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In this study, the authors sought to investigate the added value of vein of Marshall ethanol infusion (VOMEt) as first step in facilitating radiofrequency (RF)-guided mitral isthmus (MI) block.Achieving MI block with the use of RF ablation is challenging.Seventy patients planned for MI ablation were randomized 1:1 to VOMEt as a first step preceding RF (endocardial and epicardial, VOMIn VOMVOMEt as a first step in RF-guided MI line ablation significantly reduced the number of RF applications needed to achieve MI block, even if the sequence of the ablation steps did not affect the final incidence of block. (Evaluation of Vein of Marshall Ethanol Infusion During Left Atrial Linear Ablation in Patients With Persistent Atrial Fibrillation [MARSHALINE]; NCT04124328).

INTRODUCTION During left bundle branch area pacing (LBBAP) lead implantation, intermittent monitoring of unipolar pacing characteristics confirms LBB capture and can detect septal perforation. We aimed to demonstrate that continuous uninterrupted unipolar pacing from an inserted lead stylet (LS) is feasible and facilitates LBBAP implantation. METHODS Thirty patients (mean age 76 ± 14 years) were implanted with a stylet-driven pacing lead (Biotronik Solia S60). In 10 patients (comparison-group) conventional implantation with interrupted unipolar pacing was performed, with comparison of unipolar pacing characteristics between LS and connector-pin (CP)-pacing after each rotation step. In 20 patients (uninterrupted-group) performance and safety of uninterrupted implantation during continuous pacing from the LS were evaluated. RESULTS In the comparison-group, LS and CP-pacing impedances were highly correlated (R2 =0.95, p

Aims Very high-power short-duration (vHPSD) via temperature-controlled ablation (TCA) is a new modality to perform radiofrequency pulmonary vein isolation (PVI), conceivably at the cost of a narrower safety margin towards the oesophagus. In this two-centre trial, we aimed to determine the safety of vHPSD-based PVI with specific emphasis on silent oesophageal injury. Methods and results Ninety consecutive patients with atrial fibrillation (AF) underwent vHPSD-PVI (90 W, 3–4 s, TCA) using the QDOT MICRO catheter, in conjunction with the nGEN (Bad Neustadt, n = 45) or nMARQ generator (Bruges, n = 45). All patients underwent post-ablation oesophageal endoscopy. Procedural parameters and complications were recorded. A subgroup of 21 patients from Bad Neustadt underwent cerebral magnetic resonance imaging (cMRI) to detect silent cerebral events (SCEs). Mean age was 67 ± 9 years, 59% patients were male, and 66% patients had paroxysmal AF. Pulmonary vein isolation was obtained in all cases after 96 ± 29 min. No steam pop, cardiac tamponade, stroke, or fistula was reported. None of the 90 patients demonstrated oesophageal ulceration (0%). Charring was not observed in the nMARQ cohort (0% vs. 11% in the nGEN group). In 5 out of 21 patients (24%), cMRI demonstrated SCE (exclusively nGEN cohort). Conclusion Temperature-controlled vHPSD catheter ablation allows straightforward PVI without evidence of oesophageal ulcerations or symptomatic complications. Catheter tip charring and silent cerebral lesions when using the nGEN generator have led to further modification.

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and represents a heterogeneous disorder with a complex pathological basis. While significant technological advances have taken place over the last decade in the field of catheter ablation of AF, response to ablation varies and long-term success rates in those with persistent AF remain modest. Mechanistic studies have highlighted potentially different sustaining factors for AF in the persistent AF population with substrate-driven focal and re-entrant sources in the body of the atria identified on invasive and non-invasive mapping studies. Translation to clinical practice, however, remains challenging and the application of such mapping techniques to clinical ablation has yet to demonstrate a significant benefit beyond pulmonary vein isolation (PVI) alone in the persistent AF cohort. Recent advances in catheter and ablation technology have centered on improving the durability of ablation lesions at index procedure and although encouraging results have been demonstrated with early studies, large-scale trials are awaited. Further meaningful improvement in clinical outcomes in the persistent AF population requires ongoing advancement in the understanding of AF mechanisms, coupled with continuing progress in catheter technology capable of delivering durable transmural lesions.

Case description : A 74-year-old man suffering from severe heart failure (NYHA III – LVEF 28%) associated with left bundle branch block (LBBB) (Figure 1(A)) and uncontrolled permanent atrial fibrillation (AF) despite optimal medical treatment was referred for His ablation and rescue physiological pacing after a first unsuccessful LV lead implantation through the coronary sinus (CS). Careful review of the occluded CS angiogram indeed revealed no side branches. Concordantly, the patient was offered a ‘rescue’ HBP procedure. Using the SelectSecure lead (model 3830) and a C315 His sheath (Both Medtronic, Inc. MN), His mapping (HV ¼ 106ms) and recruitment were easily obtained, unfortunately without LBBB correction.

Introduction: We investigated whether pacing-induced electrical dyssynchrony at the time of cardiac resynchronization therapy (CRT) device implantation was associated with chronic CRT response. Methods and Results: We included a total of 69 consecutive heart failure patients who received a CRT device. Left (LVp-RVs) and right (RVp-LVs) pacing-induced interlead delays were measured intraoperatively and used to determine if there was paced left ventricular (LV) dyssynchrony, defined as present when LVp-RVs is larger than RVp-LVs. CRT response was defined as a reduction in LV end-systolic volume ≥15%, 6 months after implantation. Paced left ventricular dyssynchrony (PLVD) was associated with ischemic cardiomyopathy (ICM) (χ 2: 8; P =.005) but not with QRS morphology nor with pacing lead positions. In a univariate analysis, PLVD (odds ratio [OR], 6.53; 95% confidence interval [CI], 2.2-18.9; P =.001), atypical left bundle branch block (LBBB) (OR, 3.3; 95% CI, 1.2-9.4; P =.022), and ICM (OR, 5.2; 95% CI, 1.6-17; P =.006) were associated with nonresponse. In a multivariate analysis, both PLVD (OR, 9.74; 95% CI, 2.8-33.9; P 2 to enter: 8; P

This subanalysis of the Euro-CRT survey II specifically focus on Belgian practice for CRT implantation. It explores Belgian adherence with the guidelines but also benchmark CRT practice in Belgium against the other European countries. Overall, Belgian management of CRT implantation is performed with great agreement with guidelines. This report could be used to provide guidance for both practical and economical approaches.

