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Aims Limited data exist on the efficacy of catheter ablation (CA) for sport-related atrial fibrillation (AF). Impact of sports practice resumption post-CA remains unknown. We aimed to determine AF CA efficacy in athletes vs. non-athletes, and to assess the impact of sport practice resumption. Methods and results From 1153 first-time AF CA performed between 2009 and 2017, 73 athletes were matched with 73 sedentary patients based on age, sex, and closest CA procedure date. Athletes were defined as performing ≥6 h/week of vigorous sports to achieve ≥2000 h accumulated lifetime sports activity. They were mostly males (93.2%) with a mean age of 55 ± 9.8 years. Before CA, athletes practiced 10.2 ± 3.9 h/week of vigorous exercise vs. 4.6 ± 3.4 after CA. Within first year after CA, physical activity was stopped in 12 (16.4%) athletes, lowered in 45 (61.9%), and resumed at same intensity in 16 (21.9%). Athletes and non-athletes suffered from same AF recurrence rates during 5-year follow-up after CA: 38 (52.0%) vs. 35 (47.9%), respectively [adjusted hazard ratio (HR) on age, body mass index (BMI), obstructive sleep apnoea (OSA), and reduced left ventricular ejection fraction (LVEF), 1.17 (0.70–1.97, P = 0.54)]. No significant impact of physical activity resumption status was found regarding AF recurrence rates at 1-year and beyond (P = 0.60). Procedure effectiveness was significantly lower in athletes with non-paroxysmal AF [adjusted on age, BMI, reduced LVEF, and OSA HR 2.36 (confidence interval 1.19–4.70), P = 0.01]. Conclusion Sports practice before and after CA has no significant impact on AF recurrence rates in athletes within 5-year after AF CA.

The field of cardiac electrophysiology has greatly developed during the past decades. Consequently, the use of electrophysiological studies (EPSs) in clinical practice has also significantly augmented, with a progressively increasing number of certified electrophysiology centers and specialists. Since Zipes et al published the Guidelines for Clinical Intracardiac Electrophysiology and Catheter Ablation Procedures in 1995, no official document summarizing current EPS indications has been published.The current paper focuses on summarizing all relevant data of the role of EPS in patients with different types of cardiac pathologies and provides up-to-date recommendations on this topic.For this purpose, the PubMed database was screened for relevant articles in English up to December 2018 and ESC and ACC/AHA Clinical Practice Guidelines, and EHRA/HRS/APHRS position statements related to the current topic were analyzed.Current recommendations for the use of EPS in clinical practice are discussed and presented in 17 distinct cardiac pathologies. A short rationale, evidence, and indications are provided for each cardiac disease/group of diseases.In conclusion, because of its capability to establish a diagnosis in patients with a variety of cardiac pathologies, the EPS remains a useful tool in the evaluation of patients with cardiac arrhythmias and conduction disorders and is capable of establishing indications for cardiac device implantation and guide catheter ablation procedures. Keywords: Electrophysiological study, Indications, Arrhythmias

Summary Background Reversion of an implantable cardioverter defibrillator (ICD) to back-up mode degrades the operating capabilities of the device, puts patients at risk and requires rapid intervention by a manufacturer's technician. Aim To illustrate the usefulness of remote monitoring of ICDs for the early detection of reversion to back-up mode. Methods In our centre, all patients implanted with an ICD, with or without resynchronisation, were offered remote monitoring as soon as the technology became available. Alerts triggered by the remote monitoring system were included prospectively in a register. During a mean follow-up of 5.7 ± 1.3 years, a total of 1594 patients with an ICD (441 with resynchronisation function) followed with remote monitoring were included in the register. Results Among 15,874 alerts, only 10 were related to a reversion to back-up mode. Among those, seven reversions were caused by radiotherapy, two were fake events and one was caused by magnetic resonance imaging. Except for the two fake events, the eight other patients had an emergency admission for the resetting and reprogramming of their ICD. None of the reversion to back-up mode alerts was followed by a clinical alert (i.e. a shock alert) before the ICD problem was resolved. Conclusions Reversion to back-up mode is a very rare event, accounting for 0.06% of total alerts; remote monitoring facilitates the early detection of this critical event to resolve the problem faster than the next scheduled follow-up. Remote monitoring can prevent serious damage to the patient and avoids systematic ambulatory control of the ICD after each radiotherapy session.

