whereas MMP-1 was related to current treatment with ACEI and β-blockers (p

Purpose Right ventricular (RV) dysfunction is a predictor of impaired prognosis in patients presenting with an idiopathic dilated cardiomyopathy (DCM). We intended to determine which parameters were associated with RV dysfunction and to analyze the prognostic role of RV dysfunction independently of the level of LV dysfunction (LVEF and end-diastolic diameter). Methods 136 consecutive patients (73% men, mean age 59.0±13.2 years) with idiopathic DCM (LVEF 45%) were retrospectively enrolled. 34 patients (25%, group 1) presented with RV dysfunction defined as TAPSE δ15mm (tricuspid annular plane systolic excursion) and 102 (group 2) had normal RV function. Patients were followed for a mean time of 2.7±1.1 years for the occurrence of any major adverse cardiac event (MACE: cardiac death and hospitalization, heart transplantation). Results Mean LVEF was 27.5±8.7%. Mean TAPSE was 18.6±5,4mm with an interquartile range of 15-21,8mm. Multivariate predictors of RV dysfunction were LV outflow tract TVI (OR 0.8 (95% CI 0.7-0.9), p=0.003) and E-wave deceleration time δ145ms (OR 4.1 (95% CI 1.3-12.8), p=0.017). MACE-free survival at 1 and 2 years was 64% and 55% respectively in group 1, compared to 87% and 79% in group 2 (p=0.002). By multivariate analysis and after stratification using a propensity score, RV dysfunction emerged as an independent predictive factor of MACE (HR 3.2 (95% CI 1.3-7.6), p=0.009), along with right atrium area >20cm2 and age. Conclusions RV dysfunction defined by TAPSE 15mm is associated with a systolic (aortic TVI) and a diastolic (E-wave DT) LV function parameters. RV dysfunction in patients presenting an idiopathic DCM is an additional and independent prognostic factor independent of the level of LV dysfunction and dilatation.

Background— This study aims to assess the incidence and clinical relevance of slow ventricular tachycardia (VT) and the effectiveness and/or deleterious effects of antitachycardia pacing in slow VT in implantable cardioverter-defibrillator recipients. Methods and Results— This multicenter prospective randomized study included 374 patients (326 men) without prior history of slow VT (148 bpm), and a ventricular fibrillation zone. Patients were randomized to a treatment group (n=183) with therapy activated in the slow VT zone or a monitoring group (n=191) with no therapy in the slow VT zone. During follow-up (11 months), 449 slow VTs occurred in 114 patients (30.5% slow VT incidence); 181 VTs (54 patients) occurred in the monitoring group; 3 were readmitted to the hospital; and lightheadedness and palpitations occurred in 4 and 250 (60 patients) in the treatment group treated by antitachycardia pacing (89.8% success rate) and shock delivery (n=2). There were 10 crossovers from the monitoring to treatment group and 3 crossovers from the treatment to monitoring group ( P =0.09). Quality of life scores were not different between groups. Conclusions— Slow VT incidence (

During these last years, several therapeutic strategies trials have been performed in atrial fibrillation: the goal was to compare the rhythm control strategy (restoration and maintenance of sinus rhythm) to the rate control strategy (slowing of heart rate in atrial fibrillation). The most important of these different trials is the AFFIRM study. The main conclusion of this trial is that rate control can be chosen in first intention and not only in case of failure of the rhythm control strategy. These results can not be applied to 2 categories of patients: on one hand patients with heart failure and on the other hand young patients without cardiopathy in whom the strategy of rhythm control and sinus rhythm maintenance, mainly by class I antiarrhythmic drugs, remains the better choice.

