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Background Radiofrequency (RF) ablation of slow pathway (SP) is usually performed in sinus rhythm while monitoring the occurrence of a slow junctional rhythm (JR). JR although sensitive, is not specific for elimination of SP conduction. Our objective was to prospectively evaluate feasibility and safety of SP elimination using fast atrial rate pacing (FAP) during RF delivery. Methods Consecutive patients admitted for atrioventricular nodal re-rentrant tachycardia (AVNRT) ablation were included. The rate of proximal coronary sinus (CS) pacing was set to a value constantly yielding antegrade SP conduction, while carefully monitoring the AH interval. RF delivery (at the lower part of Koch's triangle) was considered successful if the AH shortened ≥ 14 ms or if transition from Wenckebach (WK) periods to a 1:1 conduction occurred. Results 24 patients were included (54 ± 20 y). Typical AVNRT was induced in all (cycle length 349 ± 83 ms). RF delivery during CS pacing (335 ± 73 ms) led to AH shortening by 51 ± 25 ms in 13 patients. In 10 patients, a transition from 3:2 or 4:3 WK periods to 1:1 conduction occurred during the successful pulse. In one patient, atrial fibrillation was systematically induced during FAP, requiring conventional ablation. Non-inducibility, and SP conduction disappearance was obtained in all patients. No patient developed AV block. After a follow-up of 12 ± 3 months, no recurrences were observed. Conclusion SP ablation using FAP during RF delivery allows direct visualisation of its disappearance. In our cohort of patients, this technique was feasible without safety compromise.

Background Electrical cardioversion is the first-line rhythm control therapy for symptomatic persistent atrial fibrillation (AF). Contemporary use of biphasic shock waveforms and anterior-posterior positioning of defibrillation electrodes have improved cardioversion efficacy; however, it remains unsuccessful in >10% of patients. Objective The purpose of this study was to assess the efficacy of applying active compression on defibrillation electrodes during AF cardioversion. Methods We performed a bicenter randomized study including patients referred for persistent AF cardioversion. Elective external cardioversion was performed by a standardized step-up protocol with increasing biphasic shock energy (50–100–150–200 J). Patients were randomly assigned to standard anterior-posterior defibrillation or to defibrillation with active compression applied over the anterior electrode. If sinus rhythm was not achieved at 200 J, a single crossover shock (200 J) was applied. Defibrillation threshold, total delivered energy, number of shocks, and success rate were compared between groups. Results We included 100 patients, 50 in each group. In the active compression group, defibrillation threshold was lower (103.1 ± 49.9 J vs 130.4 ± 47.7 J; P = .008), as well as total delivered energy (203 ± 173.3 J vs 309 ± 213.5 J; P = .0076) and number of shocks (2.2 ± 1.1 vs 2.9 ± 1.2; P = .0033), and cardioversion was more often successful (48 of 50 patients [96%] vs 42 of 50 patients [84%]; P = .0455) than that in the standard anterior-posterior group. Crossover from the compression group to the standard group was not successful (0 of 2 patients), whereas crossover from the standard group to the compression group was successful in 50% of patients (4 of 8). Conclusion Active compression applied to the anterior defibrillation electrode is more effective for persistent AF cardioversion than standard anterior-posterior cardioversion, with lower defibrillation threshold and higher success rate.

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee. Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; P =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19–10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 ( P =0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96–40.95]). Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03837574.

Background: Ultrasound-guided axillary venous puncture (UGAVP) for cardiac devices implantation has been developed because of its rapidity, safety and potential long-term lead protection. Early work excluded defibrillators (ICD), cardiac resynchronization therapy (CRT) and upgrade procedures. Compared to the cephalic approach, in previous studies, there was a greater use of pressure dressings with this technique, suggesting a higher risk of bleeding. Aims: To assess UGAVP in patients under antithrombotic therapy (ATT) undergoing cardiac devices implantation including CRT/ICD. Methods: Prospectively, consecutive patients eligible for a pacemaker or ICD implantation were included. All procedures were performed by a single operator, experienced with UGAVP for femoral access, and fluoroscopy-guided axillary vein access. Guidewires insertion time (from lidocaïne administration), and complications were systematically studied. Results: From 457 cardiac device implantations, 200 patients (77.8 ± 10 y, male 58%) 360 leads were implanted by UGAVP including 36 ICD, 54 CRT and 14 upgrade procedures. A majority (90%) was under ATT: Vitamin K Antagonist or Heparin (n = 58, 29%), direct oral anticoagulant (n = 46, 23%), dual antithrombotic therapy (n = 18, 9%) and single antiplatelet drug (n = 82, 41%). UGAVP was successful in 95.78%. Mean insertion time for 1.8 guidewires per patient was 4.68 ± 3.6 min. No complication (no hematoma) was observed during the follow-up (mean of 45 ± 10 months). Guidewires insertion time reached its plateau after 15 patients. Conclusion: UGAVP is fast, feasible and safe for patients under ATT undergoing device implantation including CRT/ICD and upgrade procedures, with a short learning curve. Keywords: Cardiac devices implantation, Vascular complications, Ultrasound guidance, Antithrombotic therapy

Introduction Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Objective We aimed to describe long-term follow-up of TOF patients implanted with ICD through a nationwide French registry. Methods Nationwide French Registry including all TOF patients with an ICD initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event endpoint was the time from ICD implantation to first appropriate ICD therapy. Clinical events were centrally adjudicated by a blinded committee. Results A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (IQR) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least one appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively, P = 0.03). Overall, 71 (43.0%) patients presented with at least one ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) primary prevention patients, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with respectively no, one, two, or ≥ three guideline-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (HR 3.47, 95% CI 1.19–10.11), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 (P = 0.006) ( Fig. 1 ). Conclusions Patients with TOF and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification.