To evaluate whether the epicardial adipose tissue (EAT) phenotype is associated with the electrophysiological properties of adjacent atrial myocardium in patients with atrial fibrillation (AF). Between January and May 2017, 30 consecutive patients referred for a first AF catheter ablation were prospectively included. For each patient, a pre-procedural computed tomography scan was performed to assess total and left atrial (LA) EAT amount and radiodensity. A detailed point-by-point voltage mapping using an electroanatomic mapping system was realized to assess the presence of LA low-voltage zone (LVZ). Ten patients (33.3%) presented at least one LVZ. Older age (65 ± 7 vs. 58 ± 10 years, p = 0.05) was the only clinical parameter associated with LVZ. Despite no greater LA-EAT thickness by CT scan (3.0 [2.6–3.5] mm vs. 2.8 [2.2–3.1] mm, p = 0.354), patients with LA-LVZ presented significantly lower LA-EAT radiodensity than patients with no LA-LVZ (− 101.8 ± 12.5 HU vs. − 90.4 ± 6.3 HU, p = 0.004). No difference between total-EAT volume (131 ± 61 cm3 vs.107 ± 58 cm3, p = 0.361) and total-EAT radiodensity (− 106.8 ± 4.3 HU vs. − 102.4 ± 6.9 HU, p = 0.119) was found. Low LA-EAT radiodensity is associated with the presence of LVZ in patients with medical history of AF. • Cardiovascular risk factors are associated with low adipose tissue computed tomography attenuation. • Epicardial adipose tissue (EAT) has emerged as an important factor in the pathogenesis of metabolic-related cardiac diseases such as atrial fibrillation. • We showed that low left atrial EAT attenuation is associated with the presence of low-voltage zone, a surrogate for atrial fibrosis, within the adjacent myocardium.

Both genetic and environmental factors interact to control left ventricular (LV) remodeling in the context of aortic stenosis (AS). Epicardial adipose tissue (EAT) is a specific visceral adipose tissue with paracrine properties in close contact with the myocardium. We sought to assess determinants of EAT amount and its association with the magnitude and pattern of LV remodeling in patients suffering from severe AS. Between January 2014 and September 2017, we prospectively explored consecutive patients referred to our Heart Valve Center for SAVR presenting with severe AS and normal left ventricular ejection fraction (> 50%). Comprehensive transthoracic echocardiography (TTE) including assessment of LV remodeling and EAT amount were performed. 202 patients were included. EAT was significantly larger in elderly, diabetic and obese patients. EAT thickness was correlated positively with indexed LV mass in AS (r2 = 0.21; p

Summary Background On-pump cardiac surgery provokes a predictable perioperative myocardial ischaemia–reperfusion injury which is associated with poor clinical outcomes. We determined the occurrence of time-of-the-day variation in perioperative myocardial injury in patients undergoing aortic valve replacement and its molecular mechanisms. Methods We studied the incidence of major adverse cardiac events in a prospective observational single-centre cohort study of patients with severe aortic stenosis and preserved left ventricular ejection fraction (>50%) who were referred to our cardiovascular surgery department at Lille University Hospital (Lille, France) for aortic valve replacement and underwent surgery in the morning or afternoon. Patients were matched into pairs by propensity score. We also did a randomised study, in which we evaluated perioperative myocardial injury and myocardial samples of patients randomly assigned (1:1) via permuted block randomisation (block size of eight) to undergo isolated aortic valve replacement surgery either in the morning or afternoon. We also evaluated human and rodent myocardium in ex-vivo hypoxia–reoxygenation models and did a transcriptomic analysis in myocardial samples from the randomised patients to identify the signalling pathway(s) involved. The primary objective of the study was to assess whether myocardial tolerance of ischaemia–reperfusion differed depending on the timing of aortic valve replacement surgery (morning vs afternoon), as measured by the occurrence of major adverse cardiovascular events (cardiovascular death, myocardial infarction, and admission to hospital for acute heart failure). The randomised study is registered with ClinicalTrials.gov, number NCT02812901. Findings In the cohort study (n=596 patients in matched pairs who underwent either morning surgery [n=298] or afternoon surgery [n=298]), during the 500 days following aortic valve replacement, the incidence of major adverse cardiac events was lower in the afternoon surgery group than in the morning group: hazard ratio 0·50 (95% CI 0·32–0·77; p=0·0021). In the randomised study, 88 patients were randomly assigned to undergo surgery in the morning (n=44) or afternoon (n=44); perioperative myocardial injury assessed with the geometric mean of perioperative cardiac troponin T release was significantly lower in the afternoon group than in the morning group (estimated ratio of geometric means for afternoon to morning of 0·79 [95% CI 0·68–0·93; p=0·0045]). Ex-vivo analysis of human myocardium revealed an intrinsic morning–afternoon variation in hypoxia–reoxygenation tolerance, concomitant with transcriptional alterations in circadian gene expression with the nuclear receptor Rev-Erbα being highest in the morning. In a mouse Langendorff model of hypoxia–reoxygenation myocardial injury, Rev-Erb α gene deletion or antagonist treatment reduced injury at the time of sleep-to-wake transition, through an increase in the expression of the ischaemia–reperfusion injury modulator CDKN1a/p21. Interpretation Perioperative myocardial injury is transcriptionally orchestrated by the circadian clock in patients undergoing aortic valve replacement, and Rev-Erbα antagonism seems to be a pharmacological strategy for cardioprotection. Afternoon surgery might provide perioperative myocardial protection and lead to improved patient outcomes compared with morning surgery. Funding Fondation de France, Federation Francaise de Cardiologie, EU-FP7-Eurhythdia, Agence Nationale pour la Recherche ANR-10-LABX-46, and CPER-Centre Transdisciplinaire de Recherche sur la Longevite.