New developments in dual chamber implantable cardioverter defibrillators (ICD) have increased the specificity of therapy delivery. This study was performed to examine the performance of an algorithm, focusing on its ability to distinguish slow ventricular tachycardia (VT) from sinus rhythm or supraventricular tachyarrhythmias. The patient population included 77 men and 13 women, 63 ± 11 years old, treated with ICDs after episodes of spontaneous or inducible ventricular tachyarrhythmias. They were randomized to programming of the ICD to a lower limit of VT detection at 128 beats/min (group I, n = 44), versus 153 beats/min II (group II, n = 46). The primary endpoint of the study consisted of comparing the specificity and sensitivity of the algorithm between the two groups of patients. Over a 10.1 ± 3.5 months follow-up, 325 episodes were detected in the Tachy zone in group I, versus 106 in group II. The sensitivity and specificity of the algorithm in group I were 98.8% and 94.4%, respectively, versus 100% and 89% in group II (NS). A single episode of VT at a rate of 132 beats/min was diagnosed as SVT in group I. The sensitivity and specificity of the algorithm for tachycardias

Background — The reentrant mechanism of postinfarct ventricular tachycardia (VT) has been documented by surgical mapping analysis, but little is known about postinfarct VT circuits and the characteristics of their related protected isthmus with the use of 3D catheter mapping systems. Methods and Results — A 3D electroanatomic mapping was performed in 21 patients with well-tolerated, postinfarct, sustained VT. In total, 33 episodes of tachycardia (mean cycle length 432±74 ms) were induced and mapped. Complete maps demonstrated macroreentrant circuits with 1 loop (n=8) or 2 loops (n=25) rotating around a protected isthmus bounded by 2 approximately parallel conduction barriers that consisted of a line of double potentials, a scar area, or the mitral annulus. A total of 26 critical isthmi were identified for the 33 VTs mapped, with the same isthmus being shared by 2 to 4 different tachycardic morphologies in 5 patients. On average, isthmi were 31±7 mm long (ranging from 18 to 41 mm) and 16±8 mm wide (ranging from 6 to 36 mm) and harbored diastolic electrograms. The isthmus axis was oriented parallel to the mitral annulus plane in perimitral circuits and perpendicular to the mitral annulus plane in all other circuits. Linear radiofrequency ablation performed across the most accessible part of the isthmus prevented the recurrence of tachycardia in 19 patients (90%) with a follow-up at 16±8 months. Conclusions — Detailed 3D electroanatomic mapping is helpful in reconstructing postinfarct VT circuits and in defining the characteristics of their related protected isthmi. The wide range of isthmus width values supports the need of linear radiofrequency lesions to eliminate the reentrant substrate of postinfarct VTs.

Introduction: Complete isthmus block has been used as an endpoint for radiofrequency ablation for common atrial flutter (AF). We sought to systematically evaluate extremely slow conduction (ESC), which is easily misinterpreted as complete block. Methods and Results: We studied 107 consecutive patients (92 men, 15 women, 58 ± 11 years) who had undergone a successful AF ablation procedure. A 24-pole catheter was positioned along the tricuspid annulus spanning the isthmus. Complete isthmus block was defined as the presence of a complete corridor of double potentials along the ablation line. Activation delay time (AT), activation difference (ΔA) between two adjacent dipoles, maximum activation difference (ΔA max), change in polarity (CP) and change in amplitude (CA) of the bipolar atrial electrogram were recorded and P-wave morphology in the surface electrocardiogram was analyzed. ESC was observed in 16 patients. Between ESC and complete block, differences were found on the two lateral dipoles adjacent to the ablation line (AT: 148 ± 17 vs. 183 ± 27 ms and 155 ± 18 vs. 170 ± 28 ms, P < 0.01; ΔA: −91 ± 22 vs. −126 ± 28 ms and −7 ± 13 vs. 13 ± 6 ms, P < 0.01). Statistically significant differences in CP were detected on the relevant dipoles (7/16 vs. 14/16 and 6/16 vs.13/16, P < 0.05). No significant difference was found either in CA or in terminal P wave positivity. Mean ΔA max were 13.8 ± 5.0 and 27.8 ± 9.5 ms (P < 0.001) respectively in ESC and complete block. Two types of ESC, regular and irregular, were demonstrated during the ablation procedure. Conclusions: (1) ESC was observed in 15% of the patients during the AF ablation procedure. (2) The parameters of AT, ΔA, and CP may help to differentiate ESC from complete block. ΔA max might be the most powerful indicator. (3) To verify complete block, it is essential to position the mapping catheter across the CTI in order to demonstrate the activation sequence up to the ablation line.