BACKGROUND Remote magnetic navigation (RMN) and contact force (CF) sensing catheters are available technologies for radiofrequency (RF) catheter ablation of atrial fibrillation (AF). Our purpose was to compare time to electrogram (EGM) modification suggesting transmural lesions between RMN and CF-guided AF ablation. METHODS AND RESULTS A total of 1,008 RF applications were analyzed in 21 patients undergoing RMN (n = 11) or CF-guided ablation (n = 10) for paroxysmal AF. All procedures were performed in sinus rhythm during general anesthesia. Time to EGM modification was measured until transmurality criteria were fulfilled: (1) complete disappearance of R if initial QR morphology; (2) diminution > 75% of R if initial QRS morphology; (3) complete disappearance of R' of initial RSR' morphology. Impedance drop as well as force time integral (FTI) were also assessed for each application. Mean CF at the beginning of each RF application in the CF group was 11 ± 2 g and mean FTI per application was 488 ± 163 gs. Time to EGM modification was significantly shorter in the RMN group (4.52 ± 0.1 seconds vs. 5.6 ± 0.09 seconds; P < 0.00001). There was no significant difference between other procedural parameters. CONCLUSION Remote magnetic AF ablation is associated with faster EGM modification suggesting transmurality than optimized CF and FTI-guided catheter ablation.

Background The electrocardiogram (ECG) is widely available and may contribute to a better risk stratification for sudden cardiac death in tetralogy of Fallot. Purpose To identify ECG predictors of appropriate therapies in patients with tetralogy of Fallot and implantable cardioverter defibrillator (ICD). Methods The DAI-T4F study is an ongoing national French registry including all patients with tetralogy of Fallot and ICD ( NCT03837574 ). Information have been collected prospectively since 2010. Cox proportional hazard models were used to identify factors associated with appropriate ICD therapies. Results A total of 134 patients (median age 41.7 years, 70.7% males) were enrolled. During a median (IQR) follow-up of 6.1 (2.7–10.2) years, 59 (44.0%) patients received at least one appropriate ICD therapy, giving annual incidence of 5.5% and 7.1% in primary and secondary prevention, respectively (P = 0.058). Overall, QRSd ≥ 180ms (P = 0.073), QRS fragmentation (P = 0.052), and QRS vector magnitude (vm, P = 0.327) were not significantly associated with appropriate ICD therapies, whereas the association of QRSd ≥ 180ms and QRS fragmentation (HR = 1.9, 95% CI: 1.1–3.4, P = 0.036) were associated with an increased risk of appropriates ICD therapies. In patients with ICD for primary prevention (47 patients, 35.1%), while non-sustained ventricular tachycardia (NSVT) considered isolated was not associated with events during follow-up (P = 0.069), combinations with QRSd ≥ 180 ms (HR = 7.2, 95% CI: 1.6–32.7, P = 0.011), QRS fragmentation (HR = 3.8, 95% CI: 1.2–12.4, P = 0.025), or decreased QRS vm (HR = 3.6, 95% CI: 1.1–12.1, P = 0.042) were all associated with a higher incidence of appropriate ICD therapies. Conclusions Our findings highlight that cumulative risk score derived from ECG may contribute to improve risk stratification in patients with tetralogy of Fallot, in particular QRS fragmentation and QRS vm in association with QRS duration and other traditional risk factors.

BACKGROUND Whether cavotricuspid isthmus (CTI) is a region of conduction slowing during typical flutter has been discussed with conflicting results in the literature. We aimed to evaluate conduction velocity (CV) along the different portions of the typical flutter circuit with a recently proposed method by means of ultra-high-resolution (UHR) mapping. METHODS Consecutive patients referred for typical atrial flutter (AFL) ablation underwent UHR mapping (Rhythmia, Boston Scientific). CVs were measured in the CTI as well as laterally and septally, respectively, from its lateral and septal borders. RESULTS A total of 33 patients (mean age: 65 ± 13 years; right atrial volume: 134 ± 57 mL) were mapped either during ongoing counterclockwise (n = 25), or clockwise (n = 3) AFL (mean cycle length: 264 ± 38 ms), or during coronary sinus pacing at 400 ms (n = 1), 500 ms (n = 1), or 600 ms (n = 3). A total of 13 671 ± 7264 electrograms were acquired in 14 ± 9 min. CTI CV was significantly lower (0.56 ± 0.18 m/s) in comparison with the lateral CV (1.31 ± 0.29 m/s; P

Background Combination of elementary parameters (force, time, power, impedance drop) has been proposed to optimize radiofrequency (RF) delivery. They have been partially validated in clinical studies. Aims The aim of this study was to assess contact-force (CF) implementation into clinical practice. Methods A 36-question electronic form was sent to 105 electrophysiologists (EP) including some general questions concerning the practice of catheter atrial fibrillation ablation and items concerning the parameters used for CF-guided ablation. Results Answers from 98 EP were collected (93% response rate). The CF-catheters used were Smart Touch, Biosense (52%), Tacticath, Saint-Jude Medical (12%), or both (27%) and no CF (9%). The power applied on the left atrial (LA) anterior (LAAW) and posterior (LAPW) wall was, respectively, 26-34 W (for 73% of the EP) and below 25 W (88% of the EP). Forty percent of the Visitag® users mostly used the nominal parameters. Seventy-five percent of the users did not use automatic display of the impedance drop. For the Tacticath users, 57% used a target value of 400 gs on the LAAW and 300 to 400 gs on the LAPW. Lesion Size Index was exceptionally used. Conclusions The parameters used for CF-guided ablation are widely variable among the different operators. Further prospective studies are needed to validate the targets for automatic annotation of the RF applications.