Introduction. During left bundle branch area pacing (LBBAP) lead implantation, intermittent monitoring of unipolar pacing characteristics validates LBB capture and can detect septal perforation. We aimed to demonstrate that continuous uninterrupted unipolar pacing from an inserted lead stylet (LS) is feasible and facilitates LBBAP implantation. Methods. Thirty patients (mean age 76 ± 14 years) were implanted with stylet-driven pacing lead (Biotronik Solia S60). In 10 patients (validation-group) conventional, interrupted implantation was performed, with comparison of unipolar pacing characteristics between LS and connector-pin (CP)-pacing after each rotation step. In 20 patients (feasibility-group) performance and safety of uninterrupted implantation during continuous pacing from the LS were analyzed. Results. In the validation-group, LS and CP-pacing impedances were highly correlated (R=0.95, p

The QDOT Micro™ catheter (Biosense Webster, Inc., CA, USA) is a new radiofrequency ablation catheter based on the SmartTouch SF™ (Biosense Webster, Inc.). It combines diffuse external irrigation with six thermocouples located within the outer metal shell and three additional microelectrodes in a 3.5 mm-tip contact force radiofrequency catheter. This article focuses on the different characteristics of the catheter, which incorporates the ability of high power delivery, irrigation flow control based on temperature sensing through the six thermocouples and the generation of microelectrograms. An outline of its performance in preclinical and clinical setting is presented, showing promising results, especially concerning procedural efficiency and short-term safety. Additional studies need to confirm long-term effectiveness, and durability studies should evaluate whether superiority on a lesion quality level can be achieved.Lay abstract Radiofrequency (RF) energy is the most widely used type of energy in the field of catheter ablation, an invasive treatment for heart rhythm disorders. In patients with atrial fibrillation (AF; the most frequent type of problem with the rhythm of the heart), catheter ablation aims at delivering RF energy around the pulmonary veins (PVs). PVs have been shown to contain AF triggers. Catheter ablation results in electrical isolation of the PV, making them less likely to trigger AF. The latest technical developments resulted in better success rate of the procedure (up to 90% success rate after 1 year follow-up) without increasing complication rates. During the last decade, the catheter used to isolate the PV has improved a lot and includes now contact force measurement in addition to the delivery mechanism for RF energy and can record the local electrical activity. The newly developed QDOT Micro™ catheter (Biosense Webster, Inc., CA, USA), presented in this article, combines different aspects of further technical development. These include the integration of smaller electrodes, resulting in higher local electrical signal resolution, more accurate feedback of local tissue temperature during the procedure and the ability to use higher RF power which reduces the RF delivery time and therefore reduced the duration of the procedure. An outline of its performance in preclinical and clinical setting is presented in this paper. These studies have shown promising results, especially concerning procedural efficiency and short-term safety. However, additional studies need to confirm long-term treatment success and potential superiority in comparison with other ablation approaches.

Conventional stylet-driven leads with extendable helix can be implanted successfully for Left Bundle Branch Area Pacing (LBBAP) with a low acute complication rate. However, removal and repositioning techniques of these leads haven’t been yet described. We report 2 cases in which lead repositioning after a first unsuccessful attempt to LBBAP was associated with fracture of the helix rotating mechanism and failure to fully extract the pacing lead.

Background: CLOSE-guided atrial fibrillation (AF) ablation is based on contiguous (intertag distance ≤6 mm), optimized (Ablation Index >550 anteriorly and >400 posteriorly) point-by-point radiofrequency lesions. The optimal radiofrequency power remains unknown. Methods: The POWER-AF study is a prospective, randomized controlled monocentric study including patients with paroxysmal AF, planned for first CLOSE-guided pulmonary vein isolation using a contact force radiofrequency catheter (Thermocool SmartTouch, Biosense Webster, Inc, Irvine, CA). A total of 100 patients were randomized into 2 groups (1:1). The control group received AF ablation using the standard CLOSE protocol (35 W), whereas in the experimental group, pulmonary vein isolation was performed using high power (45 W). Endoscopic evaluation was performed in patients with intraesophageal temperature rise >38.5 °C. Results: The resulting sample size was 96 (48+48) patients. In the high power group, shorter procedure time (80 versus 102 minutes, P P P P P =0.31) showed an ulcerative perforation in a high power group patient (treated by endoscopic stenting and normalization after ≈4 months) and a superficial ulcerative lesion in a control group patient (conservative treatment). Both occurred following excessive Ablation Index applications (up to 460 and 480, respectively) with excessive contact force (30 g on average, with peaks up to 50 g). Six-months AF recurrence was not significantly different (10% in high power versus 8% in control, P =0.74). Conclusions: This randomized controlled study shows that a 45 W radiofrequency power CLOSE protocol in patients with paroxysmal AF significantly increases the global procedural efficiency with similar midterm efficacy. However, our study showed a narrower safety margin and a limited increased efficiency at the posterior wall using high power. This advocates against the use of high power in the region neighboring the esophagus.