The ablate and pace strategy may be considered a viable therapy in the palliative management of patients with medically refractory highly symptomatic atrial fibrillation (AF). The overall success rate is approaching 100%, the inhospital course is usually event free, and the procedure is a relatively safe therapeutic option. There is no doubt that one of the major findings after atrioventricular (AV) node ablation is the significant reduction of cardiac symptoms and health care use, while exercise tolerance and quality of life significantly improved after the procedure. It is also well accepted that catheter ablation and pacemaker (PM) implantation are usually associated with significant improvement in left ventricular ejection fraction, particularly in patient with AF and reduced systolic function at baseline. On the other hand, AV node ablation seems unlikely to have a negative effect on long term survival. The mortality rate in some reports have raised concerns about excess deaths (mainly sudden deaths) attributable to AV node ablation and pacing therapy. These findings are not confirmed by recent data. Modulation of the AV node has been more recently introduced in the clinical practice in order to avoid permanent complete AV block and lifetime PM dependency. AV node modulation procedure is effective in approximately 70% of cases. The short duration of following periods does not allow to draw definitive conclusions concerning the potential evolution of AV node conduction disorders. Both AV node ablation and AV node modulation, when successful, are effective means to improve quality of life and cardiac performance in patients with medically refractory AF. The exact place of these procedures is, today, a matter of debate which is more controversial in patients with paroxysmal AF than with uncontrolled permanent AF.

Arrhythmia Discrimination by ICD.Introduction: Despite technologic developments, accurate discrimination of ventricular tachyarrhythmia from rapid rhythms of nonventricular origin remains a challenge. We sought to examine the sensitivity and specificity of a dual-chamber arrhythmia detection algorithm, the PARAD algorithm, incorporated in a dual-chamber implantable cardioverter defibrillator, the Defender (ELA Medical). Methods and Results:All detailed tachycardia episodes (i.e., with stored atrial and ventricular channel markers and electrograms) retrieved from the Holter memory of the device were analyzed from 95 patients (86 men and 9 women; age 62 ± 12 years) implanted with the Defender with the algorithm programmed at nominal settings. Over a follow-up of 15 ± 8 months, 559 detailed sustained tachycardia episodes detected in the tachycardia zone were gathered in 62 patients. Of the 300 ventricular tachycardia (VT) episodes, 298 were appropriately classified as VT by the algorithm. Of the 259 supraventricular tachycardia (SVT) episodes, 231 were appropriately classified as SVT. In 8 patients, 28 episodes of SVT were misclassified as VT: 25 atrial fibrillation episodes (6 patients), 2 sinus tachycardia (1 patient), and 1 atrial tachycardia. Calculated sensitivity and specificity were 99.3% and 89.2% on a per episode basis and 99.8% (95% confidence interval: 97.8 to 100) and 91.6% (95% confidence interval: 86.0 to 97.3) on a per patient basis, respectively. Conclusion: In this selected population of patients, the PARAD algorithm was safe and reliable for detection of a wide spectrum of tachyarrhythmias. Its specificity was high, particularly with respect to sinus tachycardia detection, but it must be improved with respect to detection of atrial fibrillation.

The European Society of Cardiology has convened a Task Force on Sudden Cardiac Death in order to provide a comprehensive, educational document on this important topic. The main document has been published in the European Heart Journal in August 2001[1]. The Task Force has now summarized the most important clinical issues on sudden cardiac death and provided tables with recommendations for risk stratification and for prophylaxis of sudden cardiac death. The present recommendations are specifically intended to encourage the development and revision of national guidelines on prevention of sudden cardiac death. The common challenge for cardiologists, physicians of other medical specialties and health professionals throughout Europe is to realize the potential for sudden cardiac death prevention and to contribute to public health efforts to reduce its burden.

We present the case of a 45-year-old man with clinical features of acute coronary syndrome with persistent ST segment elevation following an anaphylactic reaction to a wasp sting treated with adrenaline. A thrombolysis is performed with no effect on clinical signs, leading to an emergency cardiac catheterization which reveals a non-occlusive thrombosis of the right coronary artery. The pathophysiology and clinical implications of this association are discussed.