Aims The success of mitral isthmus (MI) ablation has been related to CT scan defined MI anatomy. We sought to correlate electroanatomical MI characteristics with MI ablation success in patients with perimitral flutter (PMF). Methods and results In 53 consecutive patients (46 males, 61 ± 10 years) with PMF, MI was ablated with endocardial ± coronary sinus (CS) linear radiofrequency (RF) ablation lesion. Acute (termination of PMF during ablation) and long-term procedural success were studied. Mitral isthmus characteristics (thickness—minimal endocardial to CS distance, length, maximal MI bipolar voltage), as well as MI ablation line length and width, RF duration, and delivered energy were analysed. In 43 of the 53 patients (81%), acute success was observed. This was more frequently achieved in patients with thinner MI (2.4 ± 3.1 vs. 7 ± 3.2 mm; P = 0.0009). Mitral isthmus thickness predicted ablation failure with a ROC area of 0.84. The best threshold to predict MI ablation failure was 8.3 mm with a sensitivity of 67% and a specificity of 97%. Left atrial size was of greater importance in failed cases (2D echo surface: 24.1 ± 2.5 vs. 32.5 ± 6.9 cm2, P = 0.005; electroanatomic volume: 124 ± 32 vs. 165 ± 23 mL, P = 0.02). None of the other electroanatomical characteristics were associated with outcome. After a mean follow-up of 28 ± 15 months, 21 patients (39%) had atrial fibrillation (AF) or atypical flutter (PMF recurrence in four). Conclusion Smaller MI thickness is associated with acute success in PMF ablation. Mitral isthmus electroanatomical characteristics might be used for decision-making on strategy during persistent AF ablation and for selecting the best location for interrupting PMF.

A 12 year-old boy, with no history of cardiac disease, was referred to our department for evaluation of an incessant accelerated idioventricular rhythm (AIVR) complicated with severe left ventricular (LV) dysfunction and cardiogenic shock. Extensive diagnostic work-up failed to reveal any structural heart disease. During electrophysiological study, AIVR originated from the right ventricular endocardial anterior wall and was successfully ablated using remote magnetic navigation. LV function showed complete recovery four weeks after the procedure. This case highlights a life-threatening evolution of an arrhythmia generally presented as a benign entity in children.

Successful catheter ablation of scar-related atrial tachycardia depends on correct identification of the critical isthmus. Often, this is a represented by a small bundle of viable conducting tissue within a low-voltage area. It's identification depends on the magnitude of the signal/noise ratio. Ultra-high density mapping, multipolar catheters with small (eventually unidirectional) and closely-spaced electrodes improves low-voltage electrogram detection. Background noise limitation is also of major importance for improving the signal/noise ratio. Electrophysiological properties of the critical isthmus and the characteristics of the local bipolar electrograms have been recently demonstrated as hallmarks of successful ablation sites in the setting of scar-related atrial tachycardia., SCOPUS: re.j, info:eu-repo/semantics/published

Renal insufficiency (RI) is frequent in patients eligible for cardiac resynchronization therapy (CRT) and may be worsened by the use of contrast agents. We sought to determine the feasibility of CRT implantation without contrast injection in patients with contraindication to iodine.Patients eligible for CRT and presenting with RI were prospectively included (non-contrast NC group). A contemporary control group (CG) of CRT patients with contrast injection was used for comparison. An over-the-wire coronary sinus (CS) lead with an angled distal tip was selected for this "blind harpooning" technique.Seventeen patients in the NC group were included (78 ± 7 years). Serum creatinine was 208 ± 86 μmol/L (glomerular filtration rate 33 ± 15 mL/min/1.73 m(2)). CG included 25 patients (70 ± 7 years, serum creatinine 85 ± 21 μmol/L). CRT implantation was successful in 16/17 patients (94.1 %) without contrast injection. The mean procedure and fluoroscopy times were similar in the two groups: 146 ± 29 in the NC group versus 153 ± 25 min (p = 0.57) and 25 ± 12 in the NC group versus 23 ± 16 min (p = 0.7) respectively. The mean CS lead implantation time was 36 ± 19 (NC group) versus 39 ± 15 min (p = 0.64). No major procedure-related complications were observed in both groups.CRT implantation is feasible in the majority of the cases (94.1 %) without contrast injection and without lengthening the procedure time in patients with RI.

Aims The magnetic navigation (MN) system may be coupled with a new advancement system that fully controls both the catheter and a robotic deflectable sheath (RSh) or with a fixed-curve sheath and a catheter-only advancement system (CAS). We aimed to compare these approaches for atrial fibrillation (AF) ablation. Methods and results Atrial fibrillation ablation patients (45, 23 paroxysmal and 22 persistent) performed with MN–RSh (RSh group) were compared with a control group (37, 18 paroxysmal and19 persistent) performed with MN–CAS (CAS group). Setup duration was measured from the procedure's start to operator transfer to control room. Ablation step duration was defined as the time from the beginning of the first radiofrequency (RF) pulse to the end of the last one and was separately acquired for the left and the right pulmonary vein (PV) pairs. Clinical characteristics, left atrial size, and AF-type distribution were similar between the groups. Setup duration as well as mapping times was also similar. Ablation step duration for the left PVs was similar, but was shorter for the right PVs in RSh group (46 ± 9 vs. 63 ± 12 min, P < 0.0001). Radiofrequency delivery time (34 ± 9 vs. 40 ± 11 min, P = 0.007) and procedure duration (227 ± 36 vs. 254 ± 62 min, P = 0.01) were shorter in RSh group. No complication occurred in RSh group. During follow-up, there were five recurrences (11%) in RSh group and 11 (29%) in CAS group ( P = 0.027). Conclusion The use of the RSh for AF ablation with MN is safe and improves outcome. Right PV isolation is faster, RF delivery time and procedure time are reduced.

