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International audience; Objectives: This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus.Background: Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi.Methods: Patients admitted for catheter ablation of AF (n = 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS2 score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE).Results: The incidence of atrial thrombus was 1.92%. CHADS2 score and D-dimer level were significantly associated with atrial thrombus (p < 0.0001 and p < 0.0001, respectively). A zero CHADS2 score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS2 score (p < 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus.Conclusions: An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.

To determine the prognostic value of a low T/R ratio, defined as the amplitude ratio between the T waves and the R waves, in patients (pts) with a spontaneous type-1 Brugada pattern (SBT1).Abnormalities of myocardial repolarization may play a key role in the initiation of ventricular fibrillation (VF) in Brugada syndrome (BrS). Recent studies have shown that the height of the T waves and the T/R ratio are inversely proportional to sudden cardiac arrest (SCA) risk in early repolarization syndrome and hypertrophic cardiomyopathy.In an international retrospective study, we reviewed 115 pts. (105 males, 91.3%). 45 had VF and/or SCA (38.7 ± 11.5 years old, all males), while 70 (49.3 ± 12.0 years, 10 women) remained free of ventricular arrhythmia. 6 ECG markers plus the T/R ratio in leads V5II were studied.The T/R ratio among leads IIV5 was significantly lower in the VF/SCA group (0.24 [0.14; 0.38]vs. 0.34 [0.24; 0.45]; p = 0.006). 44.4% of pts. in the VF/SCA group had a lowest T/R ratio among leads IIV5 ≤ 0.17 compared to 11.4% in the non-VF/SCA group (p 0.001). In multivariate analysis, a lowest T/R ratio among leads IIV5 ≤ 0.17 was independently associated with VF/SCA (OR 6.10, 95% CI 1.92-19.40; p = 0.002). Type 1 Brugada pattern in the peripheral leads (OR 10.78) and early repolarization (OR 3.60) were other independent markers of VF/SCA.A low T/R ratio among leads IIV5 is an independent marker for VF/SCA risk in patients with type-1 Brugada pattern.

Introduction Direct oral anticoagulants (DOACs) also influence cell signaling in various cell types, thus affecting biological systems other than coagulation, whose markers are uncertain. Material and methods To perform a pilot study of variations in plasma protein by means of Liquid chromatography–high resolution tandem mass spectrometry (LC-HRMS/MS) in 5 patients with newly-diagnosed non-valvular atrial fibrillation (NVAF) starting rivaroxaban anti-FXa DOAC treatment. Results A total of 260 proteins could be identified in plasma samples obtained before treatment and at one month of treatment. A significant sustained variation in their concentrations (doubling or halving) was evidenced in at least one patient. These variations were heterogeneous and inconstant from one patient to another. Their most striking feature was the downregulation of proteins participating in the inflammatory system reaction, and of proteins related to intravascular hemolysis. Other variations were rarer and more erratic. Conclusions Individual rivaroxaban treatment-associated variations in protein were evidenced in patients with NVAF starting rivaroxaban. This should now be tested and confirmed with a large series of carefully annotated patients. Confirming these established variations would open the door to the search for clinically-relevant correlations and consequences, if any.

Aims There is currently no reliable tool to quantify the risks of ventricular fibrillation or sudden cardiac arrest (VF/SCA) in patients with spontaneous Brugada type 1 pattern (BrT1). Previous studies showed that electrocardiographic (ECG) markers of depolarization or repolarization disorders might indicate elevated risk. We aimed to design a VF/SCA risk prediction model based on ECG analyses for adult patients with spontaneous BrT1. Methods and results This retrospective multicentre international study analysed ECG data from 115 patients (mean age 45.1 ± 12.8 years, 105 males) with spontaneous BrT1. Of these, 45 patients had experienced VF/SCA and 70 patients did not experience VF/SCA. Among 10 ECG markers, a univariate analysis showed significant associations between VF/SCA and maximum corrected Tpeak–Tend intervals ≥100 ms in precordial leads (LMaxTpec) (P Conclusion LMaxTpec and its association with pT1 and/or ER indicated elevated VF/SCA risk in adult patients with spontaneous BrT1. We successfully developed a simple risk prediction model based on age and these ECG markers.