Patients with hypertrophic cardiomyopathy (HCM) present unusual myocardial mechanics. The aim of this study was to assess the impact of hypertrophy on global and regional two-dimensional (2D) strain derived from both tomographic images (2D/2D) and volumetric image acquisition (2D/three-dimensional [3D]) in patients with HCM compared with control subjects.Comprehensive resting 2D and 3D echocardiography was performed in 40 patients with HCM and in 53 control subjects, with comparable distributions of age, gender, and left ventricular (LV) ejection fraction. LV global and segmental measurements of all 2D/2D and 2D/3D peak strain components (global and segmental longitudinal strain, global and segmental circumferential strain, global and segmental radial strain, and global and segmental area strain) and 3D indexed LV end-diastolic myocardial mass were obtained from all patients. LV wall thickness was assessed in short-axis views and classified in four quartiles (10.5, 10.5-13.0, 13.0-16.5, and16.5 mm).The reproducibility of 2D/3D strain was similar or greater and more consistent for all components compared with 2D/2D strain analysis. There was a significant correlation between 3D LV end-diastolic mass and all 2D/3D strain components (P .05). Two-dimensional/3D global circumferential strain had the strongest association with 3D LV ejection fraction (r = 0.50, P = .001). For segmental deformation, patients with HCM had lower longitudinal deformation whatever the LV wall thickness, whereas circumferential function was increased in nonhypertrophied and poorly hypertrophied segments compared with control subjects.Two-dimensional/3D strain is a reliable technique to assess myocardial deformation. Myocardial mass is related to 2D/3D strain components in patients with HCM. Circumferential deformation, compared with longitudinal deformation, seems to be the main component of the maintenance of systolic function in HCM.

Last year was the 20th anniversary of the first defibrillator implantation in a human being. Since then, the number of new defibrillator implants has gradually increased following an exponential curve. In 1998, nearly 50 000 new ICD implants were carried out worldwide. This tremendous increase was due to technological improvements in the device and the effectiveness of ICD therapy. Technological improvements in devices and leads included a gradual reduction in the size of the device, the introduction of the endocardial approach in 1988, the biphasic waveform and antitachycardia pacing in 1991, pectoral implantation in 1995, inclusion of DDD pacing in 1996 and finally, inclusion of DDDR and also atrial defibrillation in 1998. Efficacy assessment started with observational studies. In 1985, FDA approval for ICD implantation was obtained. Results of prospective randomized studies, which assessed the effectiveness of ICDs, were obtained in the late 1990s. The first reported trial was essentially an analysis of cost-effectiveness, which compared ICD implantation as first-choice therapy vs conventional strategy starting with antiarrhythmic drugs in postinfarct sudden death survivors. If drugs failed, the patient was treated with endocardial resection or a late defibrillator implant. The cost-effectiveness ratio, defined as costs per day of life, was significantly in favour of early ICD implantation. However, because the number of patients was relatively small, total mortality showed only a trend in favour of early ICD implantation.

Objectives Despite optimal pharmacological treatment a large proportion of patients with atrial fibrillation (Afib) are not arrhythmia-free, and remain at risk for complications such as stroke and cardiac morbidity. If first-line treatment fails, most patients receive second-line pharmacological treatment. The emergence of new technologies aimed at restoring and maintaining sinus rhythm, such as catheter ablation techniques, has increased the interest in the economic aspects of second-line pharmacological treatment. The objective was therefore to calculate the 5-year direct medical costs of second-line pharmacological management of paroxysmal and persistent Afib in France. Methods The analysis was based on clinical and economic literature and the input of cardiologists-electrophysiologists. The analysis included probabilities of stroke, sudden cardiac death, other cardiac and noncardiac death, direct medical costs of drugs, follow-up and complications from the healthcare payer's perspective. Included treatment strategies were (1) rhythm control with class Ic and III antiarrhythmics and (2) rate control, consisting of digoxin combined with a beta-blocker or calcium antagonist. Both strategies included aspirin or anticoagulation therapy. Results The average total 5-year cost of Afib was 16,539 Euro (FF 108,486) per patient. The result was stable to sensitivity analysis on incidence of stroke and type of stroke prevention. The main cost drivers were follow-up visits and hospitalizations and the cost of congestive heart failure. Both items being subject to some variation, they were submitted to sensitivity analysis showing minimal 5-year costs still over 14,483 Euro (FF 95,000). Conclusion Afib management places high demands on medical resources mainly through its complications and comorbidity.