Background Remote magnetic navigation is an emerging technology for atrial fibrillation (AF) ablation. General anesthesia (GA) has shown to be superior to local anesthesia (LA) for manual AF ablation in terms of catheter stability and lesion formation. We aimed at comparing GA with LA for remote magnetic AF ablation procedures. Methods All patients eligible for a remote magnetic ablation of AF were included in this study. Ninety patients (70% of the patients were male; age: 60 ± 10 years; CHA2DS2-VASC: 1.6 ± 1.2; paroxysmal AF: 60%, persistent AF: 40%), including 45 patients with GA, and 45 patients with LA were enrolled consecutively. Results There was no significant difference in total procedure time between the two groups (237 ± 50 minutes in the GA group vs 240 ± 61 minutes in the LA group; P = 0.84). Fluoroscopy time was significantly increased in the GA group (14.6 ± 6 minutes vs 11.6 ± 6 minutes, P = 0.018). Ablation time was not different between the two groups (2,320 ± 984 seconds in the GA group vs 2,055 ± 1,023 seconds in the LA group; P = 0.25). After a mean follow-up of 1 year (including repeat procedures), 39/45 patients (86.6%) within the GA group were free from recurrences versus 40/45 patients (88.8%) in the LA group (P = 0.74) without antiarrhythmic drugs. Conclusion For remote magnetic AF ablation, procedures under LA have similar results to GA in terms of efficacy and safety after 1-year follow-up.

During radiofrequency (RF) delivery, lesion volume is highly dependent on contact force (CF). It has recently been shown that changes of bipolar electrogram (EGM) predict transmurality. We hypothesized that there is a correlation between CF and EGM criteria of transmural lesion (TL) during RF.We prospectively studied consecutive 512 RF applications from atrial fibrillation ablation procedures. A force-sensing ablation catheter (Tacticath(®), Endosense) was used to continuously measure CF and force-time integral (FTI) during each RF application. Distal bipolar EGM was analysed before, during, and after each RF application. Depending on initial EGM morphology, transmurality of lesions was defined by: (i) disappearance of the positivity after RF when there was QR morphology, (ii) diminution75% of the positivity when there was QRS morphology, or (iii) disappearance of the R' positivity when there was RSR' morphology. Electrogram criteria were validated by electrophysiologists blinded to force measurements. Force-time integral was higher in TL than in non-transmural lesions (NTLs): 652 ± 248 vs. 212 ± 140 gs (P0.001). Mean CF per RF pulse was higher in TL than in NTL: 26.3 ± 12.5 vs. 11.3 ± 10.3 g (P0.001). The best cut-off to predict TL was an FTI ≥ 392 gs [sensitivity 0.89, specificity (Sp) 0.93, positive predictive value (PPV) 0.98, and negative predictive value 0.67] and a higher FTI (700 gs) warrants transmurality of RF atrial lesions (100% Sp and PPV).Contact force and FTI during RF are correlated with TL. During RF delivery, a target FTI392 gs can be used as an endpoint.

Since more than a half century, cardiac pacing and defibrillation represent a field in constant evolution, and they have shown some great technological advances from its conception to its methods of insertion. In this review, the recent developments about the accesses for pacemakers and ICD will be described: the axillary and the femoral vein. The His bundle pacing and the advantages of the entirely subcutaneous defibrillator will also be presented.

Background Pulmonary veins isolation (PVI) may be an appropriate ablation strategy for persistent atrial fibrillation (peAF) treatment. We aimed to evaluate in a peAF population 1 year-outcome and safety of a new PVI approach based on delivery of deep and closely-spaced radiofrequency (RF) lesions. Methods Outpatient pharmacological or electrical cardioversion (ECV) was intended prior to ablation in 53 peAF patients (pts). On the day of ablation, 30 peAF pts who were either in sinus rhythm (SR) or exhibited typical atrial flutter (AFL) were included in this prospective study. Ablation index (AI)-guided PVI was performed targeting interlesion distance ≤ 6 mm and AI ≥ 550 arbitrary unit (au) at anterior wall, ≥ 400 au at posterior wall and roof (≥ 300 au at vicinity of esophagus). CTI ablation was performed only in case of AFL. Recurrence was defined as any AF, atrial tachycardia (AT) or AFL (AF/AT/AFL ˃ 30s) either on Holter electrocardiographs or by cardiac devices monitoring at 3, 6 and 12 months. Results ECV was performed in 26 (87%) of pts (64 ± 9 years, 80% male), 51 ± 42 days prior to ablation. Three pts (10%) had long-standing peAF. LA anteroposterior diameter was 45 ± 7 mm. PVI was achieved in all pts and CTI ablation performed in six. Mean procedure time, RF time and fluoroscopy time were respectively 156 ± 25 min, 26 ± 6 min and 4 ± 4 min. At a median follow-up of 15 ± 4 months, 24/30 pts (80%) were free from AF/AT/AFL after a single procedure, with 8 pts (27%) still on antiarrhythmic drugs. Out of 6 recurrences, 5 were paroxysmal form. No periprocedural complications occurred ( Fig. 1 ). Conclusions After a single procedure and midterm follow-up, Ablation index-guided PVI is efficient in maintaining sinus rhythm in peAF pts who exhibit, on the day of ablation, either sinus rhythm or typical AFL. Randomized studies with larger scale and longer follow-up are required.

