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Aims Cryoballoon (CB) based pulmonary vein isolation (PVI) is a widely used technique for treatment of atrial fibrillation (AF); however the ideal energy dosing has not yet been standardized. This was a single-centre randomized clinical trial aiming at assessing the safety, acute efficacy, and clinical outcome of an individualized vs. a fixed CB ablation protocol using the fourth-generation CB (CB4) guided by pulmonary vein (PV) potential recordings and CB temperature. Methods and results Patients were randomized in a 1:1 fashion to two different dosing protocols: INDI-FREEZE group (individualized protocol): freeze-cycle duration of time to effect plus 90 s or interruption of the freeze-cycle and repositioning CB if a CB temperature of −30°C was not within 40 s. Control group (fixed protocol): freeze-cycle duration of 180 s. No-bonus freeze-cycle was applied in either patient group. The primary endpoint was freedom from atrial tachyarrhythmia at 12 months. Secondary end points included procedural parameters and complications. A total of 100 patients with paroxysmal AF were prospectively enrolled. No difference was seen in the primary endpoint [INDI-FREEZE group: 38/47 (81%) vs. control group: 40/47, (85%), P = 0.583]. The total freezing time was significantly shorter in the INDI-FREEZE group (157 ± 56 s vs. 212 ± 83 s, P < 0.001), while procedure duration (57.9 ± 17.9 min vs. 63.2 ± 20.2 min, P = 0.172) was similar. No differences were seen in the minimum CB and oesophageal temperatures as well as in periprocedural complications. Conclusion Compared to the fixed protocol, the individualized approach provides a similar safety profile and clinical outcome, while reducing the total freezing time.

Aims Pulmonary vein isolation (PVI) often is not sufficient in patients (pts) with persistent atrial fibrillation (AF). Substrate modification (SM) by catheter ablation (CA) of low-voltage zones (LVZ) has yielded favourable results, but those studies were performed before the introduction of contact force (CF) sensing technology. Surgical ablation (SA) studies support the hypothesis that empiric bi-atrial linear ablation (Cox Maze IV procedure) is able to improve success, but there is less data on outcome of patients undergoing left atrial (LA) linear lesions alone. In current guidelines, both CA and SA have Class IIa indication in pts with persistent AF. In this single-centre retrospective study, we analysed the long-term outcomes of CA and SA in pts with persistent AF. Methods and results In the CA group (Figure 1), pts underwent PVI and additional SM in the presence of LVZ (roof line and supero-septal line) using TactiCath™ or SmartTouch™ ablation catheters aiming at contact values ≥10 g 400 g/s. Ablation was performed in a temperature-controlled fashion with energy of 30 W except at the posterior wall (20–25 W). In the SA group (Figure 2), pts underwent ablation procedure (creation of a pure LA endocardial lesion set consistent with the Cox Maze IV) performed by a right mini-thoracotomy approach using the Atricure™ cryoablation probe, a left atrial appendage (LAA) epicardial exclusion using the Atriclip™ system, and mitral valve repair in the presence of severe mitral valve regurgitation. No right atrial lesions were created. 196 pts were included. 120 pts underwent CA [median age: 65 (58–72) years, median LA volume index (LAVI): 66 (56–75) ml/m2], in pts with LVZs PVI + SM was performed [bidirectional block of lines in 100%]. 76 pts underwent SA [median age: 64 (58–74) years, median LAVI 90 (78–103) ml/m2], in 42 pts a mitral valve repair was performed. At 24 months (figure), 89% and 68% of pts were free of AF in the SA and CA group, respectively, mainly without antiarrhythmic drugs (92% SA group and 89% CA group). Conclusions In patients with persistent AF, SA performed by a right mini-thoracotomy approach with linear lesions limited to LA leads to excellent 2-year freedom from AF despite significantly larger LAVI compared with the CA group. LAA epicardial exclusion likely contributed to surgical efficacy by eliminating the LAA as trigger/driver.