Aims Atrioventricular synchronous pacing exerts beneficial effects, including reduction of left ventricular outflow tract gradients, in patients with hypertrophic obstructive cardiomyopathy. The Pacing in Cardiomyopathy study was initiated to explore the effects of pacing in a double-blind randomized crossover fashion. The aims were to ascertain the beneficial effects of pacing in a controlled study and to rule out a placebo effect by pacing. This paper deals with the outcome of pacing on quality of life during 1 year of follow-up. Methods Quality of life was evaluated with the Karolinska questionnaire, validated for patients paced for bradyarrhythmias and ischaemic heart disease. Drug-refractory patients with hypertrophic obstructive cardiomyopathy were recruited for the study and after a temporary pacing procedure implanted with permanent pacemakers. Patients were randomized to two study arms defining the sequence of pacemaker programming. In one arm the pacemaker was inactive, in the other active. After 3 months the pacemaker was reprogrammed to the alternate mode and a further 3 months followed. After this period subsequent pacemaker programming corresponded to the mode preferred by the patient. A last assessment was made 1 year after baseline examinations. Results Eighty patients completed the first crossover period and 75 completed the full 1 year of follow-up. Active pacing induced significant quality of life improvements, in the order of 9–44%, regardless of programming sequence. Discontinuation of pacing after a first active period resulted in the return of symptoms. Fourteen patients requested early reprogramming after having been programmed to inactive pacing after a first period of active pacing. Seventy-six patients preferred active pacing after the crossover period. A further 6 months of pacing induced progressive improvement in symptoms already favourably influenced. Conclusion Atrioventricular synchronous pacing has a profound beneficial effect on most domains of quality of life in patients with hypertrophic obstructive cardiomyopathy refractory to drug treatment.

1. In patients with dilated cardiomyopathy, abnormal myocardial blood flow may contribute to poor myocardial function. 2. The aim of this study was to investigate the possible contribution of abnormal myocardial blood flow to the limitation of exercise capacity in patients with dilated cardiomyopathy. 3. Coronary flow reserve was assessed in 16 patients with dilated cardiomyopathy and 9 matched normal control individuals. All participants had angiographically normal coronary arteries. At rest and after dipyridamole infusion (0.56 mg/kg intravenously), peak systolic and diastolic coronary flow velocities were measured in the proximal left anterior descending coronary artery using transoesophageal pulsed Doppler echocardiography, guided by colour flow imaging. Coronary flow reserve was calculated as the ratio of hyperaemic to basal diastolic and systolic peak coronary flow reserve. 4. Baseline diastolic and systolic coronary flow velocities were significantly higher in patients (50 ± 6 and 30 ± 4 cm/s respectively) compared with control individuals (37 ± 3 and 20 ± 1 cm/s respectively) (mean ± S.E.M.) (P < 0.05). Diastolic and systolic peak coronary flow reserve were significantly lower in patients (1.60 ± 0.14 and 1.40 ± 0.09 respectively) compared with control individuals (2.89 ± 0.15 and 2.17 ± 0.17 respectively) (P < 0.001). Although peak Vo2 and exercise time were significantly lower in patients compared with control individuals, coronary flow reserve did not correlate to exercise capacity in patients with dilated cardiomyopathy. 5. These results confirm the abnormalities of coronary flow reserve previously observed in patients with dilated cardiomyopathy, but suggest that such abnormalities do not contribute to the limitation of exercise capacity in these patients.

