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Understanding dynamic propagation in persistent AF (PersAF) and identifying left atrial (LA) zones associated with AF maintenance from intracardiac electrogram (EGM) analysis is key to develop patient-tailored ablation strategy. Assess the clinical benefit of a novel AF mapping algorithm (Ockham) for individualized extra-PVI ablation. All procedures were performed under general anesthesia with a high-density mapping system (at least 2 EGM maps). The Ockham algorithm assesses local EGM activation rapidity (local cycle length, LCL) and the relative amount of continuous activity (duty cycle, DC) with repetitive EGM morphology. Ockham targets were selected with DC > 90% and fastest LCL in the scatterplot (Fig. 1). The procedure ended once all areas were ablated, or if AF converted to sinus rhythm (SR) or atrial tachycardia (AT). Cardioversion was performed if AF continued. Follow-up visits and 24H Holter monitoring were made at 4 months. Twenty-eight PersAF patients (pts) were enrolled (16 de novo, 6 long-standing PersAF, 60 ± 10 years, dilated LA, median volume 208 mL [158–267]). Median procedure time was 145 min [80–210]. LA maps included 37,822 ± 17,805 EGMs. PVI was performed with a 5-spline pulsed field ablation (PFA) catheter in 15 de novo pts and RF in the other pts. Extra-PV Ockham zones were targeted either by RF (30–35 W, 9 pts), vein of Marshall ethanol infusion (4 pts), PFA (11 pts), or a combination of techniques (RF + PFA, 7 pts). Ablation led to AF termination in 14 pts. The scatter plot mostly showed a normal LCL histogram (min 123 ± 33 ms; max 229 ± 43 ms; LCL peak 165 ± 31 ms). Personalized ablation led to a shift toward longer LCL and lower DC (Fig. 1). In the first 20 follow-up pts, 2 (10%) had AF recurrence, 3 (15%) AT. Tailored Ockham ablation led to AF termination in 50% pts with PersAF and dilated LA. Early mid-term follow-up results appear encouraging, with 75% arrhythmia-free pts. [ABSTRACT FROM AUTHOR]

Permanent pacemaker implantation (PPI) is commonly required following transcatheter aortic valve implantation (TAVI). High burden of right ventricular pacing (RVP) has been associated with increased risk of heart failure hospitalization in both general and TAVI population. There is very limited data on the predictive factors of high burden of RVP in post-TAVI patients with PPI. To identify predictive factors of high burden of RVP in patients undergoing post-TAVI PPI. High burden of RVP was defined as a pacing percentage > 40% (40%VP) at 3 to 12 months follow-up. All dual chamber pacemakers were programmed with algorithm favoring spontaneous AV conduction, except in case of persistent complete AV block (DDD mode). For the latter, AV conduction was assessed at 3-month visit; in case of AV conduction recovery, pacemaker was reprogrammed with an algorithm favoring spontaneous AV conduction and one-year ventricular pacing percentage was used for the primary analysis. Risk score for 40%VP was determined from multivariable logistic regression analysis. From January 2013 to July 2023, 2458 consecutive patients underwent a TAVI procedure in our institution. PPI was required in 289 patients (11.8%), 200 of whom had pacemaker follow-up performed at our center and were included in the analysis. 40%VP was found in 87 patients (43.5%) at 3 to 12 months follow up. The multivariable model showed that male gender (OR = 2.33, 95% CI 1.24–4.39), permanent atrial fibrillation (OR = 2.65, 95% CI 1.14–6.14), and high degree AV block as reason for PM implantation (OR = 5.36, 95% CI 2.37–12.15) were independent predictors of 40%VP (Table 1). A risk score (H2AS score) predicting 40%VP was determined from the multivariable model and included High Degree AV block indication for PPI (2 points), permanent AF (1 point) and male sex (1 points), with a score of 0 identifying 6.1% prevalence of 40%VP, a score of 1–2 identifying 31.9% prevalence of 40%VP and a score of > 3 identifying 64.6% prevalence of 40%VP (Fig. 1). 40%VP can be anticipated using a readily available pre-PPI risk assessment. The H2AS risk-score may help to better pre-define the most appropriate ventricular pacing strategy. Conduction system pacing could be favored in patients with a high H2AS score in order to avoid the deleterious effects of RVP-induced ventricular desynchronization. [ABSTRACT FROM AUTHOR]

Tricuspid annular plane systolic excursion over systolic pulmonary artery pressure (TAPSE/sPAP), a good noninvasive approach for right ventricular to pulmonary artery (RV/PA) coupling, is of prognostic significance in many cardiovascular diseases. Yet, data regarding RV/PA coupling in transcatheter aortic valve replacement (TAVR) remain sparse. To assess the change in TAPSE/sPAP between pre- and post-TAVR as well as its long-term prognostic value. All patients who underwent TAVR for severe aortic stenosis between 2002 and 2022 at Rouen University Hospital, with an available TAPSE/sPAP assessed by echocardiography before and after procedure were included in this study. When available, TAPSE/sPAP was correlated with invasive right heart catheterization data. The primary endpoint was 5-years all-cause death or hospitalization for acute heart failure. C-tree analysis was used to find the best TAPSE/sPAP cut-off to be associated with the primary outcome. Two hundred and sixty-nine patients were included in this analysis (median age 85 years, 57% women, 63% NYHA III-IV). Balloon expandable valves was implanted in 90% of cases. TAPSE/sPAP was significantly improved by TAVR (0.52 vs 0.58 mm/mmHg, P = 0.02). The lower the TAPSE/sPAP, the higher the NYHA functional class (P = 0.0017), the higher the NTproBNP level (P < 0.001) and the higher the Euroscore (P < 0.001). TAPSE/sPAP had a good correlation with pulmonary artery elastance (r = –0.61, P < 0.001). Using C-tree analysis, TAPSE/sPAP ≤0.55 mm/mmHg was the best cut-off to be associated with the primary outcome (P = 0.002). In multivariable Cox regression analysis, TAPSE/sPAP remained independently associated with the primary outcome even after adjustment with echocardiography (HR = 0.20, 95%CI [0.04–0.89], P = 0.03), comorbidities (HR = 0.24, 95%CI [0.08–0.74], P = 0.03) or Euroscore (HR = 0.30, 95%CI [0.09–0.95], P = 0.04). Both from baseline and follow-up assessment, patients with TAPSE/sPAP ≤0.55 mm/mmHg had worse event-free survival (Figure 1A–B). Interestingly, change in TAPSE/sPAP provided important prognostic value (Figure 1C). This study emphasizes the prognostic value of TAPSE/sPAP in the field of TAVR and suggest considering RV/PA coupling assessment not only before or after procedure but also the change in TAPSE/sPAP to identify patients at higher risk of worse outcome. [ABSTRACT FROM AUTHOR]

Vascular complications remain an important issue after transcatheter aortic valve implantation (TAVI) and are associated with poorer outcomes. Some studies have suggested that ultrasound-guided femoral access approach reduce the rate of vascular complications as compared to angio-guided femoral puncture. In addition, transfemoral approach has been commonly used as secondary access in transcatheter aortic valve replacement. Scarse data have reported the potential benefit of transradial approach as secondary access. The aims of our study were to compare the incidence of vascular complications in one hand between ultrasound and angio-guided femoral puncture of the principal access and between femoral and radial secondary access on the other hand during TAVI. This is a monocentric, observational, retrospective study, including 808 patients who underwent transfemoral TAVI from January 2021 to September 2023 in our institution. The incidence of in-hospital of Vascular complications were reported according to Valve Academic Research Consortium 3. The mean age was 82 ± 0.3 years. Ultrasound and angio-guided femoral puncture were performed in 445 (55.1%) and 363 (44.9%) patients, respectively. A transfemoral or a transradial approach were used as a secondary access in 482 (59.7%) and in 316 (39.1%) patients, respectively. Vascular complications occurred in 48 patients (6%) included 12 major (1.5%) and 36 minor (4.5%) complications. Only 12 (1.5%) complications occurred in the secondary access. There was no significant difference in the occurrence of total and major vascular complications after ultrasound or angio-guided puncture (5.2 vs. 5.5%, P = 0.65; 1.6 vs. 1.4%, P = 0.65; respectively). Furthermore, there was no significant difference in the incidence of vascular complications between femoral or radial secondary access (1.5 vs. 1.6%, P = 0.93). The results of our study are in apparent contradiction with recent studies suggesting that ultrasound-guided femoral puncture of the principal access and the used of transradial approach as secondary access reduce the incidence of vascular complications after TAVI. Further randomized studies are required in order to better assess their interest. [ABSTRACT FROM AUTHOR]