Introduction: Auricular low-level transcutaneous vagus nerve stimulation (aLL-tVNS) has emerged as a promising technology for cardiac arrhythmia management but is still experimental. In this physiological study, we hypothesized that aLL-tVNS modulated the autonomic nervous balance through a reduction of sympathetic tone and an increase in heart rate variability (HRV). We investigated the muscle sympathetic nerve activity (MSNA) recorded by microneurography during vagally mediated aLL-tVNS and active control on healthy volunteers. Methods: In this crossover, double-blind controlled study, healthy men (N = 28; 27 ± 4 years old) were assigned to aLL-tVNS applied to cymba and lobe (active control) of the right ear. Each participant was randomly allocated to the three sequences (5 Hz, 20 Hz, and active control-5 Hz) during one session. MSNA signal was recorded at rest, during voluntarily apnea and aLL-tVNS. Sympathetic activity was expressed as: 1) number of bursts per minute (burst frequency, BF) and 2) MSNA activity calculated as BF x mean burst amplitude and expressed as changes from baseline (%). RR intervals, HRV parameters and sympathetic activity were analyzed during 5 min-baseline, 10 min-stimulation, and 10 min-recovery periods. Mixed regression models were performed to evaluate cymba-(5—20 Hz) effects on the parameters with stimulation. Results: During apnea and compared to baseline, BF and MSNA activity increased (p = 0.002, p = 0.001, respectively). No stimulation effect on RR intervals and HRV parameters were showed excepted a slightly increase of the LF/HF ratio with stimulation in the cymba-5Hz sequence (coef. ± SE: 0.76 ± 0.32%; p = 0.02). During stimulation, reductions from baseline in BF (Coef. ± SE: −4.8 ± 1.1, p < 0.001) was observed but was not statistically different from that one in the active control. Reduction of MSNA activity was not significantly different between sequences. Conclusion: Acute right cymba aLL-tVNS did not induce any overall effects neither on heart rate, HRV nor MSNA variables on healthy subjects when compared to active control. Interestingly, these findings questioned the role of active controls in medical device clinical trials that implied subjective endpoints., SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction: The impact of gender on ICD implantation practice and survival remain a topic of controversy. We analysed differences between men and women in patients implanted with an ICD in Belgium. Methods: The Belgian governmental health care institution (RIZIV/INAMI) keeps track of every ICD implantation by a digital registry. Participation is mandatory for reimbursement. From this registry, we analysed all new ICD implantations between 01/02/2010 and 31/01/2019 in Belgian patients. We compared men with women for baseline patient characteristics. We used a Chi 2 test for categorical variables (NYHA class, primary vs secondary prevention, underlying heart disease, type of device, QRS duration, presence of atrial fibrillation, diabetes and other comorbidity, center volume, population density and average income of the area of residency) and a Mann-Whitney U test for continuous variables [age and ejection fraction(EF)]. We used the Bonferroni method to correct for multiple testing. Secondly, we performed a Kaplan-Meier analysis. At last, we performed a multivariate logistic regression for 3-year and total mortality. Results: Only 3146 (20.8%) on 14747 implantations were in women. Women were significantly younger and had a better EF compared to men. Except for oncological history, women had less comorbidities (table 1). More women functioned in NYHA class > II and had a QRS > 150ms, which was consistent with a higher CRT-D vs VVI/DDD ratio. Kaplan-Meier showed a survival benefit in women (log-rank, p= Conclusions: Only a minority of patients implanted with a new ICD in Belgium are women. Their clinical profile differs from men. Their long-term survival is better, which can in part be explained by differences in indications and comorbidities.

Introduction: According to guidelines ICD implantation should not be performed in patients with an expected survival less than 1 year. We investigated how useful validated risk scores are to predict 1-y mortality after ICD implantation in patients with ischemic heart disease (IHD). Methods: The QERMID-ICD registry, managed by the Belgian health authorities, contains data of all patients implanted with an ICD. Participation is mandatory for reimbursement. We analyzed all new implantations between 01/02/2010 and 31/01/2018 in Belgian IHD patients. Data is available about age, gender, ejection fraction (EF), NYHA class, type of prevention, type of device, QRS duration, center volume, comorbidities and socio-economic status based on the area of residency. We performed a Cox proportional hazard regression and applied a modified version of the MADIT- (Goldenberg et al., JACC 2008) risk score (reported renal failure instead of BUN > 26mg%) and AAACC (Nevzorov et al., JCE 2018) risk score (no data on anemia, so AACC score) to predict 1-y mortality. Results: On a total of 6320 IHD patients, the 1-y mortality was 5.7%. Patients who died within 1 year were significantly older (70.9 vs 65.9 years), had a worse EF (28.7 vs 31.5%) and differed in most comorbidities. In the Cox model age, worse EF, secondary prevention, VVI/DDD devices, atrial fibrillation, COPD, neurological antecedents and renal failure were independent predictors of 1-y mortality (table 1). Area under ROC was comparable for the modified Goldenberg and AACC score (0.647 vs 0.652). With a cut-off of 5 on the modified Goldenberg and 7 on the AACC-score a positive predictive value (PPV) of respectively 15.5% an 17.4% and negative predictive value of 94.2% and 94.7% were obtained. Conclusion: Despite significant differences in baseline characteristics, selection of patients not suitable for ICD implantation (because of high 1-y mortality risk) can only be slightly improved by using simple risk scores due to their low PPV.

Ballistocardiography (BCG) and seismocardiography (SCG) assess vibrations produced by cardiac contraction and blood flow, respectively, through micro-accelerometers and micro-gyroscopes. BCG and SCG kinetic energies (KE) and their temporal integrals (iK) during a single heartbeat are computed in linear and rotational dimensions. Our aim was to test the hypothesis that iK from BCG and SCG are related to sympathetic activation during maximal voluntary end-expiratory apnea. Multiunit muscle sympathetic nerve traffic [burst frequency (BF), total muscular sympathetic nerve activity (tMSNA)] was measured by microneurography during normal breathing and apnea (n = 28, healthy men). iK of BCG and SCG were simultaneously recorded in the linear and rotational dimension, along with oxygen saturation (SatO2 ) and systolic blood pressure (SBP). The mean duration of apneas was 25.4 9.4 s. SBP, BF, and tMSNA increased during the apnea compared with baseline (P = 0.01, P = 0.002, and P = 0.001, respectively), whereas SatO2 decreased (P = 0.02). At the end of the apnea compared with normal breathing, changes in iK computed from BCG were related to changes of tMSNA and BF only in the linear dimension (r=0.85, P < 0.0001; and r = 0.72, P = 0.002, respectively), whereas changes in linear iK of SCG were related only to changes of tMSNA (r = 0.62, P = 0.01). We conclude that maximal end expiratory apnea increases cardiac kinetic energy computed from BCG and SCG, along with sympathetic activity. The novelty of the present investigation is that linear iK of BCG is directly and more strongly related to the rise in sympathetic activity than the SCG, mainly at the end of a sustained apnea, likely because the BCG is more affected by the sympathetic and hemodynamic effects of breathing cessation. BCG and SCG may prove useful to assess sympathetic nerve changes in patients with sleep disturbances. NEW & NOTEWORTHY Ballistocardiography (BCG) and seismocardiography (SCG) assess vibrations produced by cardiac contraction and blood flow, respectively, through micro-accelerometers and micro-gyroscopes. Kinetic energies (KE) and their temporal integrals (iK) during a single heartbeat are computed from the BCG and SCG waveforms in a linear and a rotational dimension. When compared with normal breathing, during an end-expiratory voluntary apnea, iK increased and was positively related to sympathetic nerve traffic rise assessed by microneurography. Further studies are needed to determine whether BCG and SCG can probe sympathetic nerve changes in patients with sleep disturbances., SCOPUS: ar.j, info:eu-repo/semantics/published