Introduction Several clinical studies have demonstrated that remote monitoring (RM) offers potential benefits in transvenous implantable cardioverter defibrillator (ICD). The potential interest of RM in subcutaneous-ICD (S-ICD) recipients has never been evaluated. The aim of this study was to evaluate the alert burden and its clinical relevance in a prospective cohort of S-ICD recipients. Methods We prospectively and consecutively enrolled all patients undergoing S-ICD implantation at Lille University Hospital from September 2015 to January 2017 and gave them a LATITUDE™ NXT RM system. The relevance of transmissions was assessed by the following ratio: number of transmissions leading to reaction or intervention per patient/number of transmissions per patient. Results From September 2015 to January 2017, 69 patients were enrolled with a mean follow-up of 415 ± 96.3 days. The mean age was 44.6 ± 15.6 years old, and 25% (n = 17) had ischemic cardiomyopathy. At the end of follow-up, 12% of the patients had events recorded by RM. These events were related to nine ICD shocks and eight untreated events. A total of 1,423 transmissions were collected. Most of these transmissions were patient-initiated without any event (77%, n = 1,096) or scheduled without any event (19%, n = 272). Only 3.2% ± 1.1 of the transmissions per patient led to reactions or interventions. Conclusion On the basis of the current method of transmitting, S-ICD RM allowed detection of relevant events in 12% of patients but generated a high unactionable transmission burden. As a result of these findings, efforts should be made to optimize transmissions considering automatic transmissions and to focus on patient education.

The definition of prosthesis–patient mismatch (PPM) remains to be refined to enhance its prognosis insight after surgical aortic valve replacement (SAVR) for severe aortic stenosis, especially in obese patients [(1)][1]. We aimed at investigating the respective prevalence and prognostic value of

Little is known about atrial arrhythmias in arrhythmogenic right ventricular cardiomyopathy (ARVC). A 46-year-old man with definite ARVC presented with palpitations and exertional dyspnoea. Electrocardiogram showed a supraventricular tachycardia. Despite no prior cardiac surgery or atrial fibrillation ablation, electrophysiological study revealed a left atrial (LA) re-entrant circuit characterized by a slow fractionated potential bounded by two areas of double potentials giving a figure-of-eight pattern on activation map. Located on the LA roof within a zone of low bipolar voltages, this unusual substrate can be associated with a primitive atrial myopathy in ARVC.

Changes in parameters of longitudinal systolic function after cardiac surgery (i.e., tricuspid annular plane systolic excursion [TAPSE] and peak systolic velocity [PSV] of tricuspid annulus obtained by M-mode or Doppler tissue imaging) have been described for many years, with almost no data on their

Background The definition of prosthesis-patient mismatch (PPM) remains to be refined to enhance its prognosis insight after SAVR, especially in obese patients. Purpose To test the prognostic impact of effective and predicted prosthetic orifice area (OA) according to body weight status after surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). Methods Between 2009 and 2016, we prospectively explored all consecutive patients referred to our Heart Valve Clinic for a first SAVR for severe AS. Indexed OA predicted from reference normal value (iPOA) and calculated by transthoracic echocardiography (iEOA) were assessed at discharge. Patients were followed for major events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. Results 762 patients were included with a mean follow-up of 4 ± 2.5 years. Severe PPM was more frequently observed with iEOA than iPOA (20.5% vs. 7%, P Conclusion iEOA with the unique cut-off of 0.85 cm2/m2 showed the best accuracy to predict ME after SAVR in lean and overweight but not in obese patients. Further studies are needed to explore the lack of prognostic insight of PPM in obese patients.