Slow pathway radiofrequency (RF) ablation currently is used to treat patients with atrioventricular nodal re-entrant tachycardia (AVNRT). The aim of study was to evaluate the factors explaining the recurrence of symptoms after AVNRT ablation. 881 patients 291 males, 590 females, mean age 52±18

The radial artery compliance may be paradoxically increased in untreated arterial hypertension. However, the effect of blood pressure normalization on the radial artery compliance is not well known. We performed a cross-sectional study in order to investigate the effects of blood pressure control on the radial artery diameter and compliance (echotracking and digital photoplethysmography) by comparing these variables in a group of untreated hypertensive patients and in another group of adequately treated hypertensive patients as well as in a group of healthy normotensive subjects. All groups were sex- and age-matched. Radial artery internal diameter was increased in both untreated hypertensive patients and effectively treated hypertensive patients comparatively to controls. Cross-sectional compliance and volumic distensibility were not different between groups. As compared to controls (2.85 +/- 0.39 x 10(-3) mm2 x mm Hg(-1) and 0.42 +/- 0.05 x 10(-3) mm Hg(-1)), isobaric (100 mm Hg) compliance and distensibility were significantly increased in untreated hypertensive patients (4.46 +/- 0.44 and 0.65 +/- 0.07, P < .01) but not significantly different in treated hypertensive patients (3.19 +/- 0.33 and 0.45 +/- 0.04, P = NS). The results of this cross-sectional study suggest that compliance abnormalities of the radial artery, but not internal diameter changes may be reversed by effective therapeutic control of blood pressure in arterial hypertension.

The objective of this study was to assess the effects ofradiofrequency energy application on implanted pacemaker functions.Radiofrequency (RF) catheter ablation may cause pacemaker dysfunction dueto electromagnetic interferences. The effects of RF on pacemaker behaviorwere studied in a series of 38 pacemakers, implanted 18 ± 26 monthsprior to a RF procedure using either a right ventricular approach (AV nodeablation, n = 35) or a left ventricular approach (left concealedaccessory pathway ablation, n = 1; VT ablation, n = 2). The38 patients (mean age 65 ± 9 years) included 20 men and 18 women.Before energy applications, the 23 different pacemaker models wereprogrammed to the VVI mode at the lowest available rate. The continuoussurface ECG was recorded throughout the procedure. Thorough testing of thedevices was performed before and after each RF delivery. Unusual pacemakerresponses occurred in 20 of the 38 cases studied (53%). The impactof RF delivery was unpredictable, and variable dysfunctions were observedat different times for a given patient or could vary for a given model.Unusual pacemaker responses included pacemaker inhibition (n = 8), untoggled backup mode (n = 3), electromagnetic interference noisemode (n = 3), temporary RF-induced pacemaker tachycardia (n =2), erratic behavior (n = 1), oversensing of RF onset and offset (n= 8), and transient loss of ventricular capture, (n = 1).Postablation, most devices automatically toggled back to fullfunctionality. The three devices in the untoggled backup mode had to bereprogrammed to obtain normal operations. At the end of the procedure,pacing thresholds remained unchanged in all but one patient, in whom theincrease in ventricular threshold was due to a nicked lead. In conclusion,implanted pacemakers frequently exhibit transient, unpredictable responsesto RF energy application. Although all pacemaker functions were restored postablation, some devices had to be reset manually. The anomalies observedduring the RF application argue for the simultaneous use of an externalpacemaker in pacing-dependent patients.

International audience; Introduction: Transcatheter Aortic valve implantation is a new challenging procedure for frail patient with several co-morbidities. In this case report, the patient developed a mitral valve endocarditis on a post-TAVI mitral valve injury. The level of aortic valve implantation and mitral valve interaction are discussed and may have provoked mitral lesions making the bed of endocarditis.Case report description: An 81-year-old man with symptomatic severe aortic stenosis was referred for transcatheter aortic valve implantation. Transthoracic Echocardiographic (TTE) assessment confirmed a low-flow low-gradient aortic stenosis, with a mean gradient a moderately impaired left ventricular function and no mitral regurgitation. A 26-mm SAPIEN valve was inserted through a right transfemoral approach. Final valve positioning was performed under rapid ventricular pacing. Post-implantation control was sub-optimal with no aortic regurgitation but the valve position was found to be slightly too high relative to the aortic annulus plane. Discharge TTE showed an optimal valve function with trivial posterior paravalvular regurgitation and mean transprothetic gradient of 8 mmHg. There was no mitral regurgitation. Two weeks later he presented a multi-bacterial infective endocarditis confirmed by 2D transesophageal echocardiography (TEE) with mitral valve injury and perforation of the anterior mitral valve leaflet caused by the ventricular edge of aortic valve stent. A TEE with real-time 3D assessment showed a perforation of the anterior mitral valve leaflet caused by the ventricular edge of aortic valve stent with a 5.7 x 3.5 mm vegetation on the left atrium side. There was a mild to moderate mitral regurgitation and the ventricular tip of the metal stent passed through the mitral valve at each systole. An ECG-gated cardiac Computed tomography confirmed the supra-valvular insertion of the prosthetic aortic valve relative to the annular ring and the sinuses of Valsalva. First line medical strategy was decided and surgical valve replacement was therefore not performed due to high mortality risk and lack of clinical benefit.Conclusion: This case highlights the need for intra and peri procedural multimodality imaging monitoring to ensure a good deployment and prevent mispositionning of the device. In our case, the high positioning of the prosthesis lead to mitral valve injury making the bed of infective endocarditis secondary to contemporary transient bacteremia.

