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Funding Acknowledgements Type of funding sources: None. Introduction In a subset of patients with idiopathic ventricular fibrillation (IVF), the cause is identified as short-coupled premature ventricular complexes (ScPVCs), which mostly originate from Purkinje cells, and are often short-living and undetected. There is no consistent test allowing identification of patients vulnerable to this malignant arrhythmia. We aimed at evaluating sodium channel blocker (NaBl) testing in patients who survived IVF associated with SCPVCs. Methods We retrospectively reviewed data of 112 patients at 3 centers, with the diagnosis of IVF associated with spontaneous and documented scPVCs. No patient from the previous report was included. We analyzed all patients who underwent NaBl tests during evaluation of IVF. An arrhythmogenic NaB test was defined as the occurrence of ≥10 scPVCs and/or ≥ 1 repetitive form (couplet, triplet, run) during the test, without spontaneous scPVC at baseline. We defined scPVCs as an R-on-T pattern PVC. We evaluated the occurrence of scPVC during NaB infusion, the arrhythmia pattern and we compared the characteristics of the arrhythmogenic versus non-arrhythmogenic response groups. Data regarding anti-arrhythmic drug treatment and follow-up were collected at each center. Results In total, 48 patients were included (Table). The NaB tests were performed using ajmaline 1mg/kg/5 or 10min, or flecainide 2mg/kg/10min. Overall, an arrhythmogenic NaB test occurred in 23 of 48 (48%) patients. Isolated ScPVCs were observed in 11 patients, couplet/triplets in 10, and runs in 6. The arrhythmogenic response was reproduced in 5/5 patients who had a second NaB test during scPVC mapping before catheter ablation. There were no significant differences between patients with arrhythmogenic or non-arrhythmogenic NaB tests in all baseline clinical variables tested including VF burden (Table). All patients were followed at least 1 year after initial diagnosis and NaB test. Under hydroquinidine (600 or 900mg/day), appropriate defibrillator shocks occurred in 7 of 8 patients with arrhythmogenic NaB test; whereas shocks occurred only in 2 of 11 patients with non-arrhythmogenic NaB test (P=0.02). Conclusion Sodium blockers unravel scPVCs in up to 50% of patients with IVF and may therefore represent a valuable tool to detect a potential cause for sudden cardiac death (SCD) or unexplained syncope. Additionally, the arrhythmogenic response to NaB may be associated with the success of hydroquinidine in preventing IVF recurrence, a finding that suggests the existence of distinct scPVCs phenotypes and that may have important therapeutic implications. Further functional and genetical investigations are warranted to explore the mechanisms underlying this association.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic, inc. Introduction Advances in leadless pacemaker technology have enabled accelerometer based atrioventricular synchronous (AVS) pacing by sensing atrial mechanical contraction. However, acute safety performance of these devices in real-world clinical practice has not been assessed. Objectives To report the acute performance of the Micra AV transcatheter pacemaker from the worldwide Micra AV post-approval registry (PAR). Methods The Micra AV PAR is an ongoing prospective single-arm observational study designed to assess the safety and effectiveness of the Micra AV system in the real-world setting. Patients enrolled in the Micra AV PAR will be followed for 3 years. For the present interim analysis, baseline characteristics, total AV synchrony index (sum of %AM-VP, %AM-VS, and AV conduction mode switch percentage), and major complications occurring within 30-days of implant were summarized and compared to a historical cohort of 2,667 transvenous dual chamber (TV-DC) pacing patients. Results The device was successfully implanted in 797 of 802 patients (99.4%) at 99 centers. Mean age was 74.1±15.1 years and 42.3% were female. The most common pacing indication was AV block (55.7%). Comorbidities included diabetes (29.7%), CAD (22.8%), and heart failure (12.1%), with 31.3% precluded from transvenous device therapy. Micra AV patients were on average older (74.1 vs. 71.1 yrs, P Conclusions The Micra AV leadless pacemaker was implanted with a high rate of success in patients with a high co-morbidity burden, with a significantly lower rate of acute complications relative to dual-chamber transvenous pacemakers despite patients being older and having a higher incidence of renal disease. Longer-term performance will continue to be assessed in this ongoing trial.