Introduction: Although pulmonary vein (PV) isolation (PVI) is very effective in paroxysmal atrial fibrillation (AF), in patients (pts) with persistent AF, PVI often is not sufficient. Many studies suggested that low voltage zones (LVZs) outside of the PV might be involved in the complex mechanisms perpetuating AF. However ablation strategies involving substrate modification (SM) did not show additional benefits in persistent AF pts. Those studies were performed before the introduction of contact force technology, and the most likely explanation for these results could be the inability to achieve effective transmural lesions and continuous linear ablation. Hypothesis: We hypothesized that the use of contact force technology would improve ablation efficacy. Therefore, we analyzed the long-term outcome after two different ablation strategies in pts with persistent AF depending on whether there was evidence of LVZs in the left atrium or not. Methods: The presence of LVZs were defined as sites of >3 adjacent low-voltage points 400g/s. Ablation was performed in a temperature-controlled fashion with energy of 30W except at the posterior wall (20-25W). Results: 121 consecutive pts with persistent AF (46 female, median age 66 [59-72] years, mean duration of AF 16 [7-73] months, CT derived LA volume index 66 [56-75]ml/m2) were included: pts without LVZs underwent PVI alone (n = 74), in pts with LVZs, PVI + SM (n = 47) was performed (mitral Isthmus line in 2, supero-septal line in 39, and roof line in 47; bidirectional block was achieved in 100%, 97%, and 100%, respectively). After a median follow-up of 13 [6-21] months, 86% of pts without and 78% with substrate were in sinus rhythm, mainly without antiarrhythmic drugs (89% PVI only, 84% PVI + SM). Conclusions: In patients with persistent AF without LVZs, PVI alone leads to excellent 2-year freedom from AF. In pts with LVZs, additional substrate modification with CF sensing technology is associated with improved success rates compared to previous studies.

Background Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single-shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. Objective We hypothesized that computed tomography-derived (CT) left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. Methods In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electro-anatomic voltage maps were created. LVZs were defined as areas ≥1cm2 with bipolar peak-to-peak voltage amplitudes ≤0.5 mV. Results In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the ZAQ score (age≥65 years, female sex and CT LAVI≥57ml/m2). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (AUC 0.809, 95% CI 0.758-0.861, p Conclusions The ZAQ score identifies LVZs and may be useful for planning the ablation strategy ahead of time (single shot PVI vs 3D mapping-guided ablation) regardless of whether the AF pattern is paroxysmal or persistent. Figure legend. Proposed AF ablation workflow independent of the temporal pattern of AF (ie. paroxysmal vs. persistent). (CT) Computed Tomography, (LAVI) Left Atrial Volume Index, (PVI) Pulmonary vein isolation. *Low voltage zones, if present, could be targeted with additional substrate modification ablation Conflict of Interest None

BACKGROUND Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low-voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single-shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. OBJECTIVE We hypothesized that computed tomography (CT)-derived left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. METHODS In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electroanatomic voltage maps were created. LVZs were defined as areas ≥1 cm2 with bipolar peak-to-peak voltage amplitudes ≤0.5 mV. RESULTS In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the Zentralklinik Bad Berka and University of L'Aquila (ZAQ) score (age ≥65 years; female sex; and CT-LAVI ≥57 mL/m2 ). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (area under the curve [AUC], 0.809; 95% confidence interval [CI], 0.758-0.861; P

Background: CRT has been proven to achieve most benefit in patients with left bundle branch block morphology (LBBB). However, ECG criteria to define LBBB significantly differ from each other. Objective of the study was to evaluate the impact of different ECG criteria for LBBB definition on survival, hospitalization for heart failure and reverse remodelling in patients who received cardiac resynchronization therapy (CRT). Methods and results: Three-hundred-sixteen consecutive patients were included in the analysis. Six different classifications were assessed in baseline ECGs of patients who received a CRT device: a QRS duration of >= 150 ms and LBBB according to AHA/ACC/HRS, ESC 2006, ESC 2009, ESC 2013 and the classification proposed by Strauss and colleagues. In univariate analysis, the ESC 2009 and 2013 and the Strauss classifications were significantly associated with a reduction in cumulative probability for heart failure (HF) andmortality (HR 0.60, 95% CI 0.42-0.86, HR 0.61, 95% CI 0.43-0.87 and HR 0.57, 95% CI 0.40-0.80, respectively). Inmultivariate analysis, the association with the combined endpoint was confirmed only for ESC 2009 and 2013 classifications and for Strauss. Moreover, the cumulative probability of all-cause death and HF hospitalizations was higher in patients who were negative for all the 5 LBBB classifications. Conclusions: This study shows that the strength of the association of LBBB to outcome in CRT depends on the ECG classifications used to define LBBB, the simplest criteria (ESC 2009 and 2013) providing the best association with clinical endpoints in CRT. (c) 2018 Elsevier B.V. All rights reserved.

International audience; Cardiac resynchronization therapy is not effective in a variable proportion of heart failure patients. An accurate knowledge of each patient's electroanatomical features could be helpful to determine the most appropriate treatment. The goal of this study was to analyze and quantify the sensitivity of left ventricular (LV) activation and the electrocardiogram (ECG) to changes in 39 parameters used to tune realistic anatomical-electrophysiological models of the heart. Electrical activity in the ventricles was simulated using a reaction-diffusion equation. To simulate cellular electrophysiology, the Ten Tusscher-Panfilov 2006 model was used. Intracardiac electrograms and 12-lead ECGs were computed by solving the bidomain equation. Parameters showing the highest sensitivity values were similar in the six patients studied. QRS complex and LV activation times were modulated by the sodium current, the cell surface-to-volume ratio in the LV, and tissue conductivities. The T-wavewas modulated by the calcium and rectifier-potassium currents, and the cell surface-to-volume ratio in both ventricles. We conclude that homogeneous changes in ionic currents entail similar effects in all ECG leads, whereas the effects of changes in tissue properties show larger inter-lead variability. The effects of parameter variations are highly consistent between patients and most of the model tuning could be performed with only ~10 parameters.

Pericardial effusion (PE) may occur during the lead extraction procedure (TLE). Little is known about the incidence, causes, and predictors of this complication. From January 2009 to October 2016, TLE was attempted for 297 leads in 212 patients (age 69.3 ± 12.9 years, 169 male, BMI 27.2 ± 9.9 m²/kg, LVEF 43.4 ± 24.6%) for lead dysfunction (62.7%), upgrade (16.0%), infection (14.2%), or other (7.0%) indications. TLE was performed under general anesthesia with continuous invasive arterial blood pressure and transesophageal echocardiography (TEE) monitoring. For lead removal, the mechanical approach was first attempted, followed by the laser-assisted technique when needed. Severity of PE was defined by the presence of hemodynamically significant PE > 10 mm at TEE. Clinical success was achieved for 292 leads (98.3%). New-onset PE was observed in 14 patients (6.6%) [mild entity in 7 patients (3.3%) and severe in 7 (3.3%)]. In these latter patients, intra-procedural management included surgery (n = 3), pericardiocentesis (n = 2), or a conservative approach (n = 2). Right ventricular (RV) site lesions were treated with a simple fluid infusion. Laceration of the superior vena cava and other vessels resulted in rescue surgery. Lesions of the right atrial free wall (n = 1) and coronary sinus (n = 1) were treated with pericardiocentesis. NYHA III/IV, LVEF < 35%, renal impairment, right-sided implant, and ≥2 leads targeted for TLE were associated with new-onset PE. More than two factors identified a higher risk group (16.2%, 95% CI 6.2–32.0%, P = 0.02). New-onset PE is common during TLE and is associated with specific factors. PE severity and subsequent patient management depend on the site of injury.