Biventricular pacing (BVP) has been demonstrated to improve functional outcomes and mortality of patients with symptomatic heart failure, reduced LVEF and wide QRS. Unfortunately, difficult coronary sinus anatomy can limit left ventricular lead placement. In such clinical situation, His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP) have recently appeared as attractive alternatives to BVP. We describe the case of a patient with an indication for Cardiac Resynchronization Therapy (CRT) and AV node ablation, where left ventricular lead implantation and corrective HBP failed. LBBAP allowed for electrical and echocardiographic resynchronization with significant functional improvement.

BACKGROUND The subcutaneous implantable cardioverter-defibrillator (S-ICD) remains a new technology requiring accurate assessment of the various aspects of its functioning. Isolated cases of delayed sensing of ventricular arrhythmia have been described. OBJECTIVE The purpose of this multicenter study was to assess the quality of sensing during induced ventricular fibrillation (VF). METHODS One hundred thirty-seven patients underwent induction of VF at the end of the S-ICD implantation. RESULTS VF induction was successful in 133 patients (97%). Mean time to first therapy was 16.2 +/- 3.1 seconds, with a substantial range from 12.5 to 27.0 seconds. Four different detection profiles were arbitrarily defined: (1) optimal detection (n = 39 [29%]); (2) undersensing with moderate prolongation of time to therapy (18 seconds; n = 19 [14%]); and (4) absence of therapy or prolonged time to therapy related to noise oversensing (n = 7 [6%]). In some of the patients in the last group, despite induction of VF the initial counter was never filled, the device did not charge the capacitors, and the shock was not delivered because of a sustained diagnosis of noise (n = 5). A manual shock by the device or an external shock had to be delivered to restore the sinus rhythm. CONCLUSION Our study demonstrated a marked sensing delay leading to prolonged time to therapy in a large number of S-ICD patients. A few worrisome cases of noise oversensing inhibiting the therapies were detected. These results support the need for systematic intraoperative defibrillation testing.

Catheter ablation for atrial fibrillation (AF) is a common treatment strategy in patients with drug-resistant, symptomatic AF. In patients with paroxysmal and short-standing persistent AF, pulmonary vein isolation (PVI) is often enough to prevent recurrence of atrial tachyarrhythmia (ATA). Point-by-point encircling of the PVs with radiofrequency (RF) applications, together with cryoballoon ablation, have been the mainstay strategies for the last 10 to 20 years. Each of these strategies, however, suffers from the delicate balance between preventing PV reconnection, on the one hand (toward more energy), and preventing (mainly esophageal) complications (toward less energy), on the other. The CLOSE protocol was developed as an RF ablation strategy that would result in the safe creation of durable isolation leading to improved outcomes. Basically, the aim of the protocol is to enclose the pulmonary veins with stable, contiguous (intertag distance, ITD ≤ 6 mm) and optimized lesions (35 Watts, W, RF applications up to ablation index targets of ≥400 and ≥550 at the posterior and anterior wall). In this review, we describe the background of the CLOSE protocol and the studies from the St Jan Bruges research group on procedural performance, efficacy, and safety of the CLOSE protocol in (a) single-center prospective PILOT study (CLOSE-PILOT), (b) a single-center prospective study with continuous rhythm monitoring (CLOSE to CURE), (c) a database of systematic esophageal endoscopic studies, (d) a multicenter prospective study (VISTAX), and (e) the CLOSE database (comprising > 400 patients). We also discuss the results of the randomized POWER-AF study comparing conventional CLOSE to high power CLOSE (up to 50 W). Finally, we discuss the performance, safety, and efficacy of the CLOSE protocol in light of the emerging changes in the field of catheter ablation being ultra-short high-power ablation and electroporation.

Introduction: Management of subcutaneous implantable cardioverter defibrillator (S-ICD) patients with newly acquired pacing needs remains problematic. His bundle pacing (HBP) allows for cardiac pacing without significant changes in the QRS morphology. We hypothesized that HBP does not alter S-ICD sensing and functions. Methods: Twenty consecutive patients were implanted with a HB pacemaker. Among them, 17 demonstrated successful His recruitment and were prospectively screened with the automated screening tool (AST). Results of screenings performed immediately after implant and during follow-up, during intrinsic rhythm and while pacing from all available pacing configurations, were compared using the AST score. Positive-screening tests were defined by greater than or equal to 1 positive vector. Results: Among the 17 patients successfully implanted (male: 41%; mean age: 73), 13 presented an indication of ventricular pacing and four of cardiac resynchronization. Absolute AST scores during both HBP (all configurations) and intrinsic rhythm were similar (p: NS). Due to left bundle branch block correction, HBP resulted in higher number of positive vectors (AST >= 100). AST scores were higher during HBP when compared with right ventricular pacing (RVP) (primary vector: 272 [16; 648] vs 4.6 [0.8; 16.2]; P = .003; secondary vector: 569 [183; 1186] vs 1.5 [0.7; 8.3]; P < .0001; alternate vector: 44 [2;125] vs 4.8 [0.9; 9.3]; P = .02) and resulted in a much higher number of positive vectors. Up to 90% of the patients had a positive-screening test during HBP. This passing rate was higher when compared RVP (17%; P < .0001). Conclusion: HBP restores normal intrinsic conduction and minimally modifies the surface electrocardiograph and subcutaneous electrograms. When ventricular pacing is needed, HBP might represent an ideal pacing option for patients implanted with a S-ICD.

Background Conduction disorders requiring permanent pacemaker implantation occur frequently after transcatheter aortic valve replacement (TAVR). This multicenter study explored the feasibility and safety of His bundle pacing (HBP) in TAVR patients with a pacemaker indication to correct a TAVR‐induced left bundle branch block (LBBB). Methods Patients qualifying for a permanent pacemaker implant after TAVR were planned for HBP implant. HBP was performed using the Select Secure (3830; Medtronic) pacing lead, delivered through a fixed curve or deflectable sheath (C315HIS or C304; Medtronic). Successful HBP was defined as selective or nonselective HBP, irrespective of LBB recruitment. Successful LBBB correction was defined as selective or nonselective HBP resulting in paced QRS morphology similar to pre‐TAVR QRS and paced QRS duration (QRSd) less than 120 milliseconds with thresholds less than 3.0 V at 1.0‐millisecond pulse width. Results The study enrolled 16 patients requiring a permanent pacemaker after TAVR (age 85 ± 4 years, 31% female, all LBBB; QRSd: 161 ± 14 milliseconds). Capture of the His bundle was achieved in 13 of 16 (81%) patients. HBP with LBBB correction was achieved in 11 of 16 (69%) and QRSd narrowed from 162 ± 14 to 99 ± 13 milliseconds and 134 ± 7 milliseconds during S‐HBP and NS‐HBP, respectively (P = .005). At implantation, mean threshold for LBBB correction was 1.9 ± 1.1 V at 1.0 millisecond. Thresholds remained stable at 11 ± 4 months follow‐up (1.8 ± 0.9 V at 1.0 millisecond, P = .231 for comparison with implant thresholds). During HBP implant, one temporary complete atrioventricular block occurred. Conclusion Permanent HBP is feasible in the majority of patients with TAVR requiring a permanent pacemaker with the potential to correct a TAVR‐induced LBBB with acceptable pacing thresholds.

Blood pressure response to renal denervation is highly variable, and the proportion of responders is disappointing. This may be partly because of accessory renal arteries too small for denervation, causing incomplete ablation. Renal nerve stimulation before and after renal denervation is a promising approach to assess completeness of renal denervation and may predict blood pressure response to renal denervation. The objective of the current study was to assess renal nerve stimulation–induced blood pressure increase before and after renal sympathetic denervation in main and accessory renal arteries of anaesthetized patients with drug-resistant hypertension. The study included 21 patients. Nine patients had at least 1 accessory renal artery in which renal denervation was not feasible. Renal nerve stimulation was performed in the main arteries of all patients and in accessory renal arteries of 6 of 9 patients with accessory arteries, both before and after renal sympathetic denervation. Renal nerve stimulation before renal denervation elicited a substantial increase in systolic blood pressure, both in main (25.6±2.9 mm Hg; P P =0.047) renal arteries. After renal denervation, renal nerve stimulation–induced systolic blood pressure increase was blunted in the main renal arteries (Δ systolic blood pressure, 8.6±3.7 mm Hg; P =0.020), but not in the nondenervated renal accessory renal arteries (Δ systolic blood pressure, 27.1±7.6 mm Hg; P =0.917). This residual source of renal sympathetic tone may result in persistent hypertension after ablation and partly account for the large response variability.

This subanalysis of the Euro-CRT survey II specifically focus on Belgian practice for CRT implantation. It explores Belgian adherence with the guidelines but also benchmark CRT practice in Belgium against the other European countries. Overall, Belgian management of CRT implantation is performed with great agreement with guidelines. This report could be used to provide guidance for both practical and economical approaches.

Introduction Narrow calibre ICD leads are prone to present insulation defects and conductor externalization. Close follow-up of these leads is recommended but as long as their electrical function is maintained, no prophyllactic replacement or extraction is advised. Although the risk of thrombus formation involving externalized conductors has been described, this risk seems considered as negligible compared with the risk of a prophylactic lead extraction. However, when an intracavitar thrombus is identified, the safest therapeutic approach remains undetermined. Case presentation In the present clinical vignette, we describe the case of a giant thrombus developed along the externalized portion of an electrically functional ICD lead. In this case, the thrombus was successfully treated with a systemic oral anticoagulation. Discussion This case report supports the concept of a prolonged anticoagulation for both the diagnosis and the long-term treatment of thrombus developed along externalized ICD leads, in particular when the patient prefers to avoid or postpone the risk of a trans-venous lead extraction.

Dear Editor,A 59-year-old previously healthy man was brought to the emergency department (ED) with gastro-intestinal symptoms. He did not use tobacco, alcohol or medications. He had, that morning, ...

A 74-year-old woman had an atrial fibrillation (AF) ablation procedure. Three weeks later, she presented with sepsis and paresis of the left upper limb. Initial chest computed tomography (CT) was inconclusive (Fig. 1a, b). Brain magnetic resonance imaging (MRI) showed acute multiple embolic cerebral infarcts (Fig. 1c, d). An atrio-oesophageal fistula (AOF) was suspected. ECG-gated CT was performed (Fig. 1e, f), confirming the diagnosis.[...]

AIM: After pulmonary vein isolation (PVI), dormant conduction (DC) is present in at least one vein in a substantial number of patients. The present study seeks to determine whether there is a relationship between poor contact forces (CF) and the presence of DC after PVI. METHODS AND RESULTS: This prospective, operator-blinded, non-randomized dual-centre trial enrolled 34 consecutive patients with paroxysmal atrial fibrillation who were candidates for PVI. Radiofrequency (RF) energy was delivered by using an irrigated-tip force-sensing ablation catheter (Tacticath, St Jude Medical) at pre-defined target power. The operators were blinded to the CF data at all times. A total of 1476 RF applications were delivered in 743 pre-defined PV segments. For each application, the precise location of the catheter was registered and the following data were extracted from the Tacisys unit: application duration, minimum contact force, maximum contact force, average contact force (CF), and force-time integral (FTI). Sixty minutes after PVI, spontaneous early recovery (ER) of the left atrium (LA) to PV conduction was evaluated. In the absence of ER, the presence of a DC was evaluated by using intravenous adenosine (ATP). In the 34 patients recruited (23 males; mean age: 62 ± 9 years), all PVs were successfully isolated. At the end of the 60 min waiting period, 22 patients demonstrated at least one spontaneous ER or DC under ATP. The mean CF and FTI per PV segment differed significantly among the different veins but the sites of ER and DC were evenly distributed. However, both the minimum, the first and the mean CF and FTI per PV segment were significantly lower in the PV segments presenting either ER or DC as compared with those without ER or DC (mean CF: 4.9 ± 4.8 vs. 12.2 ± 1.65 g and mean FTI: 297 ± 291 vs. 860 ± 81 g s, P < 0.001 for both). Using multivariate analysis, both the mean CF and the FTI per lesion remained significantly associated with the risk of ER or DC. Moreover, a CF < 5 g per PV segment predicted ER+ and DC+ with a sensitivity of 71% and specificity of 82%. In contrast, ER and DC were very unlikely if RF application was performed with a mean CF > 10 g (negative predictive value: 98.7%). CONCLUSION: Both a low CF and a low FTI are associated with the ER of the PVI and DC after PVI.

Atrial fibrillation (AF) patients treated according to a rate-control strategy seem to have excellent outcomes as long as their ventricular response is kept low. However, the stringency of the rate control to adopt with pharmacologic agents is not clearly defined. In particular, the clinical importance of preserving a heart rate (HR) reserve (HRR) during exercise has not yet been investigated.We prospectively analysed the HR response profiles during exercise of 202 patients with permanent AF for whom a strict rate-control strategy was the preferred treatment option. Patients were asked to perform an exercise test on a cycle ergometer until exhaustion. The HRR was defined as the difference between the HR at peak exercise and the resting HR before exercise, divided by the resting HR. Patients were followed-up for at least 24 months or until death or hospitalization for heart failure. The mean resting HR was 80 ± 16 b.p.m. After a median follow-up period of 3 ± 1 years, 31 patients (15.3%) of our initial population (80% male, age 72 ± 12 years) presented either a hospitalization for heart failure (n = 13, 6.4%) or a death (n = 18, 8.9%). Using a univariate analysis, we found that these events correlated with a lower exercise capacity [hazard ratio, HR 0.98, 95% confidence interval, CI (0.96; 0.99), P0.001] and a lower HRR [HR 0.30, 95% CI (0.15; 0.60), P0.001]. Using a multivariate analysis, both the exercise capacity [HR 0.98, 95% CI (0.97; 0.99), P = 0.008] and the HRR [HR 0.42, 95% CI (0.20-0.87), P = 0.02] remained significantly associated with the outcome. In particular, 4-year survival free from hospitalization for heart failure was better in patients with a preserved HRR (HRR40%, P0.001). No correlation was found between the treatment category (i.e. beta-blockers, calcium channel antagonist, and digoxin) and the HRR.An impaired HRR in patients with permanent AF treated according to a strict rate-control strategy is associated with an increased risk of hospitalization for heart failure.

BACKGROUND: The number of fitness centres has increased in Western countries, some proposing specific training programmes (cardiac patients, weight loss or seniors).There is a real risk of cardiovascular events for individuals without cardiovascular evaluation. Fitness centres could represent a place at particularly high risk for sudden cardiac arrest (SCA). OBJECTIVE AND METHODS: In this observational study, we evaluated the number of fitness centres with automatic external defibrillators (AEDs) throughout the French-speaking part of Belgium, their geographic localization, the number of attendees, and the number of SCA reported. Details of AED and SCA were obtained by telephone survey. RESUITS: A total of 51 centres were surveyed. Only 5 (9.8%) had an AED and 68.8% (35/51) of centres had > 1 staff members specifically trained in CPR. Since the opening of these facilities, 5 SCA were reported from 3 centres (5.9%). Only 2 fitness centres had an AED present at the time of the SCA.Two SCA were unwitnessed, and for another 2 victims AED was used without success. Well-conducted CPR (no AED available) resulted in the only survivor of SCA. CONCLUSION: The rate of SCA in fitness centres in French-speaking Belgium is comparable to that reported in other countries. AED were available in less than 10% of centres and no CPR trained staff was available in almost one third of the centres.

ObjectivesTo better understand the quantitative relationship of recovery of regional and global dysfunction after revascularization in chronic infarcts with variable transmural extent of necrosis by delayed enhanced cardiac magnetic resonance.BackgroundStudies relating transmurality of delayed enhanced magnetic resonance to functional recovery in dysfunctional myocardium using semiquantitative Likert scales have demonstrated the intermediate likelihood (50% probability) of recovery of dysfunction in subendocardial scars.MethodsForty-two patients with chronic left ventricular dysfunction due to coronary artery disease underwent tagged and delayed enhanced magnetic resonance before and 10 ± 7 months after revascularization (coronary artery bypass graft: 35, percutaneous transluminal coronary angioplasty: 7). Left ventricular ejection fraction and regional mid-myocardial Eulerian radial thickening strain (Err) and mid-myocardial, subendocardial, and subepicardial Eulerian circumferential shortening strain (Ecc) strains were quantified in 16 segments per patient before and after revascularization and related to pre-operatively measured transmurality of necrosis.ResultsAt baseline, 256 of 672 segments were dysfunctional, having −10%) mid-myocardial Ecc. The magnitude of recovery of mid-myocardial Ecc (r = −0.33, p < 0.01) was inversely correlated with transmurality of necrosis before revascularization. Segments with

OBJECTIVES: The aim of the present study was to examine the intraoperative echocardiographic features associated with recurrent severe aortic regurgitation (AR) after an aortic valve repair surgery. BACKGROUND: Surgical valve repair for AR has significant advantages over valve replacement, but little is known about the predictors and mechanisms of its failure. METHODS: We blindly reviewed all clinical, pre-operative, intraoperative, and follow-up transesophageal echocardiographic data of 186 consecutive patients who underwent valve repair for AR during a 10-year period and in whom intraoperative and follow-up echo data were available. After a median follow-up duration of 18 months, 41 patients had recurrent 3+ AR, 23 patients presented with residual 1+ to 2+ AR, and 122 had no or trivial AR. In patients with recurrent 3+ AR, the cause of recurrent AR was the rupture of a pericardial patch in 3 patients, a residual cusp prolapse in 26 patients, a restrictive cusp motion in 9 patients, an aortic dissection in 2 patients, and an infective endocarditis in 1 patient. RESULTS: Pre-operatively, all 3 groups were similar for aortic root dimensions and prevalence of bicuspid valve (overall 37%). Patients with recurrent AR were more likely to display Marfan syndrome or type 3 dysfunction pre-operatively. At the opposite end, patients with continent AR repair at follow-up were more likely to have type 2 dysfunction pre-operatively. After cardiopulmonary bypass, a shorter coaptation length, the degree of cusp billowing, a lower level of coaptation (relative to the annulus), a larger diameter of the aortic annulus and the sino-tubular junction, the presence of a residual AR, and the width of its vena contracta were associated with the presence of AR at follow-up. Multivariate Cox analysis identified a shorter coaptation length (odds ratio [OR]: 0.8, p = 0.05), a coaptation occurring below the level of the aortic annulus (OR: 7.9, p < 0.01), a larger aortic annulus (OR: 1.2, p = 0.01), and residual aortic regurgitation (OR: 5.3, p = 0.01) as risk factors of repair failure. CONCLUSIONS: Our results demonstrate that intraoperative transesophageal echocardiography can be used to identify patients undergoing AR repair who are at increased risk for late repair failure.

Aims The aim of this article is to evaluate the accuracy and reproducibility of two-dimesional speckle tracking echocardiography (2D-STE) for the estimation of left ventricular (LV) twist, using tagged cardiac magnetic resonance (cMR) as the reference standard, and to assess how much 2D-STE rotational parameters are affected by the level at which measurements are made within the LV. Methods and results Forty-three patients with various heart diseases and 10 healthy volunteers underwent cMR and 2D-STE on the same day. With both methods, basal and apical time-rotation curves were generated at endocardial, midwall, and epicardial levels. By using the most apical cMR short-axis cross-section as a comparator, apical rotation was significantly underestimated by 2D-STE. When 2D-STE and cMR short-axis cross-sections were matched for their internal dimensions, measurements of endocardial, midwall, and epicardial twists no longer differ between cMR and 2D-STE (12.6 +/- 5.9 vs. 12.5 +/- 5.7 degrees , 10.5 +/- 4.6 vs. 9.7 +/- 4.1 degrees , and 8.9 +/- 4.0 vs. 8.4 +/- 3.7 degrees , respectively, all P = ns). Conclusion Compared with tagged cMR, 2D-STE underestimates apical rotation and LV twist. This is related to the inability of 2D-STE to image the real LV apex in most of the patients. However, when 2D-STE and cMR data are compared at similar acquisition levels, both techniques provide similar values.

Aim: To evaluate if three-dimensional echocardiography (3-DE) is as accurate and reproducible as cine magnetic resonance imaging (cMR) in estimating left ventricular (LV) parameters in patients with and without wall motion abnormalities (WMA). Methods: 83 patients (33 with WMA) underwent 3-DE and cMR. 3-DE datasets were analysed using a semi-automatic contour detection algorithm. The accuracy of 3-DE was tested against cMR in the two groups of patients. All measurements were made twice by two different observers. Results: LV mass by 3-DE was similar to that obtained by cMR (149 (SD 42) g vs 148 (45) g, p = 0.67), with small bias (1 (28) g) and excellent interobserver agreement (−2 (31) g vs 4 (26) g). The two measurements were also highly correlated (r = 0.94), irrespective of WMA. End-diastolic and end-systolic LV volumes and ejection fraction by 3-DE and cMR were highly correlated (r = 0.97, 0.98, 0.94, respectively). Yet, 3-DE underestimated cMR end-diastolic volumes (167 (68) ml vs 187 (70) ml, p

INTRODUCTION The aim of this study was to determine the rate of recurrent atrial flutter (AFl) after isolated cavotricuspid isthmus (CTI) ablation and to evaluate the impact of a waiting period with the search for early resumption of the CTI block on the long-term outcome. METHOD Three hundred and nineteen consecutive patients referred for typical AFl ablation were randomly assigned to CTI ablation with continuous reevaluation of the CTI block during 30 minutes and early reablation if needed (waiting time [WT] + group, n = 155) or to CTI ablation with no waiting period after proven bidirectional CTI block (WT - group, n = 164). All patients were regularly followed-up. RESULT In the WT+ group, 10 patients (6%) presented a recovery across the CTI (time to recovery: 17 ± 7') and were reablated at the end of the waiting period. After a median follow-up of 21 months, the rate of recurrent AFl was significantly higher in the WT - group as compared to the WT+ group (11.6% [19/164] vs 2.5% [4/155], respectively; P = 0.007). However, no significant differences in the subsequent rate of AF were observed between the two groups (29% [WT -] vs 32% [WT+], P = 0.66). During the follow-up, 28 patients from the WT - group underwent a second ablation procedure (16 AFl redo and 12 AF ablation) versus 10 patients form the WT+ group (three AFl redo and seven AF ablation). CONCLUSION Waiting 30 minutes after CTI ablation to check for early resumption and early reablation allows for decreasing significantly the rate of recurrent atrial flutter.

Coronary spasm (CS) or Prinzmetal's angina is an important cause of pectoral angina but remains difficult to diagnose. Historical descriptions presented the syndrome as a benign affection, but recent reports showed that CS could trigger ventricular arrhythmias and sudden cardiac arrest. We present the case of a 77-year-old patient referred to our hospital after several syncope. Continuous ECG monitoring during his hospital stay demonstrated recurrent episodes of sustained polymorphic ventricular tachycardia (PVT), systematically proceeded by a transient but marked ST-segment elevation without chest pain. A coronary angiography was performed and showed only a non-significant atherosclerotic plaque in the left anterior descending coronary artery (LAD). However, infusion of methylergonovine induced a dramatic CS resulting in the complete occlusion of both left coronary arteries (see Supplementary material online, Video). Simultaneously, a marked ST-segment elevation occurred, immediately followed by a sustained PVT degenerating into VF and necessitating a cardiac resuscitation. Despite an intensive therapy combining high dose of calcium channel blocker and nitroglycerin, the patient remained symptomatic. Accordingly, an implantable cardiac defibrillator (ICD) was implanted before hospital discharge. During the early follow-up, several new episodes of VF appropriately treated by ICD shocks occurred. Finally, a selective angioplasty of the proximal segment of the LAD allowed for controlling most of the episodes, the patient being finally defibrillated only once again over a 2-year follow-up period. [...]