Background Cardiac troponin I (cTnI) as measured by high-sensitive assays has been related to incident cardiovascular disease events (CVD) in the community. With the advent of ultra-sensitive assays, it is now possible to detect troponin I at very low concentration, far below the classical threshold of 1.9 pg/mL. However, the clinical relevance of these low concentrations for predicting CVD is largely unknown. Purpose To examine the association of cTnI as low as 0.013 pg/mL with incident cardiovascular disease events (CVDs) in the primary prevention setting. Methods cTnI was analyzed in the baseline plasma (2008–2012) of CVD free volunteers from the Paris Prospective Study III using for the first time a novel ultra-sensitive immunoassay (Simoa Troponin-I 2.0 Kit, Quanterix, Lexington) with a limit of detection (LOD) of 0.013 pg/mL. Incident CVD hospitalizations for coronary heart disease, stroke, arrhythmias, venous thromboembolism, arterial aneurysms and heart failure were validated by critical review of the hospital records. Hazard ratios were estimated per log-transformed standard deviation (SD) increase of cTnI in Cox models using age as the time scale. The added value (gain in discriminatory capacity) of cTnI for CVD risk prediction was examined by calculating the Harell's C-index boostraped difference of the SCORE 2 risk model with and without cTnI. Results There were 9503 CVD free participants (40% women) aged 59.6 (6.3) years at baseline. cTnI was detected in 99.6% of the participants (median value = 0.63 pg/mL, interquartile range [IQR] 0.39–1.09). After a median follow-up of 8.34 years (IQR, 8.0–10.07), 516 participants suffered 612 events. In fully-adjusted analysis, higher cTnI (per 1 SD increase of log cTnI) was significantly associated with CVD events combined (n=516, HR= 1.21; 1.06; 1.39). In univariate Cox analysis and compared to each single established risk factor, cTnI had the highest discrimination capacity for incident CVD events (C-index=0.6349) (Figure 1). Adding log cTnI to the SCORE 2 algorithm increased significantly albeit moderately discriminatory capacity (C-index 0.698 vs. 0.685; boostraped C index difference: 0.0135 (95% CI: 0.0131; 0.0138)). Conclusion cTnI concentrations as measured by a novel ultra-sensitive immunoassay is associated with a significant increased risk of incident CVD events in the primary prevention setting. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): ANR: French National Research AgencyEurope: Horizon 2020

Background Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs [1–4]. HeartLogic is an algorithm incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing preemptive treatment of congestion to prevent acute decompensation [5–7]. Objectives We aim to provide real-world data on the impact of pre-emptive HF management, guided by the HeartLogic index on unscheduled HF hospitalizations in a substantial cohort of patients. Methods The HeartLogic French Study is an investigator-initiated, prospective, multi-centre, non-randomized study. All in all, 310 patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450 ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic index calculation will be included across 10 French centers. The HeartLogic index will be monitored remotely on a weekly basis for 12 months and in case of HeartLogic index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, and unscheduled hospitalizations for ventricular or atrial arrhythmia. Blood samples will be collected for biobanking, and quality of life will be assessed. A blind and independent committee will adjudicate the events. Conclusions The HeartLogic French Cohort Study will provide robust real-world data on HF hospitalization in a cohort of patients managed with the HeartLogic algorithm allowing preemptive treatment of congestion. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

BACKGROUND: The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF.METHODS: The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events.RESULTS: Of 11,028 patients with AF, the median age was 71 (63-77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04-1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08-1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09-1.83]).CONCLUSION: In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.

Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific Background Despite aiming at improving patients’ health, healthcare consumes a large amount of resources and contributes to 4.6% of the global GHG/carbon emissions, 71% of the footprint being due the supply chain. It also produces millions of tons of complex waste per year. Yet, sustainability in EP remains a complex challenge as the performance and safety for patients are critical. Objective To set the ground to reduce electrophysiology (EP) catheters’ environmental impact. Methods A survey was conducted to poll European EP centers on 24 questions on sustainability practices and expectations. Results 278, mostly EP doctors (84%, 76% male, 43yo), working in a public environment (89%, >100 procedures/year in 53% and > 500 in 36%) participated. A majority of EP doctors uses 2 to 4 more catheters/sheath per paroxysmal AF ablation procedure. MAPPING/ABLATION catheters are discarded after the procedure (73&78%), with partial re-cycling (electrodes) in 23&26 %. Local/external sterilization is rarely used (12% & 9%). Catheters’ packaging are discarded in medical or general waste (38 & 31%) while it is recycled in only 19%. EP Healthcare professionals are highly motivated in being environment friendly in their personal (82%) and in EP practice (62%). They identify a lack of interest from their hospital in 59% (only 16% having an executive in charge). Other barriers are the complexity of sustainability processes (48%), the effort required to change practice (47%), infectious risk (41%), lack of training (37%) and cost (33%). EP Healthcare professionals would favor sustainable mapping /ablation catheters if performances were preserved (60 & 50%). They consider re-use as the most relevant solution (60%) while being currently illegal in some European countries. Packaging should be reduced in size or made reusable. Finally, they consider that regulatory (31%), education (19%) and recommendations by companies (19%) would encourage the field to transition to more environmentally friendly practices. Interestingly, age, gender, type of practice, country or experience did not impact the results. Conclusion EP Healthcare professionals demonstrate a willingness to adopt sustainable practices. They consider re-use as the most relevant approach as of today. 60/50 % would favour sustainable mapping/ablation catheters providing preserved performances. Leaping to the next level of sustainability will request development of new sustainable solutions, models and technologies. Reaching this urgent goal will require governments, industry, hospitals and doctors to work closely in a coordinated approach.