Aspirin and Low Molecular Weight Heparin in Patients Undergoing Catheter Ablation of AF Background To prevent thrombo-embolic (TE) events during ablation of atrial fibrillation (AF), warfarin is recommended in all patients irrespective of baseline TE risk. We evaluated the efficacy and safety of a simplified periprocedural anticoagulation strategy of aspirin (ASA) and low molecular weight heparin (LMWH) in patients at low TE risk. Methods We collected data from 214 low TE risk patients (CHADS2 score ≤1 and no warfarin at baseline) undergoing pulmonary vein isolation. After discontinuation of ASA, periprocedural antithrombotic therapy consisted of therapeutic subcutaneous LMWH injections (nadroparin 1 mL/kg once daily) from 10 days before until 10 days after the procedure, followed by ASA in all patients. At the time of procedure, transesophageal echocardiography (TEE) was not performed on a routine basis. During the procedure, unfractionated heparin was administered to achieve an ACT between 350 and 400 seconds. Data on TE events (stroke or transient ischemic attack), cardiac tamponade/perforation, and major vascular access complications within 3 months after the procedure were collected. Results Mean CHADS2 was 0.3 ± 0.5. TEE was performed in 3% of patients. No periprocedural TE events occurred. No cardiac tamponade/perforation was observed. Major vascular access complications occurred in 3 patients (1.4%). No permanent injury was observed (0%). Conclusion In selected low TE risk patients undergoing ablation for AF, a short period of periprocedural therapeutic anticoagulation with LMWH together with aspirin is an effective and safe strategy to prevent TE events. If confirmed in a randomized trial, this approach might simplify periprocedural antithrombotic management in ablation of selected AF patients.

Summary Background Activation mapping can be challenging and time-consuming in patients with multiple atrial tachycardias (ATs). Aims To compare multielectrode mapping using a dedicated mapping catheter – PentaRay (Biosense Webster Inc.) – and the conventional technique for mapping ATs in the context of atrial fibrillation (AF) ablation. Methods All procedures where PentaRay mapping of AT were used – after or during persistent AF ablation – were analysed. These were compared to a historical group – using conventional mapping. Results A mean of 449 ± 520 points within 14 ± 6 min were acquired per AT in the PentaRay group ( n = 17) versus 42 ± 18 points ( P P = 0.04) in the conventional group ( n = 17). All 25 AT isthmuses were easily identified and ablated in the PentaRay group (100%) versus 20/23 (87%) in the conventional group ( P = 0.056). The ablation time was shorter in the PentaRay group (760 ± 540 vs 1347 ± 962 s; P = 0.037). However, procedure and fluoroscopy times were not significantly different between the PentaRay and conventional groups: 253 ± 77 vs 267 ± 73 min ( P = 0.80) and 13.1 ± 8.0 min vs 15.1 ± 10.0 min ( P = 0.98), respectively. Recurrence occurred in less patients in the PentaRay group (0 vs 23.5%; P = 0.033) during a mean follow-up of nearly 1 year. Conclusion In patients with multiple ATs, multielectrode PentaRay mapping was faster than the conventional technique, with less radiofrequency delivery and a better mid-term outcome.

Purpose We report our initial experience with the newly released ultra-high density (UHD) electroanatomical mapping system (Rhythmia, Boston Scientific) for arrhythmias. Methods All procedures using the multielectrodes catheter (Orion, Boston Scientific) in our institution, for arrhythmias mapping were analyzed. Procedure and fluoroscopy times were also assessed. Results 20 patients were included (67,9±13 y) for radiofrequency ablation of accessory pathway (n=2) / typical flutter (n=5) / atrial fibrillation (AF n=2) / post-AF ablation left atrial tachycardia (AT n=6) / focal AT (n=2)/ left and right ventricular ectopies (n=3). 63 maps (3,15 maps per patient) were acquired within a mean mapping time of 18±10min per map, including a mean number of 10024,3±9371 electrograms per map (Figure): RA maps (flutter=12; sinus rhythm SR=14; coronary sinus CS pacing=4); left atrial maps (during tachycardia=18; SR=3; CS pacing=4); right ventricular maps (n=4); left ventricular maps (during tachycardia=3; pacing=1). Acute success was achieved in 19/20 patients. In one patient, the ablation could not be performed in the absence of clinical ectopies. Total procedure and fluoroscopy times were respectively 232±78min and 15,9±8 min. No periprocedural complications were noticed. Conclusion UHD electroanatomical endocardial mapping can be safely performed in both atria and ventricles and allows fast and accurate mapping. Download : Download high-res image (159KB) Download : Download full-size image Abstract 0340 – Figure: Ultra high density left atrial macro reentry map