PURPOSE: To compare the accuracy of planimetric and continuity equation measurements of aortic valve area (AVA) by cardiac MR (cMR) to each other and against transthoracic (TTE) and transesophageal (TEE) echocardiography. MATERIALS AND METHODS: A total of 31 patients (21 men, mean age = 67 +/- 13 years) with aortic stenosis (AS) and 16 controls (12 men, mean age = 57 +/- 14 years) underwent measurement of AVA by planimetric and continuity equation cMR. Measurements were compared to TEE planimetry and continuity equation TTE. RESULTS: AVA by continuity equation cMR correlated highly to continuity equation TTE (r = 0.98) and was not significantly different (1.8 +/- 1.3 cm2 vs. 1.8 +/- 1.4 cm2, P = 0.62). Similarly, AVA by cMR planimetry was not statistically different from TEE planimetry (2.1 +/- 1.7 cm2 vs. 2.1 +/- 1.6 cm2, P = 0.34) and correlated highly (r = 0.98). Yet planimetric measurements of AVA by cMR and TEE were significantly higher than AVA by continuity equation cMR (P < 0.001 and P < 0.001, respectively) and TTE (P < 0.001 and P < 0.001, respectively). CONCLUSION: Both planimetry and continuity equation-based measurements of AVA by cMR are equally accurate. However, similar to TEE, cMR AVA is larger by planimetry than by continuity equation. This is consistent with the contention that the anatomical maximum opening of a stenotic aortic valve is larger than the size of the functional vena contracta.

Atrioventricular (AV) block is a rare complication of cavotricuspid isthmus radiofrequency (RF) ablation. In most cases, it is related to direct lesion to the AV node. However, PR prolongation may also be an early sign of coronary artery injury during RF ablation. In this case, we report a 72-year-old patient with previous history of coronary artery bypass graft surgery, who manifested a transient AV block during cavotricuspid isthmus ablation. Because the AV node was too far to be directly damaged, and because a vagal reaction was very unlikely, coronary angiography was immediately performed with the ablation catheter positioned precisely where application resulted in AV block. Surprisingly, it demonstrated the ablation catheter to be in close relationship with a saphenous vein graft (SVG) bridging the occluded right coronary artery. Contrast injection during RF application was performed and clearly identified a vasospastic reaction of the SVG passing along the cavotricuspid isthmus and vascularizing distally the AV node through the right coronary artery (Figure). To the best of our knowledge, RF injury to a SVG during RF ablation had not yet been described.

Lead implantation in young adults with congenital heart disease is often problematic due to the reduction in the number of surgical access routes and consequent scar tissue formation related to previous surgery. In such a situation, anatomic and electromagnetic voltage mapping of the heart may be useful to find the optimal implantation site for sensing and pacing activities.

This report illustrates an unusual case of asymptomatic late cardiac perforation by an atrial pacemaker lead into the right lung. In the present case, the lead was explanted by simple manual traction through the device pocket without any complications.

The picture obtained by a computed tomography (CT) scan illustrates a cardiac perforation by a temporary transvenous lead placed in a …

Aim To determine the effect of a new automated external defibrillator (AED) system connected by General Packet Radio Service (GPRS) to an external call centre in assisting novices in a sudden cardiac arrest situation. Method Prospective, interventional study. Layperson volunteers were first asked to complete a survey about their knowledge and ability to give cardiopulmonary resuscitation (CPR) and use an AED. A simulated cardiac arrest scenario using a CPR manikin was then presented to volunteers. A telephone and semi-AED were available in the same room. The AED was linked to a call centre, which provided real-time information to ‘bystanders’ and emergency services via GPRS/GPS technology. The scene was videotaped to avoid any interaction with examiners. A standardised check list was used to record correct actions. Results 85 volunteers completed questionnaires and were recorded. Mean age was 44±16, and 49% were male; 38 (45%) had prior CPR training or felt comfortable intervening in a sudden cardiac arrest victim; 40% felt they could deliver a shock using an AED. During the scenarios, 56 (66%) of the participants used the AED and 53 (62%) successfully delivered an electrical shock. Mean time to defibrillation was 2 min 29 s. Only 24 (28%) participants dialled the correct emergency response number (112); the live-assisted GPRS AED allowed alerted emergency services in 38 other cases. CPR was initiated in 63 (74%) cases, 26 (31%) times without prompting and 37 (44%) times after prompting by the AED. Conclusions Although knowledge of the general population appears to be inadequate with regard to AED locations and recognition, live-assisted devices with GPS-location may improve emergency care.

Thromboembolic stroke is the most serious complication in patients suffering from Atrial Fibrillation. Atrial thrombi have a predilection to form in the left atrial appendage. Accordingly, oral anticoagulation is recommended for patients with high risk of stroke. However, it is widely underused and problems of compliance are associated with serious risk of bleeding or inefficacy. In these patients with non-valvular atrial fibrillation, percutaneous occlusion of the left atrial appendage might help to reduce the risk of thromboembolism. Cardiac imaging plays a crucial role at all stages of this procedure and trans-esophageal echocardiography represents the current gold-standard for the assessment of the left atrial appendage. Cardiac imaging is mandatory to precisely determine the left atrial appendage anatomy and to select the appropriate size for the device. Finally, real time three-dimension echocardiography is a powerful additional tool that improves the safety profile of the procedure. 3D-transoesophageal echocardiography allows for the accurate assessment of left atrial appendage anatomy and helps determine if it's suitable for device implantation. Finally, it also allows for continuous visualization of all intracardiac devices and catheters during the procedure, and the clear delineation of device positioning in the left atrial appendage.

Scar imaging and substrate mapping are recognized as important steps in the post-infarct revascularization strategy. It is also helpful in planning ventricular tachycardia ablation or to better define the patient prognosis. However, delayed contrast enhanced (DE) cardiac magnetic resonance (cMR), the gold standard …

A healthy 11-year-old girl was referred to our center because of dyspnea and palpitations for several weeks. A transthoracic echocardiography demonstrated a left ventricular ejection fraction of 35%. Electrocardiograms were taken and showed incessant wide QRS complex tachycardia regularly interrupted by a narrow QRS complex. A closer inspection revealed repeating similar cycles, each consisting of 4 complexes. What is the mechanism of this phenomenon?