BACKGROUND: Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear.AIM: To assess the factors associated with cTn testing in routine practice and evaluate the association with outcomes.METHODS: Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into 3 groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism /any acute coronary syndrome/cardiovascular (CV) death, defined as Major Adverse Cardiovascular Events (MACE) and all-cause death were the main endpoints.RESULTS: Among 10 445 AF patients (median age 71 years, 40.3% females) cTn were tested in 2834 (27.1%). cTn was elevated in 904/2834 (31.9%) and in-range in 1930/2834 (68.1%) patients. Female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease, and atypical AF symptoms were independently associated with cTn testing. Elevated cTn were independently associated with a higher risk for MACE (Model 1, hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.40-2.16, Model 2, HR 1.62, 95% CI 1.28-2.05; Model 3 HR 1.76, 95% CI 1.37-2.26) and all-cause death (Model 1, HR 1.45, 95% CI 1.21-1.74; Model 2, HR 1.36, 95% CI 1.12-1.66; Model 3, HR 1.38, 95% CI 1.12-1.71).CONCLUSIONS: Elevated cTn levels were associated with an increased risk of all-cause mortality and adverse CV events. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.

Background Atrial arrhythmias are common complications in adults with congenital heart disease (ACHD) and are associated with high morbi-mortality. Atrial tachycardia (AT) including intra-atrial reentrant tachycardia and focal atrial tachycardia are the most prevalent arrhythmias in ACHD. We aimed to compare mid-term outcomes according to arrhythmia management. Methods All hospitalizations for AT in ACHD were retrospectively identified from medico-administrative database from September 2006 to September 2016 in two centers. Outcomes of patients with AT managed with direct-current cardioversion (DCCV) were compared with patients referred for catheter ablation (CA). Atrial arrhythmia recurrence, stroke, admission for heart failure and death were analyzed during follow-up. Results One hundred and twenty-one ACHD with AT (median age 41 [IQR 32–52] years, male 62%, 41% moderate CHD and 38% complex CHD) were included. Median follow-up was 3.3 years [IQR 1.4–6.2]. Thirty-seven (30.5%) patients underwent DCCV and 84 (69.5%) CA. No significant difference in age, CHD complexity, history of atrial arrhythmia, heart failure, and CHA2DS2-VASC score were observe. Patients undergoing DCCV had higher NYHA class. Atrial arrhythmia recurrence was lower in CA group (Log-rank test, p ​= ​0.045). Most recurrences were AT, but atrial fibrillation was recorded in 35.1% after DCCV and 9.5% after CA (p ​= ​0.001). At the end of follow-up, patients who were initially treated by CA had a significantly lower incidence of severe cardiovascular events (48.6% in DCCV group vs. 16.7% in CA group, HR: 0.46, CI 95%: 0.22–0.93, p ​= ​0.031). Conclusions A proactive management of AT by CA is associated with better long-term outcomes in ACHD.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Abbott Vascular Int. (2011–2014), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2017), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2017), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2009–2018). The Atrial Fibrillation NETwork (AFNET), conducting the registry in Germany, received support from The Bristol Myers Squibb/Pfizer Alliance (2014–2018) and the German Centre for Cardiovascular Research (DZHK). Funding from Daiichi-Sankyo and Boehringer-Ingelheim have been received for conducting the registry in Spain. Funding from BMS-Pfizer Alliance was received to support the programme in France Background The 4S-AF scheme (Stroke risk, Symptom severity, Severity of atrial fibrillation [AF] burden, Substrate severity) has recently been described as a novel approach to in-depth characterization of AF, and included in the 2020 European Society of Cardiology guidelines for the management of AF. Purpose In the present study, we validated for the first time the 4S-AF scheme in the Spanish and French cohorts of the EurObservational Research Programme (EORP)-AF Long-Term General Registry. Methods The Spanish and French cohorts of the EORP-AF Long-Term General Registry, were merged and included. The baseline 4S-AF scheme was calculated as follows: Symptom severity (according to EHRA symptom score: 0-2 points), Severity of AF burden (according to AF type: 0-3 points), Substrate severity (according to comorbidities/cardiovascular risk factors: 0-7 points); and related to the primary management strategy (rhythm or rate control). According to the results for these 3 domains, four code colors have been defined. Patients with all domains in "green" should be managed by rhythm control. In patients with one domain in "yellow" or two domains in "green" categories, rhythm control can be attempted. On contrary, for patients with "red" color category, the 4S-AF scheme suggests a rate control strategy. All-cause mortality and the composite of ischemic stroke/transient ischemic attack/systemic embolism, major bleeding and all-cause death, were the primary endpoints. These outcomes were recorded during 1-year of follow-up. Results 1479 patients (36.9% females, median age of 72 [IQR 64-80] years) were included (Table 1). The median 4S-AF scheme score was 5 (IQR 4-7). The 4S-AF scheme, as continuous and as categorical, was associated with the management strategy decided for the patient (both p Conclusion Characterization of AF by using the 4S-AF scheme may aid in identifying AF patients that would be managed by rhythm or rate control, and could also help in identifying high-risk AF patients for worse clinical outcomes in a ‘real-world’ setting. Abstract Table 1 and Figures 1A-1B