Aims Isthmus-dependent (ID) clockwise (CW) atrial flutters (AFl) are rare in comparison with counterclockwise (CCW) AFl. Little is known about clinical and electrophysiological characteristics of CW AFl occurring after previous radiofrequency (RF) catheter ablation of CCW AFl. We sought to compare CW AFl de novo vs. CW AFl occurring after previous CCW AFl RF ablation. Methods and results A total of 246 procedures of RF catheter ablation for AFl from January 2009 to January 2011 were reviewed. Clinical and electrophysiological data were analysed. Patients were excluded if they were in sinus rhythm at the beginning of the procedure, if they had concomitant/previous atrial fibrillation ablation, or if AFl was not ID. Twenty-seven patients presented CW AFl (10.9% of all ID AFl), including 10 CW AFl occurring after a previous RF catheter ablation for CCW AFl. Mean time for recurrence after the previous procedure of CCW AFl RF ablation was 3.5 years. They were younger (61.6 ± 11 years) than patients with CW AFl de novo (74.0 ± 7.2 years; P = 0.005). Bidirectional isthmus block was obtained in all patients. There was a significant difference in terms of double potential separation after ablation (155 ± 31 ms for CW AFl de novo vs. 111 ± 7 ms for recurrent CW AFl; P = 0.028). No differences were observed concerning CHADS score, AFl cycle length, and electrocardiogram typical pattern for CW AFl between the two groups. Conclusion Patients with CW AFl occurrence after CCW AFl RF catheter ablation are younger than patients with CW AFl de novo . They also have a smaller interspike interval after block completion.

The previously unknown congenital absence of inferior vena cava, an otherwise benign condition, may create difficulties for catheter ablation of arrhythmias. We describe a case of a typical-like atrial flutter, in which magnetic navigation was important for conserving the femoral approach. Electroanatomic mapping with image integration helped define the critical isthmus between the ostia of the suprahepatic veins and the tricuspid valve.

A 60-year-old male patient, treated for mild arterial hypertension, was referred for highly symptomatic long-standing persistent atrial fibrillation (CHA2DS2VASc = 1) after a previously failed radiofrequency biatrial catheter ablation. A fast ventricular response was present despite β-blocker therapy (the mean …

Aims Radiofrequency catheter ablation (RFCA) for arrhythmias in the context of short-term medical missions (MM) in a developing country has not been reported so far. We describe here our experience with RFCA and pacemaker implantation in Morocco with a fully portable electrophysiological (EP) system under the auspice of the Monaco–Morocco Cardiology Association. Methods and results Since November 2007, two to three MM (mean duration 4 days including transportation) per year were conducted (including two physicians and one nurse from Monaco) and were alternately located in Marrakech, Fes, Agadir, Casablanca, Rabat, Essaouira, and Oujda. All patients’ files were sent by local teams and/or referring Moroccan cardiologists before MM. Each case was discussed with the Monaco EP team before the MM. Pacemakers and leads were donated by companies (Sorin Group, Medtronic, Saint-Jude Medical). The EP system (EP Tracer, CardioTek) as well as diagnostic/ablation catheters were brought for RFCA procedures. After the procedures, follow-up was performed by local teams. Procedures took place in gynaecological or orthopaedic operating room, or, when available, in the interventional cardiology cathlab. Thirty-one RFCA were performed during 11 MM (atrioventricular node re-entrant tachycardia = 12; atrioventricular re-entrant tachycardia/Mahaim fibre = 15; typical atrial flutter = 3; ventricular ectopy = 1). Acute success was 93.5% for RFCA. Two major RFCA-related complications occurred (air embolism and complete atrioventricular block). No complication was related to pacemaker implantations ( n = 44; mean 4 pacemakers per mission). Conclusion Radiofrequency catheter ablation for arrhythmias in developing countries is technically challenging but feasible, despite technical and cultural difficulties.

Since its first description about one century ago, our understanding of atrial flutter (AFL) circuits has considerably evolved. One AFL circuit can have variable electrocardiographic (ECG) manifestations depending on the presence of pre-existing atrial lesions, or impaired atrial substrate. Conversely, different (right sided or even left sided) atrial circuits including different mechanisms (macroreentrant, microreentrant, or focal) can present with a very similar surface ECG manifestation. The development of efficient high-resolution electroanatomical mapping systems has improved our knowledge about AFL mechanisms, as well as facilitated their curative treatment with radiofrequency catheter ablation. This article will review ECG features for typical and atypical flutters, and emphasize the limitations for circuit location from the surface ECG.

IntroductionMany ablations require radiofrequency delivery near to the mitral annulus (MA).No reliable data exists about the electrical criteria of mitral annulus localisation. The aim of this study was to measure the A/V ratio on the mitral annulus and compare it to the A/V ratio on its atrial and ventricular side with transesophageal echocardiographic guidance and catheter tissue contact monitoring.MethodsTen patients in sinus rhythm undergoing atrial fibrillation catheter ablation under general anesthesia using a contact-force sensing catheter were included. After double transseptal puncture, we recorded the atrial and ventricular potentials on the mitral annulus at four defined points (3,6,9 and 12 o’clock), with direct confirmation of the position of the catheter relative to the mitral annulus by transesophageal echocardio-graphy and contact assessment by the force sensor on the catheter tip. Then we performed the same procedure on the atrial and ventricular sides of the mitral annulus.ResultsThere is a homogeneous distribution of the amplitude of the atrial and ventricular electrograms on the mitral annulus with a good correlation (r=0,93; p < 0,0001). The mean A/V ratio was 0,57 (± 0,078, IC 95% 0,540,59) on the mitral annulus, 0,725 (± 0,09, IC 0,65-0,79) on the atrial side and 0,348 (± 0,09, IC 95% 0,18-0,41) on the ventricular side near to the mitral annulus. These results were significantly different (p< 0,0001). No correlation was found between this ratio and the size of the left atrium, left ventricular mass and the presence of hypertension.ConclusionsA/V ratio on the MA is 0.57. It is significantly different from the A/V ratio on the atrial and ventricular sides of the MA, and may be used as an electrical criterion for MA localisation during ablation proceduresAbstract 0166 – Figure