International audience; BACKGROUND:Most postinfarct ventricular tachycardias (VTs) are sustained by a reentrant mechanism. The "protected isthmus" of the reentrant circuit is critical for the maintenance of VTs and the target for catheter ablation. Various techniques based on conventional electrophysiology and/or detailed three-dimensional (3D) reconstruction of the VT circuit are used to unmask this isthmus.OBJECTIVE:The purpose of this study was to assess pace-maps (PMs) to identify postinfarct VT isthmuses. We hypothesized that an abrupt change in paced QRS morphology may be used to identify a VT isthmus and be targeted for successful ablation.METHODS:High-density 3D PMs were matched to the subsequent 3D endocardial reentrant VT activation mapping in 10 patients (8 men; age 70.7 ± 10.8 years) who underwent successful postinfarct VT ablation. At each pacing site in a given patient, the 12-lead ECG recorded during pacing was compared to that of VT, with the resulting matching percentage (up to 100% for perfect matches) allocated to this point to generate color-coded PMs.RESULTS:With respect to VT isthmuses, the best percentages of matching were found in the exit zones and isthmus exit part (89% ± 8% and 84% ± 7%, respectively) and the poorest adjacent to scar border in the outer entrance zones (23% ± 28%), in the entrance zones (39% ± 34%), and in the entrance part of the isthmus (32% ± 26%). The color-coded sequence (from the best to the poorest matching sites) on the PMs revealed figure-of-eight pictures matching the VT activation time maps and identifying VT isthmuses.CONCLUSION:Pace-mapping is useful for unmasking VT isthmuses in patients with well-tolerated postinfarct endocardial reentrant VTs.

Background— The occurrence of ventricular tachycardia (VT) after myocardial infarction is associated with poorer prognosis. In such patients, implantable cardioverter-defibrillators are recommended. Catheter ablation of VT is currently recommended only as an adjunctive therapy. Whether a successful VT ablation alone might be a viable strategy in some of these patients, however, remains unknown. The aim of the present study was to evaluate this strategy. Methods and Results— Between January 2002 and December 2011, 189 patients with cardiomyopathy underwent 259 VT ablations in our center. Forty-five patients (mean age, 65.2±9.6 years; 91% men) with a history of myocardial infarction and mean left ventricular ejection fraction of 39.7±9.7% matched the study criteria and were included in this analysis. Acute success was obtained in 40 of 45 patients (88.9%). During a follow-up, on the basis of our stepwise algorithm (using acute success, repeat electrophysiological study, and recurrence of VT), 19 of 45 patients (42.2%) underwent implantable cardioverter-defibrillators implantation. During a median follow-up of 4.5 (interquartile range, 2.1–7.0) years, all-cause mortality occurred in 14 of 45 patients (31.1%). Using multivariate Cox regression analysis, age (hazard ratio, 1.13; 95% confidence interval, 1.03–1.22; P =0.007) was the only independent predictor of mortality, whereas implantable cardioverter-defibrillators implantation was not (hazard ratio, 0.54; 95% confidence interval, 0.18–1.64; P =0.28) Conclusions— Our results suggest that a stepwise approach to the management of VT with ablation as a first-line treatment in postinfarct patients presenting with VT might be a reasonable option. Further studies are required to confirm these results.