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): INSERM - French Society of Cardiology OnBehalf DAIT4F Investigators Background Sudden cardiac death is a major cause of death in tetralogy of Fallot (TOF) and right ventricular overload is commonly considered as a potential trigger for ventricular arrhythmias. Purpose We aimed to assess the impact of pulmonary valve replacement (PVR) on ventricular arrhythmias burden using a population of TOF patients with continuous cardiac monitoring by implantable cardioverter defibrillator (ICD). Methods Nationwide French registry including all TOF patients with an ICD. Survival data with recurrent events were used to compare the burden of appropriate ICD therapies before and after PVR in patients who underwent PVR over the study period. Results A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% males) were included from 40 centers. Over a median (IQR) follow-up period of 6.8 (2.5-11.4) years, 26 (15.8%) patients underwent PVR. Among those patients, 18 (69.2%) experienced at least one appropriate ICD therapy. When considering all ICD therapies delivered before (n = 62) and after (n = 16) PVR, the burden of ICD appropriate therapies was significantly lower after PVR (HR 0.21, 95%CI 0.08-0.56, p = 0.002). In the overall cohort, PVR before ICD implantation was also independently associated with a lower risk of appropriate ICD therapy in primary prevention patients (HR 0.29, 95%CI 0.10-0.89, p = 0.031). Conclusions In this cohort of high-risk TOF patients implanted with an ICD, the burden of appropriate ICD therapies was significantly reduced after PVR. While optimal indications and timing for PVR are debated, these findings suggest the importance of considering ventricular arrhythmias in the overall making-decision process. Abstract Figure.

Sudden cardiac death, mostly related to ventricular arrhythmia, is a major public health issue, with still very poor survival at hospital discharge. Although coronary artery disease remains the leading cause, other etiologies should be systematically investigated. Exhaustive and standardized exploration is required to eventually offer specific therapeutics and management to the patient as well as his/her family members in case of inherited cardiac disease. Identification and establishing direct causality of the detected cardiac anomaly may remain challenging, underlying the need for a multidisciplinary and experimented team.

Sarcoidosis is a multisystemic granulomatous disease of unknown cause occurring in young adults. Cardiac sarcoidosis patients are at increased risk for atrioventricular blocks and ventricular arrhythmias. Sinus node dysfunction is scarcely reported.We report a case of cardiac sarcoidosis revealed by a sinus node dysfunction and focus on cardiac and thoracic imaging to guide diagnosis.Sinus node dysfunction may be the first manifestation of cardiac sarcoidosis. In unexplained sinus node dysfunction in young patients, advanced cardiac imaging is a key to cardiac sarcoidosis diagnostic. Early recognition of cardiac sarcoidosis enables to start immunosuppressive treatment and discuss implantable cardioverter defibrillator implantation.

Sudden cardiac death (SCD) during sports activities accounts for a small but significant proportion of all SCD, with recent studies consistently reporting around 5% of overall SCD occurring during sporting activity. The emphasis on young competitive athletes as opposed to recreational sports participants is discordant with the relative magnitudes of the respective problems, which was recently highlighted by several recent population-based studies. There is a crucial need to focus attention on this large at-risk population of subjects. Although coronary artery disease represents the vast majority of underlying mechanisms in recreational middle age cases, cardiomyopathies and inherited electrical disorders remain significant among the youngest. Strategies to reduce SCD burden related to sports should incorporate targeted screening, public education and consideration of warming symptoms, improving rates of bystander CPR and early AED use.