Background Cryoenergy is an emerging technique for the treatment of paroxysmal atrial fibrillation (AF) and atrioventricular nodal reentrant tachycardia (AVNRT). It's unclear whether left atrial ablation procedures with anticoagulation cautions have more thrombogenic effects than right atrial ablation procedures. In the vasculature, procoagulant microparticles (MP) are reliable markers of vascular damage. Purpose We sought to measure procoagulant MP before and 24 h after AF and AVNRT cryoablation procedures. Methods and results Venous blood samples were collected from patients before and 24 h after AVNRT cryoablation (n=10); and before and 24 h after AF cryoablation (n=15). Endothelial (EMP), platelet derived-MP (PMP), and concentrations of prothrombin fragment 1+2 (F 1+2) were analyzed in both groups. EMP rose from 15.04 to 30.2/μL in AVNRT group versus 2.61 to 5.63/μL in AF group. PMP decreased in both groups, respectively from 2280 to 942/μL (-59%) in AVNRT group, and from 1281 to 1079/μL (-16%) in AF group. F 1+2 were stable in AVNRT group (190.7 to 203.2 pmol/L; + 7%), but increased after AF ablation (75.4 to 141.8 pmol/L; + 88%). Variations observed after the procedure for each marker weren’t statistically different between the 2 groups, respectively for EMP (p=0.554), PMP (p=0.379), and F 1+2 (p=0.091). Conclusion Using biologic markers of vascular damage, AF cryoablation is not associated with important release of prothrombotic MP, as compared with a shorter procedure like AVNRT cryoablation in right-side chamber.

A 72-year-old female was admitted for catheter ablation of supraventricular tachycardia. A decapolar catheter was inserted in the coronary sinus (CS) and an Orion IntellaMap catheter (Boston Scientific) in the right atrium (RA; Figure , Panel A ). The induced tachycardia ( Panel A ) was suggestive …

Catheter ablation of typical atrial flutter (AFl) is succesful if double electrograms on the ablation line are widely separated. Nevertheless, a small interval may also be compatible with complete isthmus block. Predicting such a situation may avoid useless additionnal radiofrequency (RF) applications. We postulated that measuring the extra-isthmus activation time (EIAT) on the counterclockwise (CCW) flutter wave is correlated with the extra-isthmus conduction time after a proven block.Files of 76 patients (71 males, 71 ± 12 years) ablated for typical CCW AFl were reviewed. Ten had 2/1 conduction prohibiting reliable measurement. Three patients with proven crista terminalis shunt were also excluded. In the remaining 63 patients, EIAT was measured on the surface ECG before the first RF pulse from the beginning of the negative deflection of the F wave in lead III to the end of the positive deflection (or beginning of the plateau). After successful ablation and completion of block, right atrial (RA) CCW (during low septal pacing), and clockwise (CW) (during low lateral pacing) activation times were measured.Flutter cycle length was 247 ± 34 ms and EIAT was 142 ± 25 ms. A bidirectionnal isthmus block was obtained in all patients after an RF delivery time of 623 ± 546 s. At a pacing cycle length of 681 ± 71 ms, RA CCW and CW activation times were 147 ± 23 and 139 ± 26 ms, respectively. There was a good correlation between EIA, RA CCW (r = 0.75, p 0.0001), and CW (r = 0.69, p = 0.0002) activation times.EIAT on the flutter wave is an easy and feasible measure. It is correlated with extra-isthmus RA conduction time after block completion. EIAT can be used as a measure to predict the post cavo-tricuspid isthmus block RA activation time.

A 68-year-old patient with ischemic cardiomyopathy was admitted for a single-chamber implantable cardioverter-defibrillator (ICD) generator replacement after normal battery depletion. He was implanted in 2001 with a dual-coil …

Short-QT Syndrome. A 28-year-old man was admitted after aborted sudden cardiac death while sleeping. QTc was 320 ms, suggesting short-QT syndrome (SQTS). The patient then presented with electrical storm with 8 successive episodes of ventricular fibrillation while on deep sedation and hypothermia. Isoproterenol infusion was introduced, leading to rapid cessation of any arrhythmic event. Isoproterenol can be effective in managing electrical storm in patients with SQTS. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1028-1030, September 2012).

Purpose Endpoint of radiofrequency (RF) ablation of typical atrial flutter (AFl) is bidirectionnal isthmus block (BIB). The latter is diagnosed if double electrograms representing activation on both side of the ablation line are widely separated. Nevertheless, a small interval may also be compatible with complete BIB. Predicting such a situation may avoid useless additionnal RF applications. We postulated that measuring the extra-isthmus activation time (EIAT) on the counterclockwise (CCW) ECG flutter (F) wave is correlated with the extra-isthmus conduction time after proven BIB. Methods Files of 76 consecutive patients (pts; 71±12 y) ablated for CCW AFl were reviewed. Ten had 2/1 conduction prohibiting measurement. Three pts had proven crista terminalis shunt and were excluded. In the remaining 63 pts (82%) EIAT was measured before the first RF pulse in lead III from the beginning of the negative deflection of the F wave to the end of the positive deflection or the beginning of the plateau (figure). After successful ablation (completion of BIB), right atrial (RA) CCW (during low septal pacing), and clockwise (CW; during low lateral pacing) activation times were measured. Download : Download full-size image Results Mean AFl cycle length (CL) was 247±34 ms and mean EIAT was 142±25 ms. BIB was obtained in all pts after 623±546 s of RF. At a pacing CL of 681±71 ms RA CCW and CW activation times were 147±23 ms and 139±26 ms, respectively. There was a good correlation between EIAT on the F wave and RA CCW (r=0.75, p Conclusions EIAT on the F wave is an easy and feasible measure. It is correlated with extra-isthmus RA conduction time after BIB and may be used to evaluate whether block is complete in case of moderate double electrogram separation such as in patients with small RA.

We read with interest the last EHRA practical guide on the use of new oral anticoagulants (NOAC) in patients with non-valvular atrial fibrillation (AF) reported by Heidbuchel et al. ,1 and the problematic issue of NOAC during catheter AF ablation (CAFA). Several studies have confirmed the reduction of both bleeding and thromboembolic (TE) complications when performing CAFA during uninterrupted vitamin K antagonist therapy in comparison with a bridging strategy. Recent non-randomized studies with NOAC continued during CAFA showed similar safety profiles while still considering TE and bleeding events.2 In the absence of a specific classification including CAFA …

We describe a case during which a left atrial thrombus was visualized within the left atrium attached to a circular catheter during an atrial fibrillation ablation procedure. This was managed by successful thromboaspiration using a steerable sheath, preventing a potential serious complication.

A 75-year-old female patient (CHA2DS2VASc = 4) was referred to our institution for recurrent atrial tachycardia (AT) after two previous radiofrequency persistent atrial fibrillation (AF) ablation procedures. Owing to severe epistaxis under a vitamin K antagonist, an …

An 80-year-old man was admitted for cardiac failure and recurrence of electrocardiographically typical atrial flutter (figure, upper left panel). Six months earlier he has had cavo-tricuspid isthmus (CTI) ablation with successful block. A …

Background Renal insufficiency (RI) is frequent in patients eligible for cardiac resynchronization therapy (CRT) and may be worsened by the use of contrast agents. Objective We sought to determine the feasibility of CRT implantation without contrast injection in patients with contraindication to iodine. Methods Patients eligible for CRT and presenting with RI were prospectively included (non-contrast NC group). A contemporary control group (CG) of CRT patients with contrast injection was used for comparison. An over-the-wire coronary sinus (CS) lead with angled distal tip was selected for this “blind harpooning” technique. A lateral branch was targeted at first intention in a left anterior oblique fluoroscopic view. In case of failure, a contrast injection was then allowed if no lateral branch was found with the « blind » strategy. Results 9 patients in the NC group were included (78±8 y). Serum creatinine was 204±72[imol/L (clearance 34.2±17ml/min). CG included 10 patients (69,8±7 y, serum creatinine 98.7±23[imol/L). CRT implantation was successful in 8/9 patients (88.9%) without contrast injection. Patient 9 was finally implanted with CS opacification after failure of the NC technique. Mean procedure time and fluoroscopy time were similar in the two groups:146±26 in the NC group versus 157±25 min (p = 0.34) and 24.8±15 in the NC group versus 24.5±20 min (p = 0.96) respectively. Mean CS lead implantation time was 45±21 (NC group) versus 37±12 min (p = 0.24). No major procedure-related complications were observed in both groups. Conclusion CRT implantation is feasible in the majority of the cases (88.9%) without contrast injection and without lengthening procedure time in patients with RI.

Introduction Different techniques in catheter ablation (CA) of persistent (Pers) and longstanding (LS) Pers AF have been described with variable outcomes. We report long-term results in a series of Pers AF patients who underwent CA with magnetic navigation (MN). Methods We prospectively included 50 patients (pts; 43 males; 61±10 y) referred for CA of Pers AF. Pers and LS Pers AF were defined according to published guidelines. Freedom from AF is defined as the absence of symptomatic or ECG/Holter documented AF after ablation. All pts underwent stepwise CA using MN: circumferential pulmonary veins isolation, bi-atrial complex fragmented electrograms ablation, roof ± left isthmus ± cavo-tricuspid isthmus lines. Atrial tachycardia (AT) occurring during CA were also targeted. Results Total duration of AF history was 56±42m (range 4 m-12 y, median 48m). Mean duration of continuous AF was 8±12m (range 1-84m, median 5.5m; 18% LS and 82% Pers AF). AF was lone in 50%. LA size was 30±5cm2, CT-scan volume 139±51ml. Procedures’ duration was 256±56 minutes with a fluoroscopy time of 13±5 min. RF time was 47±27 min. AF stopped without electrical cardioversion in 17 pts (34%; sinus rhythm in 8 and AT in 9). A redo CA for recurring AF was performed in 6 pts (12%). Complications (4 pts) resolved w/o sequellae: acute coronary syndrome (1), pericardial effusion (1), AV fistula (1) and intraalveolar haemorrhage (1). After 19.9±9.5m (range 6-40, median 17.5m), with 1.1 procedures/pt, 40 pts (80%) had no AF recurrence, of which 28 were off AAD and 12 remained on AAD. Incidence of postablation AT was 12% (6/50). Conclusion Magnetic navigation for Pers AF ablation yields excellent (80%) long-term (20m) prevention of AF recurrence (figure next page). Download : Download full-size image Abstract 0170 – Figure: AF-free survival