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International audience; Purpose of the review - Patients with cardiomyopathy and impaired left ventricular (LV) ejection fraction are at risk of sudden cardiac death (SCD). In selected heart failure patients, cardiac resynchronization therapy (CRT) provides LV reverse remodeling and improves the cellular and molecular function leading to a reduced risk of ventricular arrhythmia and SCD. Consequently, some CRT candidates may not need concomitant ICD therapy. This review aimed at focusing on the residual risk of SCD in patients receiving CRT and discussing the requirement of a concomitant ICD therapy in CRT candidates. Recent findings - New imaging diagnostic tools may be helpful to accurately predict patient with a residual risk of SCD and who required a CRT-D implantation. Recent data highlighted that cardiac computed tomography (CT) or myocardial scar tissue analysis using contrast-enhanced cardiac magnetic resonance (CMR) was able to predict the occurrence of VA in patients with bi-ventricular pacing. Cardiac imaging and specifically myocardial scar analysis seem promising to evaluate the risk of SCD following bi-ventricular pacing and will probably be of great help in the future to accurately identify those who needs concomitant defibrillator's protection.

We thank Dr. Madaffari and colleagues for their interest in our review article ([1][1]) and for raising a crucial comment. Indeed, in their letter, the authors summarize a few seminal papers describing the role of direct interpulmonary myocardial connections, leading to the presence of connected

International audience; Introduction Atrioventricular node (AVN) ablation is usually a simple procedure but may sometimes be challenging. We aimed at identifying pre-procedural clinical predictors of challenging AVN ablation. Methods Patients referred for AVN ablation from 2009 to 2015 were retrospectively included. Baseline clinical data, procedural variables and outcomes of AVN ablation were collected. A “challenging procedure” was defined 1) total radiofrequency delivery to get persistent AVN block ≥ 400 s, 2) need for left-sided arterial approach or 3) failure to obtain AVN ablation. Results 200 patients were included (71 ± 10 years). A total of 37 (18.5%) patients had “challenging” procedures (including 9 failures, 4.5%), while 163 (81.5%) had “non-challenging” ablations. In multivariable analysis, male sex (Odds ratio (OR) = 4.66, 95% confidence interval (CI): 1.74–12.46), body mass index (BMI, OR = 1.08 per 1 kg/m2, 95%CI 1.01–1.16), operator experience (OR = 0.40, 95%CI 0.17–0.94), and moderate-to-severe tricuspid regurgitation (TR, OR = 3.65, 95%CI 1.63–8.15) were significant predictors of “challenging” ablations. The proportion as a function of number of predictors was analyzed (from 0 to 4, including male sex, operator inexperience, a BMI andgt; 23.5 kg/m2 and moderate-to-severe TR). There was a gradual increase in the risk of “challenging” procedure with the number of predictors by patient (No predictor: 0%; 1 predictor: 6.3%; 2 predictors: 16.5%; 3 predictors: 32.5%; 4 predictors: 77.8%). Conclusions Operator experience, male sex, higher BMI and the degree of TR were independent predictors of “challenging” AVN ablation procedure. The risk increases with the number of predictors by patient. © 2017

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Reliable prediction of atrial fibrillation (AF) progression from paroxysmal to non-paroxysmal form of AF could help in optimizing follow-up and decision-making regarding the rate and rhythm control management. The HATCH score and others have been proposed to identify AF patients likely to progress to sustained forms of AF, but external validation is limited. We aimed at evaluating these scores in a large series of AF patients and to identify possible factors leading to persistent/permanent AF. Methods All patients with AF seen over a period of 10 years were identified in a database and followed up for AF progression and mortality. Predictors of outcomes were identified using Cox regression model. The values of HATCH, CHA2DS2-VASc, ALARMEc, APPLE, MB-LATER scores and CHARLSON comorbidity index were evaluated with C statistics for prediction of AF progression. Results Among 8962 patients (71±14 years), 4991, 476 and 3495 had paroxysmal, persistent AF, and permanent AF, respectively. During a follow-up of 927±1084 days, 404 paroxysmal AF patients progressed to persistent or permanent AF (yearly rate of 3.0%). Progression was associated with a trend toward increased cardiovascular mortality. Independent predictors of AF progression were heart failure (hazard ratio (HR) 2.07; 95% CI 1.50–2.85, p C-statistics for AF progression All patients (n=4,991) p value* HATCH 0.576 (0.562–0.590) Conclusion Most of scores have a modest predictive value to identify the risk of evolution to permanent AF. Among them, the CHARLSON comorbidity index had the best predictive value and outperformed other tools. This suggests that AF progression may actually reflect global aging both at the individual and local atrial level.

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Summary Background Pulmonary vein isolation (PVI) using cryoballoon ablation is widely used for rhythm control in patients with paroxysmal atrial fibrillation. This technique has a steep learning curve, and PVI can be achieved quickly in most patients. However, the right inferior pulmonary vein (RIPV) is often challenging to occlude and isolate. Aim We aimed to analyse the efficacy of RIPV ablation using a systematic approach. Methods Consecutive patients referred for cryoballoon ablation of paroxysmal atrial fibrillation were enrolled prospectively. A systematic approach was used for RIPV cryoablation. The primary endpoint was acute RIPV isolation during initial freeze. Results A total of 214 patients were included. RIPV isolation during initial freeze occurred in 179 patients (82.2%). Real-time PVI could be observed in 72 patients (33.6%), whereas cryoballoon stability required pushing the Achieve™ catheter inside the RIPVs in the remaining patients. The rate of unsuccessful or aborted first freeze as a result of insufficient minimal temperature was significantly higher in patients with real-time pulmonary vein potential recording (16.7% vs. 6.3%; P = 0.031). To overcome this issue and obtain both stability and real-time PVI, a dedicated “whip technique” was developed. Twelve patients (5.6%) required a redo ablation; only two of these had a reconnected RIPV. Conclusions A systematic approach to RIPV cryoablation can lead to a high rate of first freeze application. Operators should not struggle to visualize pulmonary vein potentials before ablation, as this may decrease cryoapplication efficacy. Thus, stability should be preferred over real-time PVI for RIPV ablation. Both stability and real-time PVI can be obtained using a “whip technique”.

International audience; Objectives - This study aimed to evaluate incidence, clinical significance, and predictors of early ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients. Background - LVAD implantation is increasingly used in patients with end-stage heart failure. Early VAs may occur during the 30-day post-operative period, but many questions remain unanswered regarding their incidence and clinical impact. Methods - This observational study was conducted in 19 centers between 2006 and 2016. Early VAs were defined as sustained ventricular tachycardia and/or ventricular fibrillation occurring

International audience; Background - Ventricular arrhythmias (VAs) can occur after continuous flow left ventricular assist device (LVAD) implantation as a single arrhythmic event or as electrical storm (ES) with multiple repetitive VA episodes. Objective - We aimed at analyzing the incidence, predictors, and clinical impact of ES in LVAD recipients. Methods - Patients analyzed were those included in the multicenter ASSIST-ICD observational study. ES was consensually defined as occurrence of ≥3 separate episodes of sustained VAs within a 24-hour interval. Results - Of 652 patients with an LVAD, 61 (9%) presented ES during a median follow-up period of 9.1 (interquartile range [IQR] 2.5-22.1) months. The first ES occurred after 17 (IQR 4.0-56.2) days post LVAD implantation, most of them during the first month after the device implantation (63%). The incidence then tended to decrease during the initial years of follow-up and increased again after the third year post LVAD implantation. History of VAs before LVAD implantation and heart failure duration > 84 months were independent predictors of ES. The occurrence of ES was associated with an increased early mortality since 20 patients (33%) died within the first 2 weeks of ES. Twenty-two patients (36.1%) presented at least 1 recurrence of ES, occurring 43.0 (IQR 8.0-69.0) days after the initial ES. Patients experiencing ES had a significantly lower 1-year survival rate than did those free from ES (log-rank, P = .039). Conclusion - There is a significant incidence of ES in patients with an LVAD. The short-term mortality after ES is high, and one-third of patients will die within 15 days. Whether radiofrequency ablation of arrhythmias improves outcomes would require further studies.

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International audience; Background - Left ventricular assist device (LVAD)-associated infections may be life-threatening and impact patients' outcome. We aimed to identify the characteristics, risk factors, and prognosis of LVAD-associated infections. Methods - Patients included in the ASSIST-ICD study (19 centers) were enrolled. The main outcome was the occurrence of LVAD-associated infection (driveline infection, pocket infection, or pump/cannula infection) during follow-up. Results - Of the 652 patients enrolled, 201 (30.1%) presented a total of 248 LVAD infections diagnosed 6.5 months after implantation, including 171 (26.2%), 51 (7.8%), and 26 (4.0%) percutaneous driveline infection, pocket infection, or pump/cannula infection, respectively. Patients with infections were aged 58.7 years, and most received HeartMate II (82.1%) or HeartWare (13.4%). Most patients (62%) had implantable cardioverter-defibrillators (ICDs) before LVAD, and 104 (16.0%) had ICD implantation, extraction, or replacement after the LVAD surgery. Main pathogens found among the 248 infections were Staphylococcus aureus (n = 113' 45.4%), Enterobacteriaceae (n = 61; 24.6%), Pseudomonas aeruginosa (n = 34; 13.7%), coagulase-negative staphylococci (n = 13; 5.2%), and Candida species (n = 13; 5.2%). In multivariable analysis, HeartMate II (subhazard ratio, 1.56; 95% CI, 1.03 to 2.36; P = .031) and ICD-related procedures post-LVAD (subhazard ratio, 1.43; 95% CI, 1.03-1.98; P = .031) were significantly associated with LVAD infections. Infections had no detrimental impact on survival. Conclusions - Left ventricular assist device-associated infections affect one-third of LVAD recipients, mostly related to skin pathogens and gram-negative bacilli, with increased risk with HeartMate II as compared with HeartWare, and in patients who required ICD-related procedures post-LVAD. This is a plea to better select patients needing ICD implantation/replacement after LVAD implantation.

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Introduction Cardiac stereotactic body radiation therapy (SBRT) appears to be effective for patients with refractory ventricular tachycardia (VT) by delivering a single ablative radiation dose of 25 Gy to the arrhythmogenic region. Definition of treatment volume is a critical step, integrating combination of cardiac and respiratory motion. The main objective of this study was to evaluate the impact of cardiac and respiratory motion on the definition of target volume. Methods and materials The study presents the targeting data from the first patient enrolled in our institution for SBRT. Treatment planning was performed using different imaging modalities: a respiration-correlated 4D CT, a cardiac-correlated 4D CT, a MRI scan and electrophysiological data from prior catheter ablation. A registration was performed between the different imaging modalities. Respiratory and cardiac motions were quantified in left–right (LR), anteroposterior (AP) and supero-inferior (SI) directions for the target (calcifications) and for the defibrillation lead. The treatment area was delineated using diastolic and systolic cardiac phases of the cardiac-correlated 4D CT, to optimally define a treatment zone accounting for target's displacements related to cardiac motions. Results Target motions amplitude induced by heartbeats were close to those induced by respiration. Respiratory motions of the target were not correlated to that of defibrillation lead (see Table 1 ). The target volume was 15.9 cm3 and 17.7 cm3 for the diastolic and systolic phases, respectively, and 20.7 cm3 when joined together. These differences emphasise the target deformation, and the need of 4D cardiac imaging data for SBRT. Conclusion We showed that optimal definition of the target volume in SBRT requires respiratory and cardiac correlated images. The use of defibrillation lead as a surrogate might result in target localisation inaccuracies, which need to be taken into account in the final planning target volume.

Aims To describe the incidence, predictors, and in-hospital impact of early SVA (eSVA, occurring Methods Data of 13523 patients enrolled in the ORBI registry were analysed. Logistic regression was performed to identify predictors of eSVA, lSVA, and in-hospital all-cause mortality. Predictors of lSVA were used to build a risk score. Results eSVA occurred in 678 patients (5%) whereas 120 patients (0.9%) experienced lSVA at a median timing of 3 days post-STEMI. eSVA associated with a significantly higher risk of all-cause mortality (adjusted OR: 1.90, 95%CI: 1.39–2.61, P Table 1 . Multivariable predictors of lSVA are listed in the Figure. The score derived from these variables allowed the classification of patients into four risk categories: low (0–21), low-to-intermediate (22–34), intermediate-to-high (35–44), and high (≥ 45). Observed lSVA rates were 0.2%, 0.4%, 0.8%, and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P = 0.40). Conclusion eSVA are 5-fold more common than lSVA in the setting of STEMI, mainly associated with other early complications, and portends a 2-fold higher risk of in-hospital mortality. Moreover, we developed a risk score-identifying patients at high risk of lSVA for whom early ICU discharge may not be suitable.

Summary Background The relationship between electrical and mechanical indices of cardiac dyssynchronization in systolic heart failure (HF) remains poorly understood. Objectives We examined retrospectively this relationship by using the daily practice tools in cardiology in recipients of cardiac resynchronization therapy (CRT) systems. Methods We studied 119 consecutive patients in sinus rhythm and QRS ≥ 120 ms (mean: 160 ± 17 ms) undergoing CRT device implantation. P wave duration, PR, e PR (end of P wave to QRS onset), QT, RR–QT, JT and QRS axis and morphology were putative predictors of atrioventricular (diastolic filling time [DFT]/RR), interventricular mechanical dyssynchrony (IVMD) and left intraventricular mechanical dyssynchrony (left ventricular pre-ejection interval [PEI] and other measures) assessed by transthoracic echocardiography (TTE). Correlations between TTE and electrocardiographic measurements were examined by linear regression. Results Statistically significant but relatively weak correlations were found between heart rate ( r = −0.5), JT ( r = 0.3), QT ( r = 0.3), RR–QT intervals ( r = 0.5) and DFT/RR, though not with PR and QRS intervals. Weak correlations were found between: (a) QRS ( r = 0.3) and QT interval ( r = 0.3) and (b) IVMD > 40 ms; and between (a) e PR ( r = −0.2), QRS ( r = 0.4), QT interval ( r = 0.3) and (b) LVPEI, though not with other indices of intraventricular dyssynchrony. Conclusions The correlations between electrical and the evaluated mechanical indices of cardiac dyssynchrony were generally weak in heart failure candidates for CRT. These data may help to explain the discordance between electrocardiographic and echocardiographic criteria of ventricular dyssynchrony in predicting the effect of CRT.

Introduction et but de l’etude La radiotherapie ablative pour la tachycardie ventriculaire refractaire est une application emergente de radiotherapie stereotaxique qui consiste a delivrer une dose ablative de 25 Gy en une seance unique au niveau d’une region cardiaque arythmogene. Elle implique la definition d’un volume cible previsionnel complexe integrant la combinaison des battements cardiaques et des mouvements respiratoires. L’objectif de cette etude etait d’evaluer l’impact geometrique des mouvements cardiaques et respiratoires sur la definition du volume cible. Materiel et methodes L’etude a ete realisee sur le premier patient pris en charge dans notre institution pour une tachycardie ventriculaire refractaire du septum interventriculaire basal. La planification a ete basee sur : une tomodensitometrie synchronisee a l’electrocardiogramme avec injection de produit de contraste (TDM-4Dcardiaque), une tomodensitometrie synchronisee a la respiration (TDM-4Drespiratoire), une IRM cardiaque et une cartographie du substrat arythmogene (cartographie de voltage en rythme sinusal et cartographie d’activation des tachycardies ventriculaires). Un recalage rigide a ete effectue sur l’ensemble des images. L’amplitude des mouvements cardiaques et respiratoires du volume macroscopique tumoral (presence de calcifications) et de la sonde de defibrillation a ete quantifiee dans les trois directions de l’espace a partir du TDM-4Dcardiaque et de la TDM-4Drespiratoire. Le volume macroscopique tumoral a ete delinee sur les phases diastoliques et systoliques de la TDM-4Dcardiaque permettant d’en deduire un volume cible interne cardiaque. Resultats et analyse statistique L’amplitude des mouvements cardiaques et respiratoires du volume macroscopique tumoral et de la sonde de defibrillation sont presentes dans le Tableau 1 Les battements cardiaques induisent donc des mouvements du volume macroscopique tumoral d’amplitudes proches de ceux induits par la respiration. Le mouvement respiratoire du volume macroscopique tumoral n’est pas identique au mouvement respiratoire de la sonde de defibrillation. Le volume macroscopique tumoral etait de 15,9 cm3 et 17,7 cm3 sur les phases diastoliques et systoliques, respectivement. Le volume cible interne correspondant etait de 20,7 cm3. Ces differences de volume montrent une deformation significative du volume macroscopique tumoral et la necessite d’une imagerie quadridimensionnelle permettant de caracteriser la dynamique cardiaque. Conclusion Cette etude preliminaire, basee sur un seul patient, montre que la definition optimale du volume cible en tachycardie ventriculaire refractaire implique l’acquisition d’images quadridimensionnelles cardiaque et respiratoire. En cas d’implementation de methodes actives de gestion des mouvements respiratoires a l’appareil de traitement, l’utilisation de la sonde de defibrillation comme repere peut induire potentiellement des imprecisions de ciblage qu’il est important de considerer dans le calcul des marges du volume cible previsionnel.

Background Up to 30% of selected heart failure patients do not benefit clinically from cardiac resynchronization therapy (CRT). Left ventricular (LV) wall thickness (WT) analyzed using computed tomography (CT) has rarely been evaluated in response to CRT and mitral regurgitation (MR) improvement. Purpose We examined the association of LVWT and the ability for reverse LV remodeling and MR improvement after CRT. Methods Fifty-four patients scheduled for CRT underwent pre-procedural CT. Reduced LVWT was defined as WT Results Patients were divided in 3 groups according to the percentage of LVWT Conclusion WT evaluated using CT could help to stratify the response to CRT and predict MR improvement and outcomes.

International audience; Background - The rate of pacemaker (PM) implantations is constantly growing. Since life expectancy of the population is projected to increase, a large number of nonagenarian patients will need PM implantation. We aimed at analyzing short- and long-term outcomes after PM implantation in nonagenarians. Methods - Patients aged ≥90 years referred for PM implantation from 2004 to 2017 were included. The primary clinical endpoint was total mortality. Secondary endpoints included procedure-related and in-hospital complications. Results - A total of 172 patients were included (92.6 ± 2.1 years, from 90.0 to 101.4 years). Procedure duration was 50.0 ± 19.7 minutes. Most of the patients had VVI devices implanted (143 pts, 83.1%) and mean hospital stay was 3.5 ± 1.5 days. Nine patients (5.2%) had short-term device-related complications and 29 patients (16.8%) had post-procedural complications, non-related to the implantation, including four leading to patients' death. During a follow-up of 22.5 months (interquartile range: 7.3-38.0), 94 patients (54.7%) died. Survival rates were 82.9% (95% confidence interval [CI]: 76.0-88.0), 73.7% (95% CI: 65.7-80.1) and 37.5% (95% CI: 27.5-47.5) after 1, 2, and 5 years, respectively. The Charlson comorbidity index was a predictive factor of procedural complications (odds ratio = 1.33; 95% CI: 1.05-1.69, P = 0.02) while having a complication (hazard ratio [HR] = 4.04; 95% CI: 1.79-9.11, P = 0.001) and atrial fibrillation (HR = 1.63; 95% CI: [1.02-2.63], P = 0.043) were predictors of post-implantation death. Conclusion - PM implantation in nonagenarians is safe, with a low risk of procedural complications, but many comorbidities-related complications can occur. Caution should be taken in this old and frail population since complications significantly impact patients' survival.

International audience; Objectives - This study aimed to evaluate the incidence, clinical impact, and predictors of late ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients aiming to clarify implantable cardioverter-defibrillator (ICD) indications. Background - The arrhythmic risk and need for ICD in patients implanted with an LVAD are not very well known. Methods - This observational study was conducted in 19 centers between 2006 and 2016. Late VAs were defined as sustained ventricular tachycardia or fibrillation occurring >30 days post-LVAD implantation, without acute reversible cause and requiring appropriate ICD therapy, external electrical shock, or medical therapy. Results - Among 659 LVAD recipients, 494 (median 58.9 years of age; mean left ventricular ejection fraction 20.7 ± 7.4%; 73.1% HeartMate II, 18.6% HeartWare, 8.3% Jarvik 2000) were discharged alive from hospital and included in the final analysis. Late VAs occurred in 133 (26.9%) patients. Multivariable analysis identified 6 independent predictors of late VAs: VAs before LVAD implantation, atrial fibrillation before LVAD implantation, idiopathic etiology of the cardiomyopathy, heart failure duration >12 months, early VAs (

International audience; Aims Pulmonary vein isolation (PVI) using second-generation cryoballoon (CB2) is associated with improved outcomes compared with first generation (CB1). We aimed at investigating the characteristics of left and right PV reconnections after CB1 and CB2 ablations in patients with clinical recurrences requiring redo ablation. Methods and results From 2010 to 2016, 776 patients underwent 28-mm cryoballoon PVI for symptomatic paroxysmal atrial fibrillation (AF) in 3 centres, 279 with CB1 and 497 with CB2. Among them, 94 patients (12.1%) had symptomatic AF recurrences requiring a redo ablation [43 (15.4%) CB1 and 51 (10.3%) CB2]. The benefit of CB2 over CB1 was compared for each PV. Durable PVI was confirmed in 7 CB1 (16.3%) and 14 CB2 (27.4%) patients, and 2.7 +/- 2.1 and 1.4 +/- 1.4 gaps per patient were found, respectively (P = 0.002). Significantly more left superior and left inferior PVs were found to be isolated in CB2 compared with CB1 group (78.4% vs. 48.8%, P = 0.005 and 78.4% vs. 46.5%, P = 0.003, respectively) while the rate of durable right superior and right inferior PVs isolation were similar (68.6% vs. 60.5%, P = 0.542 and 66.7% vs. 55.8%, P = 0.387, respectively). Significantly fewer gaps were found in left PVs in CB2 patients, while there was no significant difference for right PVs. Gaps localization was similar in both groups. Conclusion Fewer reconnection gaps are observed during redo ablations of paroxysmal AF in patients primarily ablated with CB2. This difference is driven by less reconnection gaps observed in both left PVs, while no difference was observed for right PVs.

International audience; Background - Atrial fibrillation ablation is often performed by achieving pulmonary vein isolation using the "wide antral circumferential ablation" (WACA) technique, but many pulmonary veins remain connected because of conduction gaps in the ablation line. Aim - To analyse the efficacy of a novel technique based on pacing manoeuvres to detect gaps in an initial WACA lesion. Methods - Patients referred for radiofrequency atrial fibrillation ablation were enrolled prospectively. A WACA lesion set was performed, isolating ipsilateral pulmonary veins together. If pulmonary vein isolation was not achieved, the atria were paced using an ablation catheter. For each pacing site, "activation delay" and "activation sequence" were analysed using a circular mapping catheter positioned at the pulmonary vein ostium. Results - Twenty-one patients were included. A total of 25 non-isolated WACA lesion sets were studied. Three patterns were identified: (1) the activation delays converged towards one point with the shortest delay; no modification of the activation sequence (indicating one gap); (2) the activation delays converged towards at least two close locations; no change in the activation sequence (indicating at least two close gaps); (3) the activation delays converged towards at least two remote locations; modification of the activation sequence (indicating at least two remote gaps). Pacing manoeuvres and effect of ablation allowed precise localization of gaps, ultimately leading to pulmonary vein isolation in all patients. Conclusion - This simple pacing method accurately detected the location of residual connections after WACA lesion sets performed for atrial fibrillation ablation, allowing pulmonary vein isolation to be achieved.

International audience; Aims - Intensive endurance sport practice is associated with an increased risk of atrial fibrillation (AF) in male veteran athletes. Paroxysmal AF (PAF) is the very beginning step of this disease. The description of atrial remodelling occurring at this early stage might enable to depict predictive factors of AF in veteran athletes in order to give them personalized recommendation according to their sport practice.Methods and results - Twenty-seven male endurance veteran athletes with documented PAF were retrospectively enrolled and compared with 30 control endurance athletes without documented AF, with similar training level, age, and cardiovascular risk factors. All subjects underwent a resting-electrocardiogram (ECG) to assess the electric remodelling of P-waves as well as an echocardiography, to evaluate the left and right atrial (LA, RA) anatomical and functional (assessed by 2D strain) remodelling. No difference was noted between groups for the ECG P-wave parameters. Atrial function was decreased in the PAF group, particularly the peak atrial longitudinal strain (L-ɛ-Max) of LA (29.3 ± 7.9% vs. 49.1 ± 7.8% respectively in the PAF group and in controls, P Conclusion - Atrial function analysed by strain in echocardiography is strongly associated with PAF and might enable to identify male endurance veteran athletes at risk to develop AF.

International audience; The demand for tricuspid valve (TV) surgery has increased continuously in the last years. Recent registry data have confirmed that TV repair or replacement carry an increased risk of conduction disorders requiring permanent pacemaker implantation, specifically for patients having multivalve surgery. The implantation of an endocardial right ventricular lead in those patients may impair TV function, and some other approaches may be discussed to avoid traversing the valve. This contemporary review describes the different options currently available for patients requiring pacemaker or defibrillation lead implantation after TV surgery.

Although previous studies have suggested that the analysis of mechanical dyssynchrony can improve prediction of response to cardiac resynchronization therapy (CRT), current guidelines still neglect the value of left ventricular (LV) mechanical dyssynchrony assessed by imaging techniques

Summary Background The rate of pacemaker implantation is rising. Given that the life expectancy of the population is projected to increase, a large number of elderly patients are likely to be implanted in the future. As pacemaker batteries can last for 8–10 years, an increasing number of pacemaker recipients will require replacement of their devices when they become nonagenarians. Aims To analyse the short- and long-term outcomes after device replacement in nonagenarians. Methods Patients aged ≥ 90 years referred to a tertiary centre for pacemaker replacement from January 2004 to July 2014 were included retrospectively. Clinical follow-up data were obtained from clinical visits or telephone interviews with patients or their families. The primary clinical endpoint was total mortality. Secondary endpoints included early and delayed procedure-related complications and predictive risk factors for total mortality. Results Sixty-two patients were included (mean age 93.3 ± 2.9 years at time of pacemaker replacement). Mean procedure duration was 35.7 ± 17.2 minutes. Mean hospital stay was 2.2 ± 1.1 days. One patient died from a perioperative complication. Thirty-seven patients (59.7%) died during a median follow-up of 22.1 months (interquartile range, 11.8–39.8 months). Survival rates were 84.2% (95% confidence interval [CI] 71.8–91.5%) at 1 year, 66.9% (95% CI 51.8–78.2%) at 2 years and 22.7% (95% CI 10.6–37.7%) at 5 years. Atrial fibrillation (hazard ratio 2.47, 95% CI 1.1–5.6) and non-physiological pacing (i.e. VVI pacing in patients in sinus rhythm) (hazard ratio 2.20, 95% CI 1.0–4.9) were predictors of mortality. Conclusions Pacemaker replacement in nonagenarians is a safe and straightforward procedure. These data suggest that procedures can be performed securely in this old and frail population, with patients living for a median of 30 months afterwards.

International audience; Radiofrequency catheter ablation is an important therapeutic option for patients with recurrent ventricular tachycardia (VT). The procedure aims at cauterizing regions of the ventricle. A good knowledge of anatomical structures and tissues properties can improve procedure safety and efficacy. This work aimed at analysing the feasibility of a workflow based on multimodal image integration to assist the intervention. We focused here on a model including myocardial thickness and fibrosis extracted from late gadolinium enhanced MRI (LGE-MRI) sequence, and left ventricular anatomy segmented from multiphase computed tomography (CT). The produced model can be imported within Carto-3® system (Biosense Webster Inc, Diamond Bar, CA), the software used during the ablation procedure. Four patients cases have been included in this preliminary study. The four produced patient specific models have been validated by a clinician, and two of them have been integrated within Carto-3® system and used during the intervention. © 2017 IEEE Computer Society. All rights reserved.

Aims Ventricular tachycardia (VT) ablation has been proven to be effective and safe to avoid arrhythmia recurrences in patients with repaired congenital heart disease (CHD). However, some of these patients may present right ventricular (RV) access issues [agenesia or thrombosis of inferior vena cava (IVC)], making impossible to access the right ventricle through an inferior approach. In such patients, only a superior approach would theoretically be feasible. Methods and results All VT ablations performed through a jugular or subclavian approach in CHD patients between 2012 and 2017 were included. Among 247 patients scheduled for VT ablation, two patients underwent three VT ablation procedures via a superior approach for due to the inability to access the right ventricle through a conventional IVC access (IVC interruption with azygos continuation in one patient and IVC thrombosis in the other). Ablation was performed using a three-dimensional system through a superior approach, using a subclavian access in both cases. A redo ablation had to be performed in the first patient using a jugular approach. Large curve catheters were used to facilitate RV outflow tract access. Supposed critical isthmuses could be localized and ablated. Patients remained free from arrhythmias during follow-up. Conclusion In patients with repaired CHD and 'no femoral access', ablation of RV tachycardia can be performed using a subclavian or a jugular approach. Mapping may be challenging, requiring large curve catheters. Conventional isthmuses can be mapped and ablated successfully, and such patients should not be denied radiofrequency ablation.

International audience; Objectives: Extracorporeal life support is used for patients with severe heart failure as a bridge to heart transplantation or recovery. We aimed at analyzing the efficacy and safety of extracorporeal life support to treat refractory arrhythmic storm responsible for cardiogenic shock in patients resistant to antiarrhythmic drugs. Design: Retrospective study. Setting: University Hospital of Rennes, France. Patients: Patients with refractory arrhythmic storm admitted between January 2005 and March 2015. Interventions: Patients with intractable refractory arrhythmic storm and cardiogenic shock despite optimal medical therapy were implanted with an extracorporeal life support. Patients’ characteristics and outcomes after extracorporeal life support implantation were analyzed. Measurements and Main Results: Twenty-six patients (23 men, 52.4 ± 9.2 yr old) were included, most of them having ischemic cardiomyopathy (65.4%). Stable sinus rhythm restoration was immediate in 61.5% of patients and occurred after a median time of 3 hours after extracorporeal life support implantation for the remaining ones. Thirteen patients (50%) eventually died, none of them due to extracorporeal life support–related complications, but mostly due to the occurrence of multiple organ failure, and occurred after a median time of 4 days. The remaining 13 patients (50%) had extracorporeal life support withdrawn after 6.7 ± 3.6 days and were discharged after 34.7 ± 14.7 days after admission. Patients with repetitive ventricular tachycardia/ventricular fibrillation episodes alternating with periods of sinus rhythm at the time of implantation had a better survival than those in refractory ventricular fibrillation (p = 0.017). Conclusions: This is the largest database of patients temporary implanted with extracorporeal life support for refractory arrhythmic storm responsible for cardiogenic shock resistant to antiarrhythmic drugs. It provides efficient hemodynamic support and survival rate after the implantation is 50%.

International audience; A newborn with complete congenital atrioventricular block of immune origin, in severe heart failure, was implanted with a pacemaker at 1 day of life. The pacing lead was fixed to the epicardial right ventricle and the generator conventionally implanted in a pocket created beneath rectus muscles...

International audience; Background - Sodium-channel blocker challenge (SCBC) is frequently performed to unmask Brugada syndrome. Objective - We aim to identify predictors of positivity and complications of SCBC in the setting of familial screening of Brugada syndrome. Methods - All consecutive patients from 2000 to 2014 who benefit from a sodium-channel blocker and belong to a family with at least 2 subjects affected by the syndrome were enrolled and followed prospectively. Data were reviewed by 2 physicians blinded to the clinical and genetic status. Results - Of the 672 SCBCs performed in 137 families, 337 (50%) were positive. Multivariate analysis identified ajmaline (odds ratio [OR] 2.98; 95% CI 1.65-4.91) and a significant S wave in lead DII (OR 3.11; 95% CI 2.12-4.58), DIII (OR 2.75; 95% CI 1.78-4.25), or V (OR 3.71; 95% CI 2.54-5.44) as predictors of a positive SCBC (P < .0001). Eleven patients (1.6%) presented complications (10 ventricular arrhythmias and 1 atrial flutter), but no deaths occurred. Familial history of complications (OR 41; lower quartile, upper quartile 10, 203; P < .0001), young age (P = .04), and decreased electrocardiographic conduction parameters at baseline (P = .04) were predictors of complications. QRS enlargement during SCBC was not associated with complications. During a median follow-up of 106 months (lower quartile, upper quartile 54, 143 months), 11 life-threatening arrhythmias occurred. Conclusion - SCBC in the screening of familial Brugada syndrome is safe. The risk of complication is considerably increased in the case of familial history of complicated SCBC, in young patients, and in the presence of decreased electrocardiographic conduction parameters. However, QRS enlargement during the test is not directly related to complications and should not be used to prematurely stop the test unless leading to false-negative results.

International audience

Introduction Worldwide demand for transvenous lead extraction (TLE) has significantly increased over the last decades. TightRailTM rotating-mechanical-sheath is one of the latest devices available for TLE. We aimed at comparing procedural safety and efficacy before and after the use of this system. Methods Patients referred to our tertiary center for TLE from January 2014 to October 2016 were prospectively included. The TightRailTM became available in our center in May 2015. Patients were assigned to the non-TightRailTM group before May 2015 and to the TightRailTM group afterwards. The two strategies and their outcomes were compared. Procedural efficacy (definition of HRS consensus) and safety were compared in the two groups. Results Ninety-six patients were included (66.9 ± 12.5years). A total of 187 leads were extracted, divided in 102 (54.5%) and 85 (45.5%) leads in the non-TightRailTM and TightRailTM groups respectively. A trend towards complete procedural success per lead (87.3 vs 92.9% P = 0.232) or per patient (75.9 vs 83.3% P = 0.452) and clinical success per lead (89.2 vs 96.5% P = 0.092) or per patient (81.5 vs 90.5% P = 0.256) was observed. By multivariable analysis, the use of TightRailTM (OR = 3.75 and 5.94), ICD lead (OR = 0.30 and 0.18) and delay from implant (OR = 0.99 and 0.99) were associated with both complete and clinical success per lead. There was no difference regarding minor and major complications. Conclusions TLE strategy using TightRailTM is safe and predicts a higher rate of complete procedural and clinical success per lead compared to a conventional approach.

We thank Drs. Bisbal and Adelino for their interest in our review [(1)][1] and for raising, once again, important questions about cardiac magnetic resonance (CMR). To write this article about CMR, we carefully read the seminal papers in the field, and tried to summarize them as fairly as possible.

A 48-year-old man with a biventricular ischaemic cardiomyopathy with severe left ventricular ejection fraction impairment (20%) and narrow QRS complexes underwent a single-chamber implantable cardioverter-defibrillator (ICD) implantation for secondary prevention. In December 2014, despite optimal medical therapy, the …

Background High-degree atrioventricular block (HAVB) is a common complication of ST-segment elevation myocardial infarction (STEMI). HAVB in STEMI is historically considered as a marker of worse outcome but overall data about HAVB in the contemporary era of mechanical reperfusion and potent antiplatelet therapies are scarce. Aim We aimed at analyzing incidence, clinical correlates and impact on inhospital outcomes of HAVB in a large prospective registry (ORBI) of modern management of STEMI with a special focus on potential differences between patients with HAVB on admission and those who developed HAVB during hospitalization. Methods All patients enrolled in ORBI between June 2006 and December 2013 were included in the present analysis and were divided into 3 groups: patients without HAVB at any time, patients with HAVB on admission and those who developed HAVB during hospitalization. Results 6662 patients (age: 62.0 [52.0-74.0]; male: 76.3%) were included in the present analysis. HAVB was documented in 3.5% of patients, present on admission in 63.7% of patients and occurring during hospitalization in 36.3%. Patients with HAVB on admission or occurring during the first 24h of hospitalization had higher in-hospital mortality rates (18.1% and 28.6% respectively) than patients without (4.5%) or with HAVB occurring beyond the first 24h of hospitalization (8.0%). However by multivariable analysis, HAVB was not independently associated with in-hospital mortality. Conclusion Patients with HAVB had a higher mortality rate than patients without. However HAVB is not an independent predictor of in-hospital mortality. Download : Download high-res image (214KB) Download : Download full-size image Abstract 0019 – Figure: Multivariable analysis

Article history: Received 8 October 2015 Accepted 18 October 2015 Available online 19 October 2015 of life. Two months later, the patient underwent an orthotopic heart transplantation,with no complications and he remains free of any cardiac symptoms at 1 year follow-up. Two criteria must be fulfilled to validate the presence of refractory angina: 1) ischemia should be authenticated by stress tests and should be responsible for symptoms of angina; 2) the patient is under maxi

International audience; Background High-degree atrioventricular block (HAVB) is a common complication of ST segment elevation myocardial infarction (STEMI). HAVB in STEMI is historically considered as a marker of worse outcome but overall data about HAVB in the contemporary era of mechanical reperfusion and potent antiplatelet therapies are scarce. Aim Analysing incidence, clinical correlates and impact on inhospital outcomes of HAVB in a large prospective registry (Observatoire Régional Breton sur l'Infarctus, ORBI) of modern management of STEMI with a special focus on potential differences between patients with HAVB on admission and those who developed HAVB during hospitalisation. Methods All patients enrolled in ORBI between June 2006 and December 2013 were included in the present analysis and were divided into 3 groups: patients without HAVB at any time, patients with HAVB on admission and those who developed HAVB during hospitalisation. Results A total of 6662 patients (age: 62.0 (52.0–74.0) years; male: 76.3%) were included in the present analysis. HAVB was documented in 3.5% of patients, present on admission in 63.7% of patients and occurring during hospitalisation in 36.3%. Patients with HAVB on admission or occurring during the first 24 h of hospitalisation had higher inhospital mortality rates (18.1% and 28.6%, respectively) than patients without (4.5%) or with HAVB occurring beyond the first 24 h of hospitalisation (8.0%). However by multivariable analysis, HAVB was not independently associated with inhospital mortality contrarily to age, presentation as cardiac arrest, anterior STEMI location, reperfusion therapy, cardiogenic shock, mechanical ventilation and occurrence of sustained ventricular tachyarrhythmias or mechanical complication. Conclusions Patients with HAVB had a higher mortality rate than patients without. However HAVB is not an independent predictor of inhospital mortality

International audience; Non-vitamin K oral anticoagulants (NOACs) are currently recommended for patients with nonvalvular atrial fibrillation since the publication of the 4 major pivotal trials evaluating the efficacy and safety of factor IIa and factor Xa inhibitors. The definition of nonvalvular atrial fibrillation is unclear, varying from one trial to another and even between North American and European guidelines, which is a source of uncertainties in clinical practice. However, many patients with atrial fibrillation present signs of valvular involvement, and clarification of this term is needed to not deny NOACs to patients based on the wrong perception that they may have valvular atrial fibrillation. The currently unique contraindications to NOACs are patients with mechanical heart valves and those with moderate-to-severe mitral stenosis, as stated by the recent 2015 position paper of the European Heart Rhythm Association. Patients with native heart valve involvement, regardless of their severity, are suitable for NOAC therapy. Patients with bioprosthetic heart valves and mitral valve repair may be suitable for NOACs except for the first 3 and the first 3-6 months postoperatively, respectively. Patients with transaortic valve implantation or percutaneous transluminal aortic valvuloplasty are also considered as being eligible for NOACs, although the bleeding risk has to be carefully considered in this population often requiring a combination with antiplatelet therapy. Future studies are warranted to increase the level of evidence of use of NOACs, particularly in patients with transaortic valve implantation and valvular surgery, and to determine whether they could be used in the future in the only 2 remaining contraindications. © 2016 Elsevier, Inc.

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.

Both cardiac resynchronization therapy with a pacemaker (CRT-P) and with a biventricular implantable cardioverter-defibrillator (CRT-D) are electrical treatment modalities validated for the management of chronic heart failure. There is no strong scientific evidence that a CRT-D must be offered to all candidates. Common sense should limit the prescription of these costly and complicated devices. The choice of CRT-P is currently acceptable. A direction to explore could be to downgrade from CRT-D to CRT-P at the time of battery depletion in patients with large reverse remodeling and no ventricular tachycardia and ventricular fibrillation detected.

A 9-year-old black African boy was hospitalized for heart failure revealing a severe left ventricular dysfunction associated with dilated cardiomyopathy, two submitral aneurysms, occlusion of the circumflex artery and a giant coronary artery aneurysm on the proximal left anterior descending artery. The boy was coinfected with human immunodeficiency virus and Mycobacterium tuberculosis. Though rare, association of Takayasu arteritis and submitral aneurysm leads to rethinking the pathogenesis of submitral aneurysm and suggests that some of them may be acquired. In our case, a common inflammatory process, possibly triggered by tuberculosis or HIV, may underlie Takayasu and submitral aneurysms.

Resume Interet du travail Les cardiologues sont une cible de choix pour l’industrie pharmaceutique. Nous avons voulu evaluer les contacts des internes de cardiologie, futurs prescripteurs, avec les laboratoires pharmaceutiques. Methodes Une enquete a ete envoyee par courrier electronique en juillet 2009 aux 266 internes inscrits au diplome d’etudes specialisees de cardiologie et maladies vasculaires aupres de la Societe francaise de cardiologie. Resultats Le questionnaire a ete retourne par 149 (56 %) internes. Dans leur blouse blanche, 145 (97 %) internes possedaient au moins un objet offert par l’industrie. Les cadeaux les plus courants etaient les cadeaux non educatifs (stylos, bloc-notes) et les tires a parts d’articles scientifiques. Les laboratoires pharmaceutiques ont invite 117 (79 %) internes a un congres regional ou national et 42 (29 %) a un congres international. Ces cadeaux etaient accueillis plutot favorablement sur le plan deontologique, en particulier les ouvrages scientifiques, les invitations aux congres et les seminaires de formation. Parmi les 128 internes ayant renseigne le montant minimal d’un cadeau qui, a leurs yeux, pourrait influencer le jugement d’un medecin, 36 (28 %) ont estime ce montant 1000 euros. Conclusions Les internes de cardiologie francais sont frequemment en contact avec l’industrie pharmaceutique, beneficiant de « petits cadeaux » mais egalement d’aide pour leur formation medicale. Ces interactions sont plutot bien acceptees par les internes et un enseignement sur leurs implications ethiques et leur influence sur la prescription pourrait etre mis en place dans le cadre de leur formation.