Objectives This study sought to assess the relationship between an immediate invasive strategy and survival after an out-of-hospital cardiac arrest (OHCA) of presumed cardiac cause, according to prognosis evaluated on hospital arrival. Background An immediate coronary angiogram (CAG) may be associated with better outcome after OHCA in neurologically preserved patients but could be futile in other cases. Methods From May 2011 to May 2015, we collected data for all patients admitted in hospital after OHCA in Paris and its suburbs (France). Risk of in-hospital death was retrospectively calculated using the validated Cardiac Arrest Hospital Prognosis score, which includes age, setting, initial rhythm, durations from collapse to basic life support and from basic life support to return of spontaneous circulation, pH, and epinephrine dose. Independent predictors of survival at discharge (including immediate CAG) were assessed in multivariate logistic regression in each of the 3 pre-defined subgroups of Cardiac Arrest Hospital Prognosis score: low risk ( 200 points) for in-hospital death. Results A total of 1,410 patients were included and overall survival rate at hospital discharge was 32%. Distribution in the low-, medium-, and high-risk Cardiac Arrest Hospital Prognosis subgroups was 667 (47%), 469 (33%), and 274 patients (20%), respectively. The rate of early CAG was 86%, 66%, and 47% in the low-, medium-, and high-risk subgroups, respectively (p Conclusions In cardiac arrest patients, our results suggest that investigations regarding early CAG after OHCA should focus on patients with preserved neurological status.

Background Atrial arrhythmias are common complications in adults with congenital heart disease (ACHD) and are associated with a high morbidity and mortality. Intra-atrial reentrant tachycardia (IART) is the most prevalent arrhythmia in this population. This study aimed to compare outcomes according to arrhythmia management. Methods All hospitalisations for IART in ACHD patients were retrospectively identified from medico-administrative database from September 2006 to September 2016. Outcomes of patients with IART managed with direct-current cardioversion (DCCV) were compared with patients referred for catheter ablation (CA). Atrial arrhythmia recurrence, death, stroke and first admission for heart failure (HF) were analyzed during follow-up. Results Ninety-one ACHD patients with IART (baseline median age 38 years [IQR 29-50], male 64%, 45% moderate CHD and 41% complex CHD) were included. Median follow-up was 3 years [IQR 1.6-6.7]. Twenty-six (28.6%) patients underwent DCCV and 65 (71.4%) CA. No significant difference in CHD complexity, past medical history of atrial arrhythmia and HF were observed between the 2 groups. Patients who underwent DCCV were significantly older (43 years [IQR 34–51] vs. 36 years [IQR 26–44], P = 0.03), with a higher CHADS-VASC score (CHADS-VASC ≥ 1 in 61% in DCCV group vs. 44% in CA group, P = 0.001). Atrial arrhythmia recurrence was observed in 52% after CA and 65% after DCCV ( Fig. 1 A, P = 0.28). Most of recurrence were IART, but atrial fibrillation was recorded in 37.5% after DCCV and 25.8% after CA (P = 0.4). At the end of follow-up, patients who were initially treated by CA were more frequently in sinus rhythm (84% vs. 27%, P = 0.02), with a significant lower incidence of severe cardiovascular events ( Fig. 1 B, P Conclusions A proactive management of IART by catheter CA is associated with better mid-term outcomes in adult patients with CHD.

Introduction A significant increase in the prevalence of sudden cardiac arrest (SCA) with non-shockable rhythm (NSR) has been reported. Factors associated with NSR and the mode to the return of spontaneous circulation (ROSC) may help for a better understanding. Purpose We aimed to describe the frequency, characteristics and outcome of NSR related SCA in the community. Methods In this prospective ongoing multicentre population-based registry (6.7 million inhabitants), data from all SCA were analyzed. Medical records for each SCA were reviewed by two cardiologists to identify aetiology and associated conditions. Results Among the 3,028 SCAs admitted alive out of a total of 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 2,904 patients had available information regarding initial rhythm. Among them, 1,314 patients (45.3%) presented with NSR: 1,109 (38.2%) cases with asystole, 197 (6.8%) with pulseless electrical activity and 8 (0.3%) with high degree atrioventricular block. NSR cases were older (60.6 vs. 57.4 years, P Conclusions Initial NSR is encountered in almost half of SCA cases admitted alive; mostly occurs in older patients with higher proportion of females. Over three quarters of these cases did not require external defibrillation prior to ROSC.