The viscoelastic, muscular and endothelial components of the vessel wall may be altered in patients with congestive heart failure (CHF). In order to investigate the relative contribution of each of these components to the peripheral vascular mechanisms of the disease, we have studied post-ischemic (endothelial-dependent) and post-nitroglycerin (endothelial-independent) vasodilatation as well as the response to cold pressure test and the geometry and compliance of the radial artery using a non-invasive echotracking method coupled to digital photoplethysmography. Thirty-nine patients with congestive heart failure (ejection fraction = 28 +/- 2%) were compared to age- and sex-matched healthy controls. Baseline therapy was unchanged during the study. In congestive heart failure patients, cross-sectional compliance and volumic distensibility were greater (P0.05) but isobaric compliance which is independent of blood pressure value was unchanged. Post-ischemic and post-nitroglycerin vasodilatation were lower (7 +/- 1 vs. 11 +/- 1%, P0.01 and 6 +/- 1 vs. 14 +/- 2%, P0.001, respectively) and both of the arterial diameter and pressure responses to cold pressor test were blunted (-5 +/- 1 vs. -8 +/- 1%, P = 0.058 and 6 +/- 3 mmHg vs. 13 +/- 2 mmHg, P0.01, respectively) in congestive heart failure. These changes were similar in primary and ischemic congestive heart failure, suggesting that they are more likely related to common neuro-hormonal factors rather than to an atherosclerotic process.

The history of pacing in hypertrophic obstructive cardiomyopathy (HOCM) begins in 1964 and ends in the early 1990s when several well-documented articles confirmed that pacing the apex of the right ventricle could be considered as an effective primary therapy of severe, drug resistant HOCM. The first pacemaker implantation was reported in a patient with HOCM who developed a complete AV block. The efficacy of right ventricular (RV) pacing on the gradient was enhanced, but the concept of pacing in the absence of conduction abnormalities was not suggested. In 1967, Hassenstein was the first to demonstrate that right apex ventricular pacing in HOCM with intact AV conduction induced gradient reduction. He subsequently performed the first hemodynamic implantation several years later. The largest series confirming the undoubted efficacy of pacing in HOCM were reported by Jeanrenaud in Switzerland and Fananapazir in the USA in the early 1990s.

Dual chamber pacing is a new indication for the treatment of drug resistant hypertrophic obstructive cardiontyopathy (HOCM) in patients with normal atrioventricular (AV) conduction. In sinus rhythm, the efficacy of the treatment is mainly related to the ability to bypass the normal AV conduction system in order to obtain a complete and permanent right ventricular (RV) capture. This is achieved by programming short AV delays. On the other hand, patients with HOCM frequently have co-existing left ventricular diastolic dysfunction, and the atrial contribution to left ventricular filling is critical. The lack of improvement, rarely encountered, is probably due to incomplete RV capture andlor to the deleterious effect of short AV delay. Instrumental AV node prolongation may he indicated in this situation. This procedure should be undertaken when previous drug-induced AV prolongation has failed. In theory, AV node modulation (i.e., creating a I ± AV block) seems ideal. However, this technique remains difficult, with disappointing chronic results. Most authors hence perform “conventional” AV node ablation. Particular attention is taken in order to perform a proximal node ablation, resulting in a complete AV block with narrow QRS escape rhythm. The reported incidence of AV node prolongation ranges from 7.5%-37.5%. The efficacy of the procedure on symptoms is explained by improved left ventricular filling and/or a further reduction in the systolic gradient evoked by complete RV capture. Another indication for AV node ablation in HOCM is the occurrence of atrial fibrillation, in order to restore adequate and permanent RV capture.

Objectives. This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both. Background. In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients. Methods. We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [±SD] 6.7 ± 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade ≥ 2. Four cardiovascular risk factors—smoking, hypertension, hypercholesterolemin and diabetes mellitus—and eight different variables—age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography—were recorded in all patients. Results. Thrombolysis in current smokers and anterior infarct location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infarct vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location. Conclusions. These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas non-smokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty.