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BackgroundRisk-benefit for cardiac resynchronisation therapy (CRT) defibrillator (CRT-D) over CRT pacemaker remains a matter of debate. We aimed to identify patients with a poor outcome within 1 year of CRT-D implantation, and to develop a CRT-D Futility score.MethodsBased on an administrative hospital-discharge database, all consecutive patients treated with prophylactic CRT-D implantation in France (2010–2019) were included. A prediction model was derived and validated for 1-year all-cause death after CRT-D implantation (considered as futility) by using split-sample validation.ResultsAmong 23 029 patients (mean age 68±10 years; 4873 (21.2%) women), 7016 deaths were recorded (yearly incidence rate 7.2%), of which 1604 (22.8%) occurred within 1 year of CRT-D implantation. In the derivation cohort (n=11 514), the final logistic regression model included—as main predictors of futility—older age, diabetes, mitral regurgitation, aortic stenosis, history of hospitalisation with heart failure, history of pulmonary oedema, atrial fibrillation, renal disease, liver disease, undernutrition and anaemia. Area under the curve for the CRT-D Futility score was 0.716 (95% CI: 0.698 to 0.734) in the derivation cohort and 0.692 (0.673 to 0.710) in the validation cohort. The Hosmer-Lemeshow test had a p-value of 0.57 suggesting accurate calibration. The CRT-D Futility score outperformed the Goldenberg and EAARN scores for identifying futility. Based on the CRT-D Futility score, 15.9% of these patients were categorised at high risk (predicted futility of 16.6%).ConclusionsThe CRT-D Futility score, established from a large nationwide cohort of patients treated with CRT-D, may be a relevant tool for optimising healthcare decision-making.

AimsIn a recent position paper, the European Heart Rhythm Association (EHRA) proposed an algorithm for the screening and management of arrhythmias using digital devices. In patients with prior stroke, a systematic screening approach for atrial fibrillation (AF) should always be implemented, preferably immediately after the event. Patients with increasing age and with specific cardiovascular or non-cardiovascular comorbidities are also deemed to be at higher risk. From a large nationwide database, the aim was to analyse AF incidence rates derived from this new EHRA algorithm.Methods and resultsUsing the French administrative hospital discharge database, all patients hospitalized in 2012 without a history of AF, and with at least a 5-year follow-up (FU) (or if they died earlier), were included. The yearly incidence of AF was calculated in each subgroup defined by the algorithm proposed by EHRA based on a history of previous stroke, increasing age, and eight comorbidities identified via International Classification of Diseases 10th Revision codes. Out of the 4526 104 patients included (mean age 58.9 ± 18.9 years, 64.5% women), 1% had a history of stroke. Among those with no history of stroke, 18% were aged 65–74 years and 21% were ≥75 years. During FU, 327 012 patients had an incidence of AF (yearly incidence 1.86% in the overall population). Implementation of the EHRA algorithm divided the population into six risk groups: patients with a history of stroke (group 1); patients > 75 years (group 2); patients aged 65–74 years with or without comorbidity (groups 3a and 3b); and patients < 65 years with or without comorbidity (groups 4a and 4b). The yearly incidences of AF were 4.58% per year (group 2), 6.21% per year (group 2), 3.50% per year (group 3a), 2.01% per year (group 3b), 1.23% per year (group 4a), and 0.35% per year (group 4b). In patients aged < 65 years, the annual incidence of AF increased progressively according to the number of comorbidities from 0.35% (no comorbidities) to 9.08% (eight comorbidities). For those aged 65–75 years, the same trend was observed, i.e. increasing from 2.01% (no comorbidities) to 11.47% (eight comorbidities).ConclusionThese findings at a nationwide scale confirm the relevance of the subgroups in the EHRA algorithm for identifying a higher risk of AF incidence, showing that older patients (>75 years, regardless of comorbidities) have a higher incidence of AF than those with prior ischaemic stroke. Further studies are needed to evaluate the usefulness of algorithm-based risk stratification strategies for AF screening and the impact of screening on major cardiovascular event rates.

Background: Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are mainly due to pulmonary vein reconnection. However, a growing number of patients have AF recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown. We analyzed the impact of current ablation strategies in a large multicenter study. Methods: Patients undergoing a redo ablation for AF and presenting durable PVI were included. The freedom from atrial arrhythmia after pulmonary vein-based, linear-based, electrogram-based, and trigger-based ablation strategies were compared. Results: Between 2010 and 2020, 367 patients (67% men, 63±10 years, 44% paroxysmal) underwent a redo ablation for AF recurrences despite durable PVI at 39 centers. After durable PVI was confirmed, linear-based ablation was performed in 219 (60%) patients, electrogram-based ablation in 168 (45%) patients, trigger-based ablation in 101 (27%) patients, and pulmonary vein-based ablation in 56 (15%) patients. Seven patients (2%) did not undergo any additional ablation during the redo procedure. After 22±19 months of follow-up, 122 (33%) and 159 (43%) patients had a recurrence of atrial arrhythmia at 12 and 24 months, respectively. No significant difference in arrhythmia-free survival was observed between the different ablation strategies. Left atrial dilatation was the only independent factor associated with arrhythmia-free survival (HR, 1.59 [95% CI, 1.13–2.23]; P =0.006). Conclusions: In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.

Background: High incidence of covert paroxysmal atrial fibrillation (CPAF) detected by an implantable cardiac monitor (ICM) is expected in embolic stroke of undetermined source (ESUS) patients. This study aimed to determine the CPAF rate in an ESUS cohort using ICMs and compare stroke characteristics of patients with CPAF to those with known or inpatient-diagnosed AF (KIDAF). Methods: ESUS patients with ICMs were enrolled. ESUS diagnosis was defined as a non-lacunar stroke in the absence of symptomatic atherosclerotic stenosis (≥50%), no major-risk cardioembolic source, and no other specific cause. ESUS characteristics of patients with CPAF were compared to ESUS patients without CPAF and to KIDAF stroke patients. Results: During the median follow-up of 476 (371–615) days, CPAF was newly detected in 38/163 (23.31%) patients within 236 (115.50–510.75) days after the stroke. CPAF was independently associated to older age, coronaropathy, left atrial dilation, and atrial hyperexcitability, but not to stroke severity. Compared to KIDAF strokes, ESUS with CPAF had lower rates of proximal occlusion leading to milder clinical severity (NIHSS: 3.00 (1.00–8.25) vs. 14.50 (6.00–21.00)). Conclusions: Our study revealed a high proportion of CPAF in ESUS. We highlight that CPAF is a distinct clinical entity compared to KIDAF based on differences in stroke characteristics and AF diagnosis temporality.

International audience; Objectives: Temporary circulatory support (TCS) as a bridge-to-left ventricular assist device (BTL) in cardiogenic shock patients has been increasing, but limited data exists on this BTL strategy. We aimed at analyzing the outcome of BTL patients in a population of cardiogenic shock patients compared with those without TCS at the time of the left ventricular assist device (LVAD) surgery and identify predictors of postoperative mortality in this specific population.Design: A multicenter retrospective observational study conducted in 19 centers from 2006 to 2016.Setting: Nineteen French centers.Patients: A total of 329 cardiogenic shock patients at the time of LVAD implantation were analyzed. Patients were divided in three groups: those under TCS at the time of LVAD implantation (n = 173), those with TCS removal before LVAD surgery (n = 24), and those who did not undergo a bridging strategy (n = 152). Primary endpoint was 30-day mortality.Interventions: None.Measurements and main results: Among the BTL group, 68 (39.3%), 18 (10.4%), and 15 (8.7%) patients were under venoarterial extracorporeal membrane oxygenation, Impella, and IABP support alone, and 72 patients (20.6%) were under multiple TCS support. BTL patients presented similar 30 days survival compared with the TCS removal and non-BTL groups. However, BTL group had a significantly longer ICU duration stay, with two-fold duration of mechanical ventilation time, but the three groups experienced similar postoperative complications. Multivariate analysis identified three independent predictors of mortality in the BTL group: combined surgery with LVAD, body mass index (BMI), and heart failure (HF) duration. BTL strategy was not an independent predictor of mortality in cardiogenic shock patients who underwent LVAD.Conclusions: BTL strategy is not associated with a lower survival among cardiogenic shock patients with LVAD implantation. Predictors of mortality are combined surgery with LVAD, higher BMI, and HF duration.

International audience

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Funding Acknowledgements Type of funding sources: None. Objective. Risk-benefit assessment for cardiac resynchronization therapy defibrillator (CRT-D) over a CRT pacemaker (CRT-P) is still a matter of debate. We aimed to identify patients with a bad outcome within one year after CRT-D implantation, and to develop a Futile CRT-D score. Methods. Based on the administrative hospital-discharge database, all consecutive patients treated with CRT-D implantation in France between 2010 and 2019 were included. A prediction model was derived and validated for one-year all-cause death after CRT-D implantation (considered as futility) by using split-sample validation. Results. 28,503 patients were included in the analysis (mean age 68 ± 10 years); 2,139 (7.5%) deaths were recorded in the first year. In the derivation cohort (n = 14,252), the final logistic regression model included as main predictors of futility older age, diabetes, mitral regurgitation, history of hospital stay with heart failure, history of pulmonary oedema, atrial fibrillation, renal, pulmonary, liver, or thyroid disease, denutrition and anemia. Based on Futile CRT-D score, 17% of these patients were categorized at high risk (Futile CRT-D score ≥13) and predicted futility at 17%. Conclusion. The futility CRT-D score, established from a large nationwide cohort of patients treated with CRT-D may provide a relevant tool for optimizing healthcare decision. Death at one year in patients with CRTD OR (95%CI)pPointsAge (quartile)1.353 (1.266-1.446)61, 2 points when age >69, 3 points when age >75.Abstract Figure. AUC and incidences of all-causes death

Background QTc interval monitoring, for the prevention of drug-induced arrhythmias is necessary, especially in the context of coronavirus disease 2019 (COVID-19). For the provision of widespread use, surrogates for 12‑lead ECG QTc assessment may be useful. This prospective observational study compared QTc duration assessed by artificial intelligence (AI-QTc) (Cardiologs®, Paris, France) on smartwatch single‑lead electrocardiograms (SW-ECGs) with those measured on 12‑lead ECGs, in patients with early stage COVID-19 treated with a hydroxychloroquine−azithromycin regimen. Methods Consecutive patients with COVID-19 who needed hydroxychloroquine−azithromycin therapy, received a smartwatch (Withings Move ECG®, Withings, France). At baseline, day-6 and day-10, a 12‑lead ECG was recorded, and a SW-ECG was transmitted thereafter. Throughout the drug regimen, a SW-ECG was transmitted every morning at rest. Agreement between manual QTc measurement on a 12‑lead ECG and AI-QTc on the corresponding SW-ECG was assessed by the Bland-Altman method. Results 85 patients (30 men, mean age 38.3 ± 12.2 years) were included in the study. Fair agreement between manual and AI-QTc values was observed, particularly at day-10, where the delay between the 12‑lead ECG and the SW-ECG was the shortest (−2.6 ± 64.7 min): 407 ± 26 ms on the 12‑lead ECG vs 407 ± 22 ms on SW-ECG, bias −1 ms, limits of agreement −46 ms to +45 ms; the difference between the two measures was, Highlights • Artificial intelligence fairly interpreted QTc • Single lead smartwatch ECG is an option for home monitoring ECG • Because of social distancing necessity with COVID-19, home monitoring ECG is crucial.

Adenosine is a nucleoside that impacts the cardiovascular system via the activation of its membrane receptors, named A1R, A2AR, A2BR and A3R. Adenosine is released during hypoxia, ischemia, beta-adrenergic stimulation or inflammation and impacts heart rhythm and produces strong vasodilation in the systemic, coronary or pulmonary vascular system. This review summarizes the main role of adenosine on the cardiovascular system in several diseases and conditions. Adenosine release participates directly in the pathophysiology of atrial fibrillation and neurohumoral syncope. Adenosine has a key role in the adaptive response in pulmonary hypertension and heart failure, with the most relevant effects being slowing of heart rhythm, coronary vasodilation and decreasing blood pressure. In other conditions, such as altitude or apnea-induced hypoxia, obstructive sleep apnea, or systemic hypertension, the adenosinergic system activation appears in a context of an adaptive response. Due to its short half-life, adenosine allows very rapid adaptation of the cardiovascular system. Finally, the effects of adenosine on the cardiovascular system are sometimes beneficial and other times harmful. Future research should aim to develop modulating agents of adenosine receptors to slow down or conversely amplify the adenosinergic response according to the occurrence of different pathologic conditions.

Introduction Demonstration of exit block after pulmonary vein isolation (PVI) is the cornerstone of ablation for atrial fibrillation (AF). It requires the demonstration of local pulmonary vein (PV) capture and absence of conduction to the atrium but is often challenging due to the inability to see local paced PV-evoked potentials. We retrospectively examined the ability of adenosine to augment this technique during CARTO-based radiofrequency ablation procedures. Methods Retrospective analysis of evoked PV potentials during adenosine administration while testing for PV exit block at a single UK center. Results One hundred and twenty-nine PVs in 33 patients were isolated using radiofrequency energy to demonstrate entry block. Of those, the pacing of 24 veins under baseline conditions did not clearly demonstrate local PV-evoked potentials sufficient to be sure that the local vein was truly captured and dissociated from the atrium. Adenosine was administered in 19 of these, with 10 of 19 (52.6%) veins then demonstrating clear local PV-evoked potentials transiently during adenosine administration, sufficient to allow assessment of definite exit block. Conclusion Adenosine administered during PV pacing allows transient visualization of local PV-evoked potentials after PVI facilitating the clearer demonstration of PV exit block in over 50% veins.

Purpose Ablation of premature ventricular complexes (PVCs) originating from left-sided papillary muscles is challenging. We tested a new approach by performing high-density mapping of PVC. Methods and results We used a 20-pole deflectable spiral catheter during ablation procedures in four consecutive patients. Three presented with mitral valve prolapse, one with dilated cardiomyopathy. PVC burden was 24 ± 13%. The procedures lasted 182 ± 55.4 minutes, including 10 ± 3.2 minutes of radiofrequency. In all patients, mapping evidenced internal primary activation relative to the left ventricle shell (mean distance 21.3 ± 5.1 mm). Endocavitary prematurity was -38.3 ± 4.8 ms. Primary ablation success was achieved for all patients. Conclusions High-density mapping of the papillary muscles in the left ventricle using a spiral catheter may be feasible. We identified the PVC foci away from the left ventricular shell. This consolidates the assumption for the origin of these ectopic beats at the junction between the chordae tendineae and the papillary muscles.

INTRODUCTION The ConfiDENSE™ module (Carto3 v4) allows rapid annotation of endocardial electrograms acquired by multielectrode (ME) mapping. However, its accuracy in assessing atrial voltages is unknown. METHODS AND RESULTS Two ConfiDENSE™ left atrial voltage maps were created during continuous pacing in 20 patients undergoing catheter ablation for persistent AF using a ME lasso catheter and a contact force (CF) sensing ablation catheter. The automated tissue proximity indicator (TPI) filter was then applied to the ME map to yield a TPI map. Reference maps (RM) were created offline by a blinded observer by manually assessing all points against fidelity criteria. Bipolar voltages and proportion of low voltage points (

Aims Reimplantation of cardiac implantable electronic devices (CIEDs) after extraction due to device infection is a major issue in pacemaker-dependent patients. We compared in-hospital and long-term outcomes with two techniques: epicardial reimplantation (EPI) before CIED extraction and temporary pacing (TP) with a view to delayed endocardial reimplantation. Methods and results Two cohorts of consecutive pacemaker-dependent patients who underwent transvenous lead extraction at our tertiary centre were included in this retrospective cohort study. According to successive policies, either the EPI or the TP approach was used. In-hospital complications occurred at similar rates in the EPI (n = 59) and TP (n = 52) cohorts (37.3% vs. 32.7%, respectively; P = 0.61). Thirteen (25.0%) patients in the TP cohort eventually were reimplanted epicardially, mainly because of infection of the temporary lead. Finally, 65 patients were discharged with an epicardial device and 37 with an endocardial device. Median follow-up was 41.7 (interquartile range 34.1-51.5) months. No difference was observed in long-term mortality according to the reimplantation strategy, but use of TP was associated with a reduced risk of late endocarditis and device reintervention (hazard ratio (HR) 0.25, 95% confidence interval (CI) 0.09-0.069, P = 0.01), whereas epicardial device reimplantation was associated with an increased risk (HR 3.62, 95% CI 1.07-12.21, P = 0.04). Conclusion We observed similar in-hospital outcomes in our EPI and TP cohorts. Twenty-five percent of the patients initially paced by a TP strategy finally needed an epicardial device, mainly because of infection of their TP lead. Use of TP resulted in lower rates of late endocarditis and device reintervention.

Background The previous studies have shown that a systematic assessment, during the initial hospitalization after sudden cardiac death (SCD), provides the capacity to unmask specific etiology. The diagnosis of idiopathic ventricular fibrillation (IVF) is probably overestimated because of an unsystematic workup. Purpose We aimed to assess the profitability of comprehensive medical investigation strategy after SCD in a single university center. Methods Based on an implantable cardiac defibrillator data-base interrogation, the patients who survived from ventricular fibrillation without reversible cause were identified between 2012 and 2019. The etiological examinations performed during the initial hospitalization or planned after discharge were collected. Results In a cohort of 66 patients, retrospectively included, a minimal assessment including twelve-lead ECG, trans-thoracic echocardiography and coronary imaging allowed to unmask etiology for 40 (61%) patients. Ventricular fibrillation remained idiopathic for 16(24%) patients by adding magnetic resonance imaging, and for 12(18%) patients by performing provocative and genetic tests. Among the 54 patients for whom the diagnosis was confirmed, we reported 12(22%) electrical cardiac disorders, 11(20%) ischemic cardiopathy, 9(17%) dilated cardiomyopathy, 9(17%) valvular disease, 8(15%) hypertrophic cardiomyopathy, 4(7%) myocarditis and 1(2%) tako-tsubo syndrome. The number of examinations carried out in the IVF cohort did not differ from the others (6 vs. 5, P = 0.06). In the IVF group, SCD event occurred more frequently at rest (8/12 vs. 14/54, P = 0.02) and the patients were preferably women (9/12 vs. 13/54, P = 0.02). Conclusion Systematic etiologic investigations, carried out during initial assessment after SCD, allowed to unmask etiology for a large number of patients. Further studies are needed to standardize the workup to implement in all tertiary centers.

International audience; The mechanism of atrial fibrillation (AF) in patients with normal heart remains unclear. While exogenous adenosine can trigger AF, nothing is known about the behavior of endogenous adenosine plasma level (APL) at the onset of AF and during ablation procedure. Ninety-one patients (68 with paroxysmal AF: 40 males, 66 ± 16 years; 23 with persistent AF: 14 males, 69 ± 11 years) and 18 controls were included. Among paroxysmal patients: i) medical therapy alone was performed in 45 cases and ablation procedure in 23. AF was spontaneously resolutive in 6 cases; ii) 23 underwent ablation procedure and blood was collected simultaneously in a brachial vein and in the left atrium; 17 were spontaneously in sinus rhythm while 6 were in sinus rhythm after direct current cardioversion. Among persistent patients: i) in 17 patients, blood samples were collected in a brachial vein before and after direct current cardioversion; ii) in 6 patients, blood samples were collected simultaneously in a brachial vein and in left atrium before and after cardioversion during ablation procedure. CV-APL was higher in patients with persistent AF vs patients with paroxysmal AF (median [range]: 0.9[0.6-1.1] vs 0.7[0.4-1.1] μM; p < 0.001). In patients with paroxysmal AF, LA-APL increased during the AF episode (0.95[0.85-1.4] vs 2.7[1.5-7] μM; p = 0.03) and normalized in sinus rhythm after DCCV. In patients with persistent AF, LA-APL was higher than CV-APL (1.2[0.7-1.8] vs 0.9[0.6-1.1] μM; p < 0.001), and both normalized in sinus rhythm (CV-APL: 0.8[0.6-1.1] vs 0.75[0.4-1] μM; p = 0.03), (LA-APL: 1.95[1.3-3] vs 1[0.5-1.15] μM; p = 0.03). The occurrence of AF is associated with a strong increase of APL in the atrium. The cause of this increase needs further investigations.

Adverse left atrial (LA) remodeling is known to be associated with persistent atrial fibrillation (PeAF). The time course and pattern of reversal of LA remodeling following catheter ablation is poorly understood. We aimed to evaluate LA chamber volumes and dimensions, LA conduction velocities, and LA bipolar voltages at baseline and at 2 months after catheter ablation for PeAF. Twenty-three patients with PeAF underwent detailed LA mapping during fixed rate atrial pacing using the CARTO3 navigation system prior to undergoing pulmonary vein isolation. All patients returned for protocol-mandated repeat electrophysiology study at 2 months, irrespective of symptoms or arrhythmia recurrence, during which all measurements were repeated using an identical mapping protocol. Patients then underwent daily ECG monitoring for 12 months. Nineteen out of twenty-three (83.6%) patients had durable PVI of all veins at repeat electrophysiology study, while 4 (17.4%) patients had late reconnection of a single vein each. In the blinded offline analysis, LA volume at follow-up was significantly lower as compared with baseline (55 ± 14 mL/m2 vs. 65 ± 15 mL/m2, P

Introduction Atrial fibrillation (AF) is a multifactorial sustained cardiac arrhythmia with genetic predisposition. Genome-wide association studies (GWAS) have identified loci near key cardiac transcription factors encoding genes (TBX5, GATA4, NKX2.5) associated with AF risk. Consistently, adult-specific Tbx5 knockout mice showed primary spontaneous and sustained AF, induced by calcium handling abnormalities. The adenosinergic system may be implicated in the onset of AF. We previously showed that adenosine plasma levels increase in persistent AF, and atrial adenosine receptor overexpression is associated with reentry mechanisms. While calcium signaling proteins and potassium channels are major effectors of the adenosinergic system, and also triggers of AF, the link between TBX5, AF and the adenosinergic system has not yet been studied. Objective To assess how the intra-atrial adenosinergic system is associated with a higher susceptibility to atrial fibrillation in a mouse model. Methods Transgenic Cx40-CreERT2::Tbx5 floxed/floxed mice allow conditional deletion of Tbx5 in atria and the ventricular conduction system. Cre-mediated recombination was induced by intraperitoneal injection of tamoxifen in control (Cx40-CreERT2::Tbx5++) and mutant newborn mice. AF was investigated by surface ECGs between 2 weeks and 3 months. The adenosinergic system was assessed by adenosine plasma measurement, in vivo pharmacological tests, immunofluorescence and western blot analyses. Results At 2 weeks, prolonged P wave and PR interval durations (P Conclusion Tbx5 deletion specifically in atria increases susceptibility for atrial fibrillation confirming our model as a good one to study the role of the adenosinergic system in AF.

Background Cardiac resynchronization therapy (CRT), known as an effective treatment for heart failure in dilated cardiomyopathy (DCM), remains uncertain in hypertrophic cardiomyopathy (HCM), with conflicting results reported from previous studies. Purpose We aimed to study the efficiency of CRT in patients with HCM, heart failure and left ventricle systolic dysfunction. Methods From implantable cardioverter defibrillator (ICD) data-base of a single university center, patients with HCM, who received CRT, were identified and matched with resynchronized DCM in a 2:1 ratio on age at implantation (± 5 years), gender and left ventricular ejection fraction (LVEF) at implantation (± 5%). Clinical, electro-cardiographic and echocardiographic parameters were gathered at 1–6 months, 6–12 months and last follow-up after implantation. Results Between 2007 and 2018, we included 18 HCM patients (women 7(39%); at ICD implantation, age 59 ± 9 years, LVEF 38 ± 6%, NYHA class 2.8 ± 0.4) matched with 36 controls. At one year after implantation, the relative median change from baseline showed better improvement in HCM patients regarding: 1/NYHA class (−50% vs. − 20%, P Conclusion CRT improved heart failure symptoms and carried out reverse remodeling of the left ventricle in HCM with better outcomes than in DCM in long-term follow-up.

Background New-onset left bundle branch block (NO-LBBB) isfrequent after aortic valve replacement (AVR) andis associated with a higher occurrence of high-grade atrioventricular block (AVB) at one year. Standard electrophysiologic study (sEPS) is suboptimal for predicting occurrence of AVB. The incremental value of ajmaline challenge (ajEPS) in addition to sEPS to detect, among patients with NO-LBBB after AVR, those at risk of AVB still remains unknown. Methods We identified all the consecutive patients with NO-LBBB after AVR in a single academic center from January 2016 to December 2018. EPS consisted in infra-hisian conduction assessment at baseline and after atrial pacing without AJ and, since January 2018, before and after ajmaline injection. EPS was positive if HV interval 370ms at baseline or 3100ms after ajmaline and if intra/infra hisian block was reported at baseline of after AJ. Permanent pacemaker (PPI) was implanted if EPS was positive. Primary composite endpoint was occurrence of AVB (documented by ECG or PM control) or cardiac syncope during the follow-up. Results We included 86 patients (79 ± 10 years old), 63 transcatheter aortic valve implantation and 23 aortic bioprosthesis. sEPS was performed in 56/86 patients and this test was positive for 21/56. In ajEPS group (30/86 patients), the test was positive for 8/30. During the follow-up (11 ± 7 months), in sEPS group, 6/35 patients, with negative test, reached the endpoint (3 with AVB and 3 with cardiac syncope) while there was no event after negative ajEPS. sEPS and ajEPS provided respectively a sensivity of 45% and 100%; a specificity of 64% and 81%; a positive predictive value of 24% and 37,5% and negative at 83% and 100%. ajEPS is more efficiency to predict endpoint occurrence (P-value 0.014 Fisher test) compared to sEPS (P-value 0,73 fisher test) Conclusions Our results are in favour the use of Ajmaline in addition to standard EPS to identify patients with NO-LBBB after AVR who need a PPI.

Background Early repolarization pattern (ERP) is a common ECG aspect in general population. However, it is also associated with sudden cardiac death (SCD). ERP consensus definition has been recently published in 2015. While syncope is a common occur, ERP prevalence using new diagnostic criteria n this population remains unknown. Purpose We sought to determine prevalence of ERP in patient referred to syncope unit. Method We retrospectively analyzed the baseline 12-lead ECG of 150 patients without structural heart disease eferred to syncope unit for confirmed syncope between January 2017 and December 2018. After complete evaluation, yncope were classified as reflex, hypotensive, cardiac or unexplained. RP was defined as he presence of an end-QRS slur or notch with Jp elevation ≥ 0.1 mV, in ≥ 2 contiguous leads, excluding V1 to V3 nd QRS duration Results ERP was identified in 19 (12.7%) patients. A slurring was observed in 8 (42.1%) patients, a notch in 7 (36.8%) and 4 (21.1%) had both notching and slurring. p elevation was 1.63 ± 0.68 mm, with 9 (47.4%) patients presenting Jp elevation ≥ 0.2 mV. ERP was localized in inferior (n = 11(57.9%)), lateral (n = 3(15.8%)) or in both inferior and lateral leads (n = 5(26.3%)). It was associated with an ascendant ST-segment in 16 (84.2%) patients. Male and unexplained syncope were significantly more represented in patient with ERP, respectively 15 (79%) vs.62 (47.3%) (P = 0.01) and 8 (42.1%) vs.19 (14.5%) (P = 0.003). There was no difference between the two groups in term of age, number of syncope, family history of SCD, duration of syncopal history and injuries concomitant with syncope. Conclusion ERP was present in 12.7% of patients referred to syncope unit for confirmed syncope. There was a higher rate of unexplained syncope and men in this group. Further studies are needed to determine prognosis of ERP in this population.

Infections of cardiac implantable electronic devices (CIEDs) have increased over the past decade. However, the impact of the climate on CIED infections is unknown. To determine whether there is a seasonal variation in CIED infections. In this single-center observational study, retrospective analysis of prospectively collected data was performed. Timone Hospital in Marseille (south-east France) is a tertiary care institution and the regional reference center for management of CIED infections. All consecutive patients with CIED extractions for infectious reasons were included over a 12-year period. We noted the mean temperature (°C), precipitation (mm) and the incidence of CIED infections over this period. Among 612 patients [mean (standard deviation) age, 72.4 (13.0) years; 74.0% male], 238 had endocarditis alone (38.9%), 249 had pocket infection alone (40.7%), and 125 had both (20.4%). We found bacterial documentation in 428 patients (70.0%), commensal in 245 (40.0%). The incidence of CIED infections was positively associated with high temperature (regression coefficient = 0.075; P = 0.01) and precipitation (regression coefficient = 0.022; P 0.01). Seasonal variation was specific of pocket infections, whether they were associated with endocarditis or not. Subgroups with infection seasonality were: women, elderly people ( 75 years), late CIED infection and skin commensal bacterial infections. We found a seasonal variation in pocket infections, whether associated with endocarditis or not. Infections were associated with elevated temperatures and precipitation. Therefore, specific prevention strategy should be discussed in high-risk patients.

International audience; Subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD to prevent sudden cardiac death. Subcutaneous ICD implantation frequently requires general anesthesia because of procedure nociceptive steps during creation of a large device pocket and lead tunneling. This study aims to determine if a strategy of operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective in alleviating pain during S-ICD implantation. This prospective study included consecutive patients undergoing S-ICD implantation under controlled sedation with midazolam and combined analgesia with nalbuphine. The Critical-Care Pain Observation Tool (CPOT), a behavioral pain scale, was used for pain assessment during S-ICD placement and the Numeric Rate Scale (NRS) was used for evaluation of pain recollection after patient recovery. CPOT score of 3 or above and NRS score of 4 or above are considered to be associated with significant pain. Sixteen patients were included in this study: Ten men (62.5%) and six women with a mean age of 54 +/- 11 years. Indication for S-ICD implantation was primary prevention in 11 patients (68.8%). Mean dose of administrated midazolam and nalbuphine was 0.11 +/- 0.03 and 0.27 +/- 0.05 mg/kg, respectively. Mean CPOT during the whole procedure was 1.4 +/- 1.6. No patient presented procedural pain recollection as all 16 patients had NRS score less than 4. No serious adverse event related to sedation occurred during S-ICD implantation. This study suggests that operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective to alleviate procedural pain in patients undergoing S-ICD implantation and may constitute an alternative to general anesthesia.

Background A total of 25% to 40% of ischemic strokes are considered as cryptogenic stroke (CS) because etiology remain unclear, potentially because of misdiagnosis of Atrial Fibrillation (AF). Optimal monitoring duration to detect occult AF is debated but prospective data have demonstrated the benefits of long-term Holter Monitoring (HM). Purpose The aim of our study was to compare, in a real life study, 7 days Holter Monitoring (7DH) to 3 days Holter Monitoring (3DH) after CS, firstly in term of AF detection performance but also in term efficiency. Methods We performed a retrospective pilot study including all consecutives patients who had 7DH, performed in our university centre, after CS. The primary end point was the presence of AF episode lasting at least 30 seconds. When AF was detected, we newly interpreted the 7DH to consider if this AF episode happened during the first 3 days of monitoring, or later. Thus each patient was compared to himself and the conditions of the exam were similar between 7DH and 3DH. Results From the 01/08/2015 to 01/03/2018, 217 patients with no history of AF had a 7DH for CS. Mean population age was 67 ± 10 years old, with a median CHADSVASc score of 5 (4,6) and 22% of patients had a dilated left atrium. AF was detected in 13 patients (5.9%), among them 11 were detected in the first 72 hours (5%) (P = 0.157), which corresponded to one extra AF diagnosis every 108 HM. In term of efficiency, according to the availability, mean 7DH delay was 182 ± 380 days, which would be shorter using 3DH without additional recorders. HM reimbursement price by the Public French medical insurance is fixed at 77 euros unrelated to the monitoring duration. Finally, time consuming for the practitioner were lower according to the 3DH. Conclusion This pilot study showed a very low incremental benefit of AF detection performance with a worse efficiency, considering the 7DH compare to a 3DH. However further investigations are necessary to achieve definitive conclusions.

Aims We sought to compare outcomes and costs of a stepwise approach to transvenous lead extraction (TLE) involving laser-assisted sheaths or mechanical polypropylene sheaths, with/without crossover. Methods and results We prospectively included patients who underwent TLE (between August 2013 and December 2014) as part of a stepwise approach involving simple traction, lead snaring, and sheath-assisted dissection; all of these patients underwent a first-line polypropylene-sheath-extraction approach (Group A). The comparison group (Group B) was consecutive patients who had undergone TLE before August 2013, during which laser-assisted sheath extraction was the first-line approach. The number of patients in Group B was adjusted to match the number who eventually needed sheaths in Group A. Procedural data, outcomes, and costs were compared between groups (comparison of approaches) and in patients who needed sheath-assisted extraction (comparison of techniques). Overall, 521 leads were extracted (131 patients in Group A, 104 in Group B). Radiological and clinical success rates were similar; crossover from polypropylene to laser sheaths was needed in 10 patients in Group A (vs. none in Group B). Radiological ( P < 0.001) and clinical ( P = 0.01) success rates were higher and were achieved with a lower radiation exposure ( P = 0.03) with laser sheaths in patients (60 in each group) who needed sheath-assisted extraction. Complication rates were similar in both groups ( P = 0.66) but two deaths occurred in Group B. The laser approach had higher material cost ( P = 0.002). Conclusions Although laser-assisted TLE was more effective than polypropylene sheath-assisted TLE, the latter was associated with fewer complications and was more cost-effective.

International audience; Development of direct-acting antiviral agents against hepatitis C virus (HCV) has changed the management of chronic HCV infection. We report three cases of newly diagnosed or exacerbated pulmonary arterial hypertension (PAH) in patients treated with sofosbuvir. All patients had PAH-associated comorbidities (HIV coinfection in two, portal hypertension in one) and one was already being treated for PAH. At admission, all patients presented with syncope, World Health Organization functional class IV, right-sided heart failure, and extremely severe hemodynamic parameters. After specific PAH therapy, the clinical and hemodynamic properties for all patients were improved. Severity and acuteness of PAH, as well as chronology, could suggest a causal link between HCV treatment and PAH onset. We hypothesize that suppression of HCV replication promotes a decrease in vasodilatory inflammatory mediators leading to worsening of underlying PAH. The current report suggests that sofosbuvir-based therapy may be associated with severe PAH.

International audience; Although paroxysmal atrial fibrillation (AF) is known to be initiated by rapid firing of pulmonary veins (PV) and non-PV triggers, the crucial role of cardiac autonomic nervous system (ANS) in the initiation and maintenance of AF has long been appreciated in both experimental and clinical studies. The cardiac intrinsic ANS is composed of ganglionated plexi (GPs), located close to the left atrium-pulmonary vein junctions and a vast network of interconnecting neurons. Ablation strategies aiming for complete PV isolation (PVI) remain the cornerstone of AF ablation procedures. However, several observational studies and few randomized studies have suggested that GP ablation, as an adjunctive strategy, might achieve better clinical outcomes in patients undergoing radiofrequency-based PVI for both paroxysmal and nonparoxysmal AF. In these patients, vagal reactions (VR) such as vagally mediated bradycardia or asystole are thought to reflect intrinsic cardiac ANS modulation and/or denervation. Vagal reactions occurring during cryoballoon- (CB-) based PVI have been previously reported; however, little is known on resulting ANS modulation and/or prevalence and significance of vagal reactions during PVI with the CB technique. We conducted a review of prevalence, putative mechanisms, and significance of VR during CB-based PVI.

Background— Electromyography-guided phrenic nerve (PN) monitoring using a catheter positioned in a hepatic vein can aid in preventing phrenic nerve palsy (PNP) during cryoballoon ablation for atrial fibrillation. We wanted to evaluate the feasibility and efficacy of PN monitoring during procedures using second-generation cryoballoons. Methods and Results— This study included 140 patients (43 women) in whom pulmonary vein isolation was performed using a second-generation cryoballoon. Electromyography-guided PN monitoring was performed by pacing the right PN at 60 per minute and recording diaphragmatic compound motor action potential (CMAP) via a quadripolar catheter positioned in a hepatic vein. If a 30% decrease in CMAP amplitude was observed, cryoapplication was discontinued with forced deflation to avoid a PNP. Monitoring was unfeasible in 8 of 140 patients (5.7%), PNP occurred in 1. Stable CMAP amplitudes were achieved before ablation in 132 of 140 patients (94.3%). In 18 of 132 patients (13.6%), a 30% decrease in CMAP amplitude occurred and cryoablation was discontinued. Each time, recovery of CMAP amplitude took Conclusions— Electromyography-guided PN monitoring using a catheter positioned in a hepatic vein seems feasible and effective to prevent PNP during cryoballoon ablation using second-generation cryoballoon.

Introduction : la stimulation du système de conduction est une technique innovante permettant d’éviter la cardiopathie induite par la stimulation. Elle semble également prometteuse comme méthode de resynchronisation cardiaque et de plus en plus de centres d’électrophysiologies cherchent à étendre son utilisation à l’ensemble des indications de stimulation cardiaque. Nous avons réalisé cette étude pour évaluer et comparer la faisabilité, la fiabilité et la sécurité de deux méthodes de stimulation du système de conduction : la stimulation hissienne (SH) et la stimulation de la zone de la branche gauche (SBG) pendant la période d’apprentissage des opérateurs au sein du service de rythmologie du CHU Timone.Méthodes : tous les patients ayant bénéficié d’une tentative d’implantation de stimulation du système de conduction entre avril 2019 et mai 2022 ont été inclus dans l’étude. Les critères de succès étaient la présence de critères électrocardiographiques de capture hissienne pour la SH et la présence d’un aspect de bloc de branche droit en v1 et/ou d’un LVAT ≤ 80 ms pour la SBG. Le critère de jugement principal était le taux de persistance de critères électrocardiographiques de stimulation du système de conduction à plus de 3 mois de l’implantationRésultats : nous avons réalisé 42 implantations de SH et 50 de SBG. Le taux de succès d’implantation a été de 33(83%) pour la SH et 46(92%) pour la SBG alors que le taux de persistance ≥ 3 mois des critères de stimulation du système de conduction était supérieur pour la SBG (19(45%) vs 42(84%) ; p < 0,001). Les paramètres de sonde sont meilleurs et plus stables dans le temps pour la SBG que pour la SH. La courbe d’apprentissage est plus rapide pour la SBG que pour la SH.Conclusion : la stimulation de la zone de la branche gauche réalisée pendant la période d’apprentissage des opérateurs apparait comme une technique plus simple et plus fiable que la stimulation hissienne pour débuter la stimulation du système de conduction cardiaque dans un centre encore non expérimenté. En effet, nous avons observé un taux de persistance de capture du système de conduction au cours du suivi plus élevé, des paramètres de sonde de meilleurs qualités ainsi qu’une courbe d’apprentissage plus rapide pour la stimulation de la zone de la branche gauche.