Background Ventricular arrhythmias and sudden death are potential late complications in patients with tetralogy of Fallot. Data regarding the value of implantable cardioverter defibrillators (ICD) are scarce in this population. Purpose To assess long-term rates of appropriate ICD therapies and ICD-related complications in a large registry of ICD recipients with tetralogy of Fallot. Methods The DAI-T4F study is an ongoing national French registry including all patients with tetralogy of Fallot and ICD (NCT03837574). Information have been collected prospectively since 2010 with annual update. Baseline patient characteristics and clinical events during follow-up were analyzed with central adjudication. Cox proportional hazard models were used to identify factors associated with appropriate ICD therapies and complications. Results A total of 134 patients (median age 41.7 years, 70.7% males) were enrolled. The median (IQR) follow-up duration was 6.1 (2.7–10.2) years. ICDs were implanted for primary prevention in 47 (35.1%) patients and for secondary prevention in 87 (64.9%) patients. Overall, 14 (29.8%) and 45 (51.7%) patients received at least one appropriate ICD therapy in primary and secondary prevention, respectively, giving annual incidences of 5.5% and 7.1% (p=0.06). Patients with altered left ventricle ejection fraction (LVEF) at inclusion ≤35% experienced less appropriate ICD therapies (HR=0.31, 95% CI: 0.11–0.86, p=0.02), whereas a history of sustained or non-sustained ventricular arrhythmia (HR=2.7, 95% CI: 1.2–3.9, p=0.03) was positively associated with appropriate therapies. Fifty-seven (42.5%) patients had ICD-related complications, including 32 (24.2%) inappropriate ICD shocks, 22 (16.4%) significant lead dysfunction, 14 (10.4%) device infection, and 5 (3.7%) generator dysfunction/recall. History of supraventricular arrhythmias (HR=2.2, 95% CI: 1.2–3.7, p=0.01) and congestive heart failure (HR=2.0, 95% CI: 1.2–3.6, p=0.01) were both associated with a higher risk of complications. During follow-up, 7 (5.2%) patients underwent cardiac transplantation and 12 (9.0%) patients died, mainly from progressive heart failure (n=5). Only one sudden death due to electrical storm was recorded. Figure 1 Conclusions Appropriate therapies are frequent in patients with tetralogy of Fallot and ICDs, including in primary prevention. The relatively important proportion of ICD-related complication highlights the need for improving risk stratification in this population, considering associated conditions in the individual benefit-risk equation.

Introduction Implantable Cardioverter Defibrillator (ICD) in sudden cardiac arrest (SCA) is indicated in non-reversible cardiac causes. A systematic description of SCA survivors discharged without an ICD has not been undertaken thus far. Purpose We aimed to describe the frequency, characteristics and etiologies of SCA survivors discharged without an ICD. Methods In this prospective ongoing multicentre community-based study (6.7 million inhabitants), data from all SCA cases alive at hospital discharge, over a 5-year period, were analyzed with a specific focus on survivors. All medical records were reviewed by two cardiologists to identify underlying mechanisms and ascertain etiologies. Results Among the 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 717 survivors at hospital discharge fulfilled definition for cardiac SCA. Among them, 247 patients (34.5%) received an ICD and 468 (65.4%) did not. Compared to the ICD group, the group without ICD were older (58.9 vs. 52.6 years, P Conclusions Almost two third of SCA survivors were discharged without an ICD; while this was largely related to ACS and coronary stenting, some cases of chronic CAD as well as drug refractory coronary spasm in this population may represent lost opportunity, warranting further studies addressing this specific issue.

Introduction Since a large proportion of patients resuscitated from out-of-hospital sudden cardiac arrest (SCA) die in the intensive care unit (ICU), early systematic investigation towards identifying etiology may be crucial to ensure appropriate future prevention among relatives, especially when the index case is young. Purpose We hypothesized that etiologic investigations were not initiated in a timely manner in a significant proportion of young SCA patients prior to death. Methods In this prospective ongoing multicenter, population-based registry (6.7 million inhabitants), data from all SCA over a 5-year period were analyzed with a specific focus on young patients ( Results Of the 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 3,028 were admitted alive to ICU. Among them, 2,190 (72.3%) died in ICU, including 367 (16.8%) young cases ( Conclusion More than half of young SCA cases who died in ICU remained unexplained. Efforts to promote early systematic investigation through better collaboration between intensivist and cardiologist may improve future targeted preventive strategies for family members.

Background Acute myocarditis is associated with cardiac arrhythmia in 25% of cases; a third of these arrhythmias are ventricular tachycardia (VT) or ventricular fibrillation (VF). The implantation of a cardiac defibrillator (ICD) following sustained ventricular arrhythmia remains controversial in these patients. Objectives We sought to assess the risk of major arrhythmic ventricular events (MAE) over time in patients implanted with an ICD following sustained VT/VF in the acute phase of myocarditis compared to those implanted for VT/VF occurring on myocarditis sequelae. Methods Our retrospective observational study included patients implanted with an ICD following VT/VF during acute myocarditis or VT/VF on myocarditis sequelae, from 2007 to 2017, in 15 French university hospitals. MAE was defined as any appropriate intervention of the defibrillator (antitachycardia pacing or shock) on VT/VF. Results Over a median follow-up period of 3 years, 11(39%) patients of the acute myocarditis group and 24(60%) patients of the myocarditis sequelae group experienced one or more MAE. Kaplan–Meier MAE rate estimates at one and three years follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group, respectively. There was no significant difference in the number or type of MAEs in the two groups. Conclusion Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results challenge current guidelines for ICD implantation in acute myocarditis associated with VT/VF by showing that the risk of MAE recurrence remains high after the resolution of the acute episode.

Background Considering major shifts in coronary artery disease (CAD) epidemiology over the last two decades, we hypothesized that CAD was probably henceforth the main etiology of sudden cardiac arrest (SCA) among young adults. Purpose To describe burden and features of CAD-related SCA in young (≤ 40 year-old) adults using a contemporary community-based study. Methods From May 2011 to 2016, all cases of SCA admitted alive across 48 hospitals of the Greater Paris Area were prospectively enrolled and young SCA ( Results Out of 18,662 out-of-hospital cardiac arrests, 3028 SCA were admitted alive, with 353 (11.7%) being ≤ 40 year-old (32.1 ± 6.2 year-old, 70.8% males). Among the 1,557 (51.4%) patients with an established cardiac cause, 142 (9.1%) were aged less than 40-years. CAD accounted for 58 (40.8%) cases, whereas non-ischemic heart disease and non-structural heart disease for 52 (36.6%) and 32 (22.5%), respectively. Within the 30–40 year age group, CAD represented 53.7% of all diagnoses. While 86.2% of CAD-related young SCA was due to an acute coronary syndrome (ACS), rate of immediate coronary angiography at hospital admission was only 39.2% compared to 63.4% among those > 40-years (OR = 0.38, 95% CI: 0.27–0.53, P Fig. 1 ). Conclusions CAD is a major cause of SCA in young adults, representing > 50% of SCAs occurring in the fourth decade. With ACS representing the major part of these events, the observed low rates of immediate coronary angiography suggest an important missed opportunity for early intervention.

Some anomalous connections of the coronary arteries may be associated with a risk of sudden cardiac death. In opposite with others cardiac diseases at risk of sudden cardiac death, the relationship between these congenital abnormalities and the risk of sudden cardiac death are not well understood. A correction of the anomaly is generally indicated after an aborted sudden cardiac death. Primary prevention strategy after the discovery of an anomaly at risk is debated. Even if the absolute risk of sudden death is very low, a pre-participation screening in young athletes may be discussed due to a non-rare incidence.

Sudden cardiac death is defined as a natural and unexpected death, in a previous apparently healthy individual. It represents a major public health issue, with up to 50% of the cardiovascular mortality. Using data from the Paris Sudden Death Expertise Centre registry, this article summarises the main cardiovascular abnormalities associated with sudden cardiac death, the different preventives approaches, and provides a systematic diagnostic approach.

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Background TOF is the most frequent congenital heart disease managed by cardiologists, at particularly high risk of sudden cardiac death (SCD). However, few studies have reported long-term outcomes of TOF with ICD. Purpose We aimed to report characteristics and outcomes from a large population of TOF with ICD. Methods Between 2005 and 2016, all TOF implanted with an ICD in 22 centers were enrolled to determine characteristics at implantation and outcomes. Results Overall, 101 patients (43 ± 13 years, 69% males) were enrolled. A majority was implanted for secondary prevention (71%), whereas the remaining (29%) was for primary prevention. Among the latter, risk factors for SCD were: severe pulmonary regurgitation (25%), prior palliative shunt (43%), syncope (21%), inducible ventricular tachycardia (VT) (39%), non-sustained VT (29%), QRS duration ≥ 180 ms (19%), left ventricular significant dysfunction (29%, with ejection fraction ≤ 45%), and sustained supra-VT (46%). After a mean follow-up of 6.0 ± 4 years, 44 (43%) experienced ≥ one appropriate therapy (25% in the primary vs. 51% in the secondary prevention group), giving annual-incidences of 4.95% and 14.1%, respectively (P = 0.009). The median time between ICD implantation and the first appropriate therapy was 0.70 years (0.26–3.75), without significant differences between primary and secondary prevention (P = 0.27). Overall, ≥ 1 complication occurred in 40 patients (39%), including inappropriate shock (n = 26), major pocket hematoma (n = 1), lead dysfunction (n = 15), infection (n = 6), algodystrophia (n = 2), device failure needing reintervention (n = 3). Eventually, 6 patients received heart transplant (6%), and 9 (9%) died during the course of follow-up. Conclusions TOF and ICDs experience high rates of appropriate therapies, especially in secondary prevention. ICD-related complications remain very high. Selection of candidates for primary prevention remains challenging and can be potentially improved.

Background Cocaine use in the general population has increased in recent years and although cardiovascular effects of cocaine have been investigated, cocaine-related sudden cardiac arrest (SCA) in the overall community has been described only through forensic studies. Methods In this prospective ongoing multicentre population-based registry, all SCA alive at hospital admission over a 5-year period were prospectively enrolled. Cocaine-associated SCA were compared to other causes of SCA in terms of characteristics, management and outcomes. Results Among the 3028 SCAs admitted alive out of a total of 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 32 SCAs (1.1%) were eventually associated with cocaine use, including 18 (56.3%) after acute use. Compared to SCA from other cause, cocaine-related SCA victims were younger (44.1 vs. 59.3 years, P Conclusions In the general population, cocaine-associated SCA is a rare cause of SCA (1.1%), mostly occurring in young actively smoking men, immediately after acute use in more than half of cases. Coronary spasm, though representing the principal underlying mechanism, explains finally only one third of cocaine-associated SCA.