Background— Percutaneous left atrial appendage (LAA) closure is an emerging option for patients with atrial fibrillation at high risk for cerebrovascular events. The multicenter FLAAC registry (French Nationwide Observational LAA Closure Registry) was established to assess LAA closure outcomes in everyday practice. Methods and Results— Four hundred thirty-six patients referred from April 2013 to September 2015 to 33 French interventional cardiology centers for percutaneous LAA closure were included prospectively in the FLAAC registry. Mean age was 75.4±0.4 years. The stroke risk was high (mean CHA 2 DS 2 –VASc score, 4.5±0.1) and most patients had experienced clinically significant bleeding (HAS-BLED score, 3.1±0.05). The device used was Amplatzer LAA occluder in 58% and the Watchman device in 42% of the patients. The procedural success rate was 98.4%. Median postprocedure follow-up was 12.0 (11.8–12.0) months and a single patient was lost to follow-up. During the periprocedural and subsequent follow-up period, procedure-related severe adverse events occurred in 21 (4.9%) and 10 (2.3%) patients, respectively. One-year cumulative incidences of ischemic stroke and cerebral hemorrhage were 2.9% (1.6–5.0) and 1.5% (0.7–3.2), respectively. Overall, 1-year mortality was 9.3% (6.9–12.5) with 7 of the 39 deaths related or possibly related to the device or procedure. Conclusions— This nationwide prospective registry shows that, in the French population, LAA closure is mainly used in patients with high comorbidity rates and a poor prognosis. LAA closure in such patients seems reasonable to decrease the stroke rate. The overall health status of these patients should be taken into account during the preprocedural evaluation process. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02252861.

International audience; BACKGROUND Real-time monitoring of radiofrequency (RF) abla-tion remains challenging. OBJECTIVE We used intravascular ultrasound (IVUS) to describe atrial wall changes during RF ablation and to assess the extent of RF-induced lesions. METHODS In 9 piglets, RF and IVUS catheters were coupled and introduced into the right atrium. RF applications were performed along the intercaval line. Corresponding IVUS images were analyzed. Wall thickness was correlated with electrogram (EGM) changes (n ¼ 9) and histology (n ¼ 5). RESULTS There were 66 RF applications performed in 57 sites. IVUS provided real-time imaging of the atrial wall during RF application in all but 2 sites. IVUS demonstrated significant (420%) and immediate increase in atrial wall thickness in 71.4% of RF applications. It showed epicardial or intramyocardial effusion in 30% of cases, 2 steam pops, 1 intramural hematoma, and 1 thrombus. EGM amplitude decreased and thickness increased after RF application than at baseline (2.20 1.11 to 0.99 0.62 mV and 1.34 0.53 to 1.93 0.80 mm, respectively; P o .001 for each). However, EGM and thickness changes were poorly correlated (r ¼ 0.43; P o .05). Histologically and echographically measured thicknesses were correlated (r ¼ 0.71; P ¼ .004), but echographic thickness change was not related to histological lesion transmurality. CONCLUSION An IVUS probe coupled to an RF catheter can provide relevant real-time imaging of the atrial wall during ablation. Although thickness change does not appear as a good predictor of the transmural extent, direct visualization and monitoring of RF application may provide new information to guide and secure RF ablation. KEYWORDS Radiofrequency ablation; RF ablation; Transmural extent of RF lesions; Radiofrequency ablation in a porcine model; IVUS imaging of atrial wall; RF lesion extent; Transmural lesion extent; Atrial fibrillation ABBREVIATIONS EGM ¼ electrogram; IVUS ¼ intravascular ultrasound; RA ¼ right atrium; RF ¼ radiofrequency .