Sudden cardiac death is a major public health problem with around 40,000 cases per year in France. Epidemiological, clinical and prognostic differences according to gender have been described in most cardiovascular diseases, including sudden cardiac death. In this article, we will review gender differences in sudden cardiac death incidence, circumstance of occurrence, management, and prognosis.

Tropical endomyocardial fibrosis (FET) is a leading cause of heart failure and the most common restrictive cardiomyopathy worldwide. Extensive fibrosis of the ventricular endocardium causing architectural distortion, impaired filling and valvular insufficiency define the disease. Confined to peculiar and limited geographical areas, the aetiology remains blurred and it carries a grim prognosis. The changing burden reported recently in some endemic areas and the refinement of diagnostic tools have emphasized alternative routes for understanding and treatment of the disease.

Cardiac arrhythmias, with, on top of the list, atrial fibrillation, are frequent conditions and any physician might have to get involved at any stage of patient care (from diagnosis to treatment), without always having the opportunity to immediately refer to the cardiologist. The aim of this review is to present a summary of pathophysiology, clinical and electrocardiographic presentations, as well as diagnostic and therapeutic strategies for the main cardiac arrhythmias. Supra-ventricular tachycardias (atrial fibrillation and flutter, atrioventricular reciprocating tachycardias) and ventricular tachycardias will be consecutively presented and discussed.

Background Sudden cardiac arrest (SCA) is a major cause of deaths in Europe, but population-based data on specific etiologies, such as structural non ischemic heart disease (SNIHD) are lacking. Purpose We sought to determine the frequency, characteristics and outcomes of SCA associated with SNIHD in the general population. Methods In this prospective ongoing multicentre population-based registry, data from all SCA were analyzed. SNIHD included different non ischemic cardiomyopathies, as well as valvular, hypertensive and congenital heart diseases. Medical records were reviewed by cardiologists to identify clinical conditions underlying SCA. Results Of the 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 3028 SCAs (16.2%) were admitted alive to hospital. Two hundred and twenty four (7.4%) SNIHD were diagnosed during hospitalization, including dilated cardiomyopathy (DCM) (44.2%), valvular heart disease (19.2%), hypertrophic cardiomyopathy (13.4%), myocarditis (6.7%), congenital heart disease (3.1%) and arrhythmogenic right ventricular dysplasia (2.7%). As compared to other causes of SCA, SNIHD patients were significantly younger (55.2 vs. 59.6 years, P Conclusion In our registry, SCA associated with SNIHD presented distinctive features compared to non-SNIHD, and overall accounted for only 7% of the overall SCA burden. Main causes were DCM and valvular heart disease. Better characterization of this population, especially the sizeable subgroup with left ventricular ejection fraction > 35% can improve sudden death risk stratification in this group.

Background Considering that most patients resuscitated from out-of-hospital sudden cardiac arrests (SCA) die in the intensive care unit (ICU), early systematic etiologic investigation may represent an important strategy towards targeted therapy and appropriate prevention to first-degree relatives at risk. Purpose We aimed to determine the extent to which SCA cases who died in the ICU were investigated. Methods In this prospective ongoing multicentre population-based registry, data from all SCA patients who died in ICU were analyzed. The extent of investigations was defined as complete either in case a combination of coronary angiography (CA), brain, chest CT scan, and trans-thoracic echocardiography (TTE) was performed, or diagnosis found after one of those. SCAs dying in the first 24 hours were excluded because of their poor hemodynamic condition for investigation. Results Of the 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 3028 SCA (16%) were admitted alive to ICU, and 2190 (72.3%) died in ICU. After first day exclusion, 947/1417 (66.8%) fulfilled criteria for complete investigations and 470/1417 (33.2%) in the other group. In the group with incomplete investigations, CA was performed in 162 patients (34.6%), TTE in 207 (44.2%), and brain and/or chest CT in 186 (39.6%). A final diagnosis was made for 895 patients (94.5%) in the group with complete investigations: 403 (45.0%) acute CAD, 149 (16.7%) chronic CAD, 115 (12.9%) neurological causes, 80 (8.9%) structural non-ischemic heart disease, 48 (5.4%) pulmonary embolism. Overall, among all unexplained SCA who died in ICU, 434 (89.3%) had incomplete investigation. Conclusions Over a third of SCA who died in ICU did not undergo complete etiologic investigations, preventing from potential adequate familial screening. Improvement in systematic medical assessment is crucial to provide appropriate therapy and